Journal: Resuscitation

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<div><h4>High Central Venous Pressure Amplitude Predicts Successful Defibrillation in a Porcine Model of Cardiac Arrest.</h4><i>Balzer C, Eagle SS, Yannopoulos D, Aufderheide TP, Riess ML</i><br /><b>Aim</b><br />Increasing venous return during cardiopulmonary resuscitation (CPR) has been shown to improve hemodynamics during CPR and outcomes following cardiac arrest (CA). We hypothesized that a high central venous pressure amplitude (CVP-A), the difference between the maximum and minimum central venous pressure during chest compressions, could serve as a robust predictor of return of spontaneous circulation (ROSC) in addition to traditional measurements of coronary perfusion pressure (CPP) and end-tidal CO<sub>2</sub> (etCO<sub>2</sub>) in a porcine model of CA.<br /><b>Methods</b><br />After 10 minutes of ventricular fibrillation, 9 anesthetized and intubated female pigs received mechanical chest compressions with active compression/decompression (ACD) and an impedance threshold device (ITD). CPP, CVP-A and etCO<sub>2</sub> were measured continuously. All groups received biphasic defibrillation (200J) at minute 4 of CPR and were classified into two groups (ROSC, NO ROSC). Mean values were analyzed over 3 minutes before defibrillation by repeated-measures Analysis of Variance and receiver operating characteristic (ROC).<br /><b>Results</b><br />Five animals out of 9 experienced ROSC. CVP-A showed a statistically significant difference (p=0.003) between the two groups during 3 minutes of CPR before defibrillation compared to CPP (p=0.056) and etCO<sub>2</sub> (p=0.064). Areas-under-the-curve in ROC analysis for CVP-A, CPP and etCO<sub>2</sub> were 0.94 (95% Confidence Interval 0.86, 1.00), 0.74 (0.54, 0.95) and 0.78 (0.50, 1.00), respectively.<br /><b>Conclusion</b><br />In our study, CVP-A was a potentially useful predictor of successful defibrillation and return of spontaneous circulation. Overall, CVP-A could serve as a marker for prediction of ROSC with increased venous return and thereby monitoring the beneficial effects of ACD and ITD. Institutional protocol number 1810-36421A.<br /><br />Published by Elsevier B.V.<br /><br /><small>Resuscitation: 01 Feb 2023:109716; epub ahead of print</small></div>
Balzer C, Eagle SS, Yannopoulos D, Aufderheide TP, Riess ML
Resuscitation: 01 Feb 2023:109716; epub ahead of print | PMID: 36736947
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<div><h4>Scoping Review of Echocardiographic Parameters Associated with Diagnosis and Prognosis After Resuscitated Sudden Cardiac Arrest.</h4><i>Liu L, Karatasakis A, Kudenchuk PJ, Kirkpatrick JN, ... Counts C, R H Branch K</i><br /><b>Aim</b><br />Current international guidelines recommend early echocardiography after resuscitated sudden death despite limited data. Our aim was to analyze published data on early post-resuscitation echocardiography to identify cardiac causes of sudden death and prognostic implications.<br /><b>Methods</b><br />We reviewed MEDLINE, EMBASE, and CENTRAL databases to December 2021 for echocardiographic studies of adult patients after resuscitation from non-traumatic sudden death. Studies were included if echocardiography was performed <48 hours after resuscitation and reported 1) diagnostic accuracy to detect cardiac etiologies of sudden death or 2) prognostic outcomes. Diagnostic endpoints were associations of regional wall motion abnormalities (RWMA), ventricular function, and structural abnormalities with cardiac etiologies of arrest. Prognostic endpoints were associations of echocardiographic findings with survival to hospital discharge and favorable neurological outcome.<br /><b>Results</b><br />Of 2877 articles screened, 16 (0.6%) studies met inclusion criteria, comprising 2035 patients. Two of six studies formally reported diagnostic accuracy for echocardiography identifying cardiac etiology of arrest; RWMA (in 5 of 6 studies) were associated with presumed cardiac ischemia in 17-89% of cases. Among 12 prognostic studies, there was no association of reduced left ventricular ejection fraction with hospital survival (n=10) or favorable neurologic status (n=5). Echocardiographic high mitral E/e\' ratio (n=1) and right ventricular systolic dysfunction (n=2) were associated with poor survival.<br /><b>Conclusion</b><br />This scoping review highlights the limited data on early echocardiography in providing etiology of arrest and prognostic information after resuscitated sudden death. Further research is needed to refine the clinical application of early echocardiographic findings in post arrest care.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 01 Feb 2023:109719; epub ahead of print</small></div>
Liu L, Karatasakis A, Kudenchuk PJ, Kirkpatrick JN, ... Counts C, R H Branch K
Resuscitation: 01 Feb 2023:109719; epub ahead of print | PMID: 36736949
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<div><h4>Implementation of a Regional Extracorporeal Membrane Oxygenation Program for Refractory Ventricular Fibrillation Out-of-Hospital Cardiac Arrest.</h4><i>Bosson N, Kazan C, Sanko S, Abramson T, ... Gausche-Hill M, Shavelle D</i><br /><b>Background</b><br />eCPR, the modality of extracorporeal membrane oxygenation (ECMO) applied in the setting of cardiac arrest, has emerged as a novel therapy which may improve outcomes in select patients with out-of-hospital cardiac arrest (OHCA). To date, implementation has been mainly limited to single academic centres. Our objective is to describe the feasibility and challenges with implementation of a regional protocol for eCPR.<br /><b>Methods</b><br />The Los Angeles County Emergency Medical Services (EMS) Agency implemented a regional eCPR protocol in July 2020, which included coordination across multiple EMS provider agencies and hospitals to route patients with refractory ventricular fibrillation (rVF) OHCA to eCPR-capable centres (ECCs). Data were entered on consecutive patients with rVF with suspected cardiac aetiology into a centralized database including time intervals, field and in-hospital care, survival and neurologic outcome.<br /><b>Results</b><br />From July 27, 2020 through July 31, 2022, 35 patients (median age 57 years, 6 (17%) female) were routed to ECCs, of whom 11 (31%) received eCPR and 3 (27%) treated with eCPR survived, all of whom had a full neurologic recovery. Challenges encountered during implementation included cost to EMS provider agencies for training, implementation, and purchase of automatic chest compression devices, maintenance of system awareness, hospital administrative support for staffing and equipment for the ECMO program, and interdepartmental coordination at ECCs.<br /><b>Conclusion</b><br />We describe the successful implementation of a regional eCPR program with ongoing patient enrolment and data collection. These preliminary findings can serve as a model for other EMS systems who seek to implement regional eCPR programs.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 28 Jan 2023:109711; epub ahead of print</small></div>
Bosson N, Kazan C, Sanko S, Abramson T, ... Gausche-Hill M, Shavelle D
Resuscitation: 28 Jan 2023:109711; epub ahead of print | PMID: 36720300
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<div><h4>On-site Treatment of Avalanche Victims: Scoping Review and 2023 Recommendations of the International Commission for Mountain Emergency Medicine (ICAR MedCom).</h4><i>Pasquier M, Strapazzon G, Kottmann A, Paal P, ... Jaques C, Brugger H</i><br /><b>Introduction</b><br />The International Commission for Mountain Emergency Medicine (ICAR MedCom) developed updated recommendations for the management of avalanche victims.<br /><b>Methods</b><br />ICAR MedCom created Population Intervention Comparator Outcome (PICO) questions and conducted a scoping review of the literature. We evaluated and graded the evidence using the American College of Chest Physicians system.<br /><b>Results</b><br />We included 120 studies including original data in the qualitative synthesis. There were 45 retrospective studies (38%), 44 case reports or case series (37%), and 18 prospective studies on volunteers (15%). The main cause of death from avalanche burial was asphyxia (range of all studies 65-100%). Trauma was the second most common cause of death (5-29%). Hypothermia accounted for few deaths (0-4%).<br /><b>Conclusions</b><br />and recommendations: For a victim with a burial time ≤60 minutes without signs of life, presume asphyxia and provide rescue breaths as soon as possible, regardless of airway patency. For a victim with a burial time >60 minutes, no signs of life but a patent airway or airway with unknown patency, presume that a primary hypothermic CA has occurred and initiate cardiopulmonary resuscitation (CPR) unless temperature can be measured to rule out hypothermic cardiac arrest. For a victim buried >60 minutes without signs of life and with an obstructed airway, if core temperature cannot be measured, rescuers can presume asphyxia-induced CA, and should not initiate CPR. If core temperature can be measured, for a victim without signs of life, with a patent airway, and with a core temperature <30°C attempt resuscitation, regardless of burial duration.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 26 Jan 2023:109708; epub ahead of print</small></div>
Pasquier M, Strapazzon G, Kottmann A, Paal P, ... Jaques C, Brugger H
Resuscitation: 26 Jan 2023:109708; epub ahead of print | PMID: 36709825
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<div><h4>Diagnostic test accuracy of life-threatening electrocardiographic findings (ST-elevation myocardial infarction equivalents) for acute coronary syndrome after out-of-hospital cardiac arrest without ST-segment elevation.</h4><i>Yoshimura S, Kiguchi T, Irisawa T, Yamada T, ... Kitamura T, Iwami T</i><br /><b>Aim</b><br />Life-threatening electrocardiographic (ECG) findings aid in the diagnosis of acute coronary syndrome (ACS), which has not been well-evaluated in patients with out-of-hospital cardiac arrest (OHCA). This study aimed to evaluate the diagnostic test accuracy (DTA) of ST-elevation myocardial infarction (STEMI) equivalents following the return of spontaneous circulation (ROSC) in patients with OHCA to identify patients with ACS.<br /><b>Methods</b><br />Using the database of the Comprehensive Registry of In-Hospital Intensive Care for OHCA Survival study from 2012 to 2017, patients aged ≥ 18 years with non-traumatic OHCA and ventricular fibrillation or pulseless ventricular tachycardia on the arrival of emergency medical service personnel or arrival at the emergency department, who achieved ROSC, were included. Patients without ST-segment elevation or complete left bundle branch block on ECG and those who did not undergo ECG or coronary angiography, were excluded from the study. We evaluated the DTA of STEMI equivalents for the diagnosis of ACS: isolated T-wave inversion, ST-segment depression, Wellens\' signs, and ST-segment elevation in lead aVR.<br /><b>Results</b><br />Isolated T-wave inversion and Wellens\' signs had high specificity for ACS with 0.95 (95% confidence interval [CI], 0.87-0.99) and 0.92 (95% CI, 0.82-0.97), respectively, but their positive likelihood ratios were low, with a wide range of 95% CI: 1.89 (95% CI, 0.51-7.02) and 0.81 (95% CI, 0.25-2.68), respectively.<br /><b>Conclusion</b><br />The DTA of STEMI equivalents for the diagnosis of ACS was low among patients with OHCA. Further investigation considering the measurement timing of the ECG after ROSC is required.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 23 Jan 2023:109700; epub ahead of print</small></div>
Yoshimura S, Kiguchi T, Irisawa T, Yamada T, ... Kitamura T, Iwami T
Resuscitation: 23 Jan 2023:109700; epub ahead of print | PMID: 36702338
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<div><h4>Guedel oropharyngeal airway: The validation of facial landmark-distances to estimate sizing in children - visualisation by magnetic resonance imaging (GUEDEL-I): a prospective observational study.</h4><i>Nemeth M, Ernst M, Asendorf T, Wilmers S, ... Kunze-Szikszay N, Miller C</i><br /><b>Objective</b><br />To validate the ERC-recommended facial landmark-distance for oropharyngeal airway sizing in children.<br /><b>Methods</b><br />We conducted a prospective observational study in anaesthetised, spontaneously breathing children ≤12 years undergoing cranial MRI. Oropharyngeal airways were inserted following the distance from the maxillary incisors to the mandibular angle. Primary outcome was the rate of properly sized oropharyngeal airways on MRI, defined as the distal end positioned within 10mm from the epiglottis without contacting it. Secondary outcomes were the occurrence of tongue protrusion, oropharyngeal airways clinical efficacy, and related adverse events. Furthermore, we calculated probabilities for the estimation of proper size when considering five facial landmark-distances and optimal rules based on biometric parameters.<br /><b>Results</b><br />In 94 children with a mean (SD) age of 4.7 (±3) years, 47.9% [95%-CI 38%-57.9%] oropharyngeal airways were properly sized, while 23.4% [95%-CI 15.9%-33%] were undersized, and 28.7% [95%-CI 20.5%-38.7%] oversized. Tongue protrusion occurred in 59.1% [95%-CI 38.2%-77.2%] of undersized and 15.6% [95%-CI 7.6%-29.2%] of properly sized oropharyngeal airways. No oropharyngeal airway required replacement. Comparing probabilities for five landmark-distances, \"maxillary incisors to the angle of the mandible\" proved superior for proper sizing at 41.2% [95%-CI 32%-51.7%]. The best-fit formula was \"22.43+17.54 x log(weight[kg])\" with a probability of 61.7% [95%-CI 51.5%-70.9%].<br /><b>Conclusion</b><br />Although the facial landmark-distance \"maxillary incisors to the angle of the mandible\" does not reliably predict oropharyngeal airway size, no clinical problems have been encountered. Since it can be considered the least inaccurate facial landmark-distance, it can serve as an approximation, but the efficacy of oropharyngeal airways should be evaluated clinically.<br /><b>Registered clinical trial</b><br />German Clinical Trials Register; DRKS00025918.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 23 Jan 2023:109702; epub ahead of print</small></div>
Nemeth M, Ernst M, Asendorf T, Wilmers S, ... Kunze-Szikszay N, Miller C
Resuscitation: 23 Jan 2023:109702; epub ahead of print | PMID: 36702339
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<div><h4>Clinical characteristics and outcomes after extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients with an initial asystole rhythm.</h4><i>Shirasaki K, Hifumi T, Goto M, Shin K, ... Otani N, SAVE-J II study group Investigation Supervision</i><br /><b>Aim</b><br />This study aimed to describe the characteristics of cases of out-of-hospital cardiac arrest (OHCA) with an initial asystole rhythm in which extracorporeal cardiopulmonary resuscitation (ECPR) was introduced and discuss the clinical indications for ECPR in such patients.<br /><b>Methods</b><br />This was a secondary analysis of the SAVE-J II study, a retrospective, multicentre, registry study involving 36 participating institutions in Japan. Patients with an initial asystole rhythm were selected. Favourable neurological outcomes (cerebral performance categories 1-2) constituted the primary outcome.<br /><b>Results</b><br />In total, 202 patients met the inclusion criteria, with favourable neurological outcomes at hospital discharge in 12 patients (5.9%). Causes of cardiac arrest with favourable neurological outcomes were hypothermia (7 cases), acute coronary syndrome (2 cases), arrhythmia (2 cases), and pulmonary embolism (1 case). Among patients with non-hypothermia (temperature ≥32°C) on hospital arrival with the cardiac rhythm of asystole or pulseless electrical activity (PEA) on arrival, all 107 patients (66 asystole, 41 PEA) who lacked one or more of the requirements (witness; bystander CPR; signs of life or pupil < 5 mm) had unfavourable neurological outcomes. All 5 cases with favourable neurological outcomes, except for 1 case with a short duration of no-flow time that was highly suspected based on the patient\'s history, met all the requirements on hospital arrival.<br /><b>Conclusions</b><br />A total of 202 ECPR cases with an initial asystole rhythm, including 12 patients with favourable neurological outcomes, were described. Even if the initial cardiac rhythm is asystole, ECPR could be considered if certain conditions are met.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 13 Jan 2023:109694; epub ahead of print</small></div>
Shirasaki K, Hifumi T, Goto M, Shin K, ... Otani N, SAVE-J II study group Investigation Supervision
Resuscitation: 13 Jan 2023:109694; epub ahead of print | PMID: 36646370
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<div><h4>Clinical outcomes following out-of-hospital cardiac arrest: the minute-by-minute impact of bystander cardiopulmonary resuscitation.</h4><i>Cournoyer A, Grunau B, Cheskes S, Vaillancourt C, ... Castonguay V, Daoust R</i><br /><b>Aims</b><br />The time-dependent prognostic role of bystander cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) patients has not been described with great precision, especially for neurologic outcomes. Our objective was to assess the association between bystander CPR, emergency medical service (EMS) response time, and OHCA patients\' outcomes.<br /><b>Methods</b><br />This cohort study used the Resuscitation Outcomes Consortium Cardiac Epidemiologic Registries. Bystander-witnessed adult OHCA treated by EMS were included. The primary outcome was survival to hospital discharge and secondary outcome was survival with a good neurologic outcome (modified Rankin scale 0-2). Multivariable logistic regression models were used to assess the associations and interactions between bystander CPR, EMS response time and clinical outcomes.<br /><b>Results</b><br />Out of 229,637 patients, 41,012 were included (18,867 [46.0%] without bystander CPR and 22,145 [54.0%] with bystander CPR). Bystander CPR was independently associated with higher survival (adjusted odds ratio [AOR]=1.70 [95%CI 1.61-1.80]) and survival with a good neurologic outcome (AOR=1.87 [95%CI 1.70-2.06]), while longer EMS response times were independently associated with lower survival to hospital discharge (each additional minute of EMS response time: AOR=0.92 [95%CI 0.91-0.93], p<0.001) and lower survival with a good neurologic outcome (AOR=0.88 [95%CI 0.86-0.89], p<0.001). There was no interaction between bystander CPR and EMS response time\'s association with survival (p=0.12) and neurologic outcomes (p=0.65).<br /><b>Conclusions</b><br />Although bystander CPR is associated with an immediate increase in odds of survival and of good neurologic outcome for OHCA patients, it does not influence the negative association between longer EMS response time and survival and good neurologic outcome.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 13 Jan 2023:109693; epub ahead of print</small></div>
Cournoyer A, Grunau B, Cheskes S, Vaillancourt C, ... Castonguay V, Daoust R
Resuscitation: 13 Jan 2023:109693; epub ahead of print | PMID: 36646371
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<div><h4>Doppler Ultrasound Peak Systolic Velocity versus End Tidal Carbon Dioxide during Pulse Checks in Cardiac Arrest1.</h4><i>Haddad G, Margius D, Cohen AL, Gorlin M, ... Becker L, Rolston DM</i><br /><b>Background</b><br />An accurate, non-invasive measure of return of spontaneous circulation (ROSC) is needed to improve management of cardiac arrest patients.<br /><b>Objectives</b><br />During a pulse check in Emergency Department (ED) cardiac arrest patients, we compared the correlation between 1) end tidal carbon dioxide (ETCO<sub>2</sub>) and systolic blood pressure (SBP), and 2) Doppler ultrasound peak systolic velocity (PSV) and SBP. Additionally, we assessed the accuracy of PSV ≥20 cm/sec in comparison to previously suggested ETCO<sub>2</sub> ≥20 or ≥25 mmHg thresholds to predict ROSC with SBP ≥60 mmHg.<br /><b>Methods</b><br />This was a secondary analysis of a previously published prospective observational study of ED cardiac arrest patients with an advanced airway and femoral arterial line in place. During each pulse check, highest SBP, highest PSV, and ETCO<sub>2</sub> at the end of the pulse check were recorded. Spearman correlation coefficients were calculated and compared using a Fisher Z-transformation. Accuracy of previously determined PSV and ETCO<sub>2</sub> thresholds for detecting ROSC with SBP ≥60 mmHg were compared using McNemar\'s tests.<br /><b>Results</b><br />Based on data from 35 patients with 111 pulse checks, we found a higher correlation between PSV and SBP than ETCO<sub>2</sub> and SBP (0.71 vs. 0.31; p<0.001). Diagnostic accuracy of PSV ≥20 cm/sec for detecting ROSC with SBP ≥60 mmHg was 89% (95% CI: 82%-94%) versus 59% (95% CI: 49%-68%) and 58% (95% CI: 48%-67%) for ETCO<sub>2</sub> ≥20 and ≥25 mmHg, respectively.<br /><b>Conclusions</b><br />During a pulse check, Doppler ultrasound PSV outperformed ETCO<sub>2</sub> for correlation with SBP and accuracy in detecting ROSC with SBP ≥60 mmHg.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 13 Jan 2023:109695; epub ahead of print</small></div>
Haddad G, Margius D, Cohen AL, Gorlin M, ... Becker L, Rolston DM
Resuscitation: 13 Jan 2023:109695; epub ahead of print | PMID: 36646373
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<div><h4>Characteristics of patients resuscitated after burn related out-of-hospital cardiac arrest.</h4><i>Hoshino T, Enomoto Y, Inoue Y</i><br /><b>Aim</b><br />This study\'s objective was to describe the characteristics of burn injury patients who were resuscitated after burn related out-of-hospital cardiac arrest (OHCA).<br /><b>Method</b><br />We conducted a retrospective cohort study and examined characteristics of burn related OHCA using data from a Japanese nationwide burn registry that was collected between April 1, 2011 and March 31, 2020. First, we compared the characteristics of burn patients with and without OHCA. Second, among burn patients with OHCA, we compared the characteristics of survivors with non-survivors.<br /><b>Results</b><br />In the database, there were 16,995 hospitalised burn patients and 256 burn related OHCA. Thirty-two of the 256 burn patients (13%) survived after admission. Among patients with burns who also had OHCA, flames were the most common injury mechanism (74%); in comparison to all other injury mechanisms, the rate of flame burn was significantly higher in burn patients with OHCA than in burn patients without OHCA. The most common cause of death for burn related OHCA is carbon-monoxide poisoning (46%). Compared with survivors, non-survivors had a larger burn area, greater age and more complications. such as inhalation injuries and perineal burn injuries. Compared to other mechanisms of burn injury, electrical burn injuries were more common among survivors. In twelve patients with electrical burns, eight patients survived (67%) OHCA; of those eight patients, six (50%) could be discharged home.<br /><b>Conclusion</b><br />Patients with burn related OHCA have a poor prognosis; however, patients who sustain electrical shock injuries may do better.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 12 Jan 2023:109692; epub ahead of print</small></div>
Hoshino T, Enomoto Y, Inoue Y
Resuscitation: 12 Jan 2023:109692; epub ahead of print | PMID: 36642246
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<div><h4>When the machine is wrong. Characteristics of true and false predictions of Out-of-Hospital Cardiac Arrests in Emergency Calls using a machine-learning model.</h4><i>Nikolaj Blomberg S, Jensen TW, Porsborg Andersen M, Folke F, ... Lippert F, Collatz Christensen H</i><br /><b>Background</b><br />A machine-learning model trained to recognize emergency calls regarding Out-of-Hospital Cardiac Arrest (OHCA) was tested in clinical practice at Copenhagen Emergency Medical Services (EMS) from September 2018 to December 2019. We aimed to investigate emergency call characteristics where the machine-learning model failed to recognize OHCA or misinterpreted a call as being OHCA.<br /><b>Methods</b><br />All emergency calls were linked to the dispatch database and verified OHCAs were identified by linkage to the Danish Cardiac Arrest Registry. Calls with either false negative or false positive predictions of OHCA were evaluated by trained auditors. Descriptive analyses were performed with absolute numbers and percentages reported.<br /><b>Results</b><br />The machine-learning model processed 169,236 calls to Copenhagen EMS and suspected 5,811 (3.4%) of the calls as OHCA, resulting in 84.5% sensitivity and 97.1% specificity. Among OHCAs not recognised by machine-learning model, a condition completely different from OHCA was presented by caller in 31% of the cases. In 28% of unrecognised calls, patient was reported breathing normally, and language barriers were identified in 23% of the cases. Among falsely suspected OHCA, the patient was reported unconscious in 28% of the cases, and in 13% of the false positive cases the machine-learning model interpreted calls regarding dead patients with irreversible signs of death as OHCA.<br /><b>Conclusion</b><br />Continuous optimization of the language model is needed to improve the prediction of OHCA and thereby improve sensitivity and specificity of the machine-learning model on recognising OHCA in emergency telephone calls BACKGROUND: Survival after Out-of-Hospital Cardiac Arrest (OHCA) has increased in several countries after the implementation of initiatives to improve early recognition, dispatch protocol, bystander action and activation, as well as post-resuscitation care.[1-11] Steps to improve survival from OHCA have been summarized in the chain of survival and the Global Resuscitation Alliance \'10 steps to improve survival\'.[12] One of the central elements emphasised is the important role of early recognition of OHCA and the role of the dispatcher[4] who play a central role in early recognition and allocating rapid response to increase survival. In 15-20% of calls to Copenhagen Emergency Medical Services (EMS) regarding OHCA, resuscitation was initiated prior to the call.[3,13] For the remaining calls, it has been the dispatcher who establish clear recognition of OHCA and initiates a rapid response and dispatcher assisted cardiopulmonary resuscitation (DA-CPR).[3,14] The role of the dispatcher in recognizing OHCA has been proven to be challenging, as several aspects of telecommunication provide only limited insights to what is happening at the scene. Due to the inherent limitations of cognitive processing whilst communicating the dispatcher might miss recognizing a substantial number of OHCA or give delayed responses.[15] Several characteristics of OHCA have previously shown to present challenges in recognition with lower frequency of recognition and delayed or absent rapid response. While some characteristics has proven to ease recognition as suicide and trauma, other characteristics have shown to increase the difficulties of recognition namely difficulties in assessing breathing patterns and consciousness, language and linguistic challenges and the presence of seizures.[1,2,15-24]. To improve OHCA recognition, a machine-learning model was implemented into clinical practice in August 2018 at Copenhagen EMS.[14] The machine-learning model deciphered the conversation between dispatcher and caller and assisted the dispatcher in recognizing OHCA in the conversation in real-time. From September 2018 until December 2019 the machine-learning model alerted dispatchers in case of an ongoing emergency call showing a high probability of OHCA.[25] The aim of this study was to investigate and describe calls where the machine-learning model was unable to recognise OHCA or misinterpreted a call as being OHCA (false negatives and false positive OHCA calls).<br /><b>Methods</b><br />Copenhagen EMS serves 1.8 million inhabitants with an annual OHCA incidence of 80 per 100,000 persons and receives approximately 130,000 calls to the Danish emergency number (1-1-2), annually.[26] From September 1\'st 2018 to December 31\'st 2019, a machine-learning model was implemented that analysed all 1-1-2 emergency calls, deciphering the audio real time and alerting the dispatchers in case of a suspected OHCA[14,25]. The machine-learning model analysed all calls to 1-1-2, and information was stored on time of call, time of suspected OHCA and call-length. All calls were linked to the Danish Cardiac Arrest Register[11] to identify and verify calls as true or false OHCAs.<br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 09 Jan 2023:109689; epub ahead of print</small></div>
Nikolaj Blomberg S, Jensen TW, Porsborg Andersen M, Folke F, ... Lippert F, Collatz Christensen H
Resuscitation: 09 Jan 2023:109689; epub ahead of print | PMID: 36634755
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<div><h4>Ventilation devices for neonatal resuscitation at birth: a systematic review and meta-analysis.</h4><i>Tribolet S, Hennuy N, Rigo V</i><br /><b>Unlabelled</b><br />Initial management of inadequate adaptation to extrauterine life relies on non-invasive respiratory support. Two types of devices are available: fixed pressure devices (FPD; T-pieces or ventilators) and hand driven pressure devices (HDPD; self- or flow-inflating bags). This systematic review and meta-analysis aims to compare clinical outcomes after neonatal resuscitation according to device type.<br /><b>Methods</b><br />Four databases were searched from inception to 2022, January. Search strategies included Mesh/Emtree terms as well as free language without any restriction. Randomized, quasi-randomized studies and prospective cohorts comparing the use of the two types of devices in neonatal resuscitation were included.<br /><b>Results</b><br />Nine studies recruiting 3621 newborns were included: 5 RCTs, 2 RCTs with interventions bundles and 2 prospective cohorts. Meta-analysis of the 5 RCTs demonstrated significant reductions in bronchopulmonary dysplasia (RR0,68[0,48-0,96]-NNT 31) and other respiratory outcomes: intubation in the delivery room (RR0,72[0,58-0,88]-NNT 13,4), mechanical ventilation requirements (RR0,81[0,67-0,96]-NNT 17) and duration (MD-1,54 days[-3,03- -0,05]), need for surfactant (RR0,79[0,64-0,96]-NNT 7,3). The overall analysis found a lower mortality in the FPD group (OR0,57[0,47-0,69]-NNT 12,7) and confirmed decreases in intubation, surfactant requirement and mechanical ventilation rates (OR 0,56[0,40-0,79]- NNT7,5; OR 0,67[0,55-0,82]-NNT10,7 and OR0,58[0,42-0,80]- NNT 7,4 respectively). The risk of cystic periventricular leukomalacia (cPVL) decreased significantly with FPD (OR0.59[0.41-0.85]-NNT 27). Pneumothorax rates were similar (OR0.82[0.44-1.52]).<br /><br /><b>Conclusion:</b><br/>and relevance</b><br />Resuscitation at birth with FPD improves respiratory transition and decreases BPD with a very low to moderate certainty of evidence. There is suggestion of decreases in mortality and cPVL. Further studies are still needed to confirm those results.<br /><br />Copyright © 2022. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 06 Jan 2023:109681; epub ahead of print</small></div>
Tribolet S, Hennuy N, Rigo V
Resuscitation: 06 Jan 2023:109681; epub ahead of print | PMID: 36623747
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<div><h4>Effect of video laryngoscopy for non-trauma out-of-hospital cardiac arrest on clinical outcome: A registry-based analysis.</h4><i>Risse J, Fischer M, Matteo Meggiolaro K, Fariq-Spiegel K, ... Kill C, Fistera D</i><br /><b>Aim</b><br />Videolaryngoscopy (VL) is a promising tool to provide a safe airway during cardiopulmonary resuscitation (CPR) and to ensure early reoxygenation. Using data from the German Resuscitation Registry, we investigated the outcome of non-traumatic out-of-hospital cardiac arrest (OHCA) patients treated with VL versus direct laryngoscopy (DL) for airway management.<br /><b>Methods</b><br />We analysed retrospective data of 14,387 patients from 1 January 2018 until 31 December 2021 (VL group, n = 2201; DL group, n = 12186). Primary endpoint was discharge with cerebral performance categories one and two (CPC1/2). Secondary endpoints were the rate of return of spontaneous circulation (ROSC), hospital admission, hospital admission with ongoing cardiopulmonary resuscitation, 30-day survival/ hospital discharge and airway management complications. We used multivariate binary logistic regression analysis to identify the effects on outcome of known influencing variables and of VL vs DL.<br /><b>Results</b><br />The multivariate regression model revealed that VL was an independent predictor of CPC1/2 survival (OR = 1.34, 95% CI = 1.12-1.61, p = 0.002) and of hospital discharge/30-day survival (OR = 1.26, 95% CI = 1.08-1.47, p=0,004).<br /><b>Conclusion</b><br />VL for endotracheal intubation (ETI) at OHCA was associated with better neurological outcome in patients with ROSC. Therefore, the use of VL for OHCA offers a promising perspective. Further prospective studies are required.<br /><b>Trial registration</b><br />German Clinical Trial Register DRKS00028137, prospectively registered on 23 February 2022 prior to data analysis. https://drks.de/search/de/trial/DRKS00028137.<br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 05 Jan 2023:109688; epub ahead of print</small></div>
Risse J, Fischer M, Matteo Meggiolaro K, Fariq-Spiegel K, ... Kill C, Fistera D
Resuscitation: 05 Jan 2023:109688; epub ahead of print | PMID: 36621529
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<div><h4>Updating the Model for Risk-Standardizing Survival for In-Hospital Cardiac Arrest to Facilitate Hospital Comparisons.</h4><i>Chan PS, Kennedy KF, Girotra S, American Heart Association\'s Get With The Guidelines®-Resuscitation Investigators</i><br /><b>Background</b><br />Risk-standardized survival rates (RSSR) for in-hospital cardiac arrest (IHCA) have been widely used for hospital benchmarking and research. The novel coronavirus 2019 (COVID-19) pandemic has led to a substantial decline in IHCA survival as COVID-19 infection is associated with markedly lower survival. Therefore, there is a need to update the model for computing RSSRs for IHCA given the COVID-19 pandemic.<br /><b>Methods</b><br />Within Get With The Guidelines®-Resuscitation, we identified 53,922 adult patients with IHCA from March, 2020 to December, 2021 (the COVID-19 era). Using hierarchical logistic regression, we derived and validated an updated model for survival to hospital discharge and compared the performance of this updated RSSR model with the previous model.<br /><b>Results</b><br />The survival rate was 21.0% and 20.8% for the derivation and validation cohorts, respectively. The model had good discrimination (C-statistic 0.72) and excellent calibration. The updated parsimonious model comprised 13 variables-all 9 predictors in the original model as well as 4 additional predictors, including COVID-19 infection status. When applied to data from the pre-pandemic period of 2018-2019, there was a strong correlation (r=0.993) between RSSRs obtained from the updated and the previous models.<br /><b>Conclusion</b><br />We have derived and validated an updated model to risk-standardize hospital rates of survival for IHCA. The updated model yielded RSSRs that were similar to the initial model for IHCAs in the pre-pandemic period and can be used for supporting ongoing efforts to benchmark hospitals and facilitate research that uses data from either before or after the emergence of COVID-19.<br /><br />Copyright © 2022. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 04 Jan 2023:109686; epub ahead of print</small></div>
Chan PS, Kennedy KF, Girotra S, American Heart Association's Get With The Guidelines®-Resuscitation Investigators
Resuscitation: 04 Jan 2023:109686; epub ahead of print | PMID: 36610502
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<div><h4>Mechanical ventilation during cardiopulmonary resuscitation: influence of positive end expiratory pressure and head-torso elevation.</h4><i>Segond N, Terzi N, Duhem H, Bellier A, ... Guérin C, Debaty G</i><br /><b>Background</b><br />Efficient ventilation is important during cardiopulmonary resuscitation (CPR). Nevertheless, there is insufficient knowledge on how the patient\'s position affects ventilatory parameters during mechanically assisted CPR. We studied ventilatory parameters at different positive end-expiratory pressure (PEEP) levels and when using an inspiratory impedance valve (ITD) during horizontal and head-up CPR (HUP-CPR).<br /><b>Methods</b><br />In this human cadaver experimental study, we measured tidal volume (V<sub>T</sub>) and pressure during CPR at different randomized PEEP levels (0, 5 or 10 cmH<sub>2</sub>O) or with an ITD. CPR was performed, in the following order: horizontal (FLAT), at 18° and then at 35° head-thorax elevation. During the inspiratory phase we measured the net tidal volume (V<sub>T</sub>) adjusted to predicted body weight (V<sub>T</sub>PBW), reversed airflow (RAF), and maximum and minimum airway pressure (P<sub>max</sub> and P<sub>min</sub>).<br /><b>Results</b><br />Using ten thawed fresh-frozen cadavers we analyzed the inspiratory phase of 1843 respiratory cycles, 229 without CPR and 1614 with CPR. In a mixed linear model, thoracic position and PEEP significantly impacted V<sub>T</sub>PBW (p < 0.001 for each), and the insufflation time, thoracic position and PEEP significantly affected the RAF (p < 0.001 for each) and P<sub>max</sub> (p < 0.001). For P<sub>min</sub>, only PEEP was significant (p < 0.001). In subgroup analysis, at 35° V<sub>T</sub>PBW and P<sub>max</sub> were significantly reduced compared with the flat or 18° position.<br /><b>Conclusion</b><br />When using mechanical ventilation during CPR, it seems that the PEEP level and patient position are important determinants of respiratory parameters. Moreover, tidal volume seems to be lower when the thorax is positioned at 35°.<br /><br />Copyright © 2022 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 04 Jan 2023:109685; epub ahead of print</small></div>
Segond N, Terzi N, Duhem H, Bellier A, ... Guérin C, Debaty G
Resuscitation: 04 Jan 2023:109685; epub ahead of print | PMID: 36610503
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<div><h4>Application of Adult Prehospital Resuscitation Rules to Pediatric Out of Hospital Cardiac Arrest.</h4><i>Matsui S, Kitamura T, Kurosawa H, Kiyohara K, ... Sobue T, Nitta M</i><br /><b>Background</b><br />Prehospital termination of resuscitation (TOR) rules can be recommended for adults with out-of-hospital cardiac arrests (OHCAs). This study aimed to investigate whether adult basic life support (BLS) and advanced life support (ALS) TOR rules can predict neurologically unfavorable one-month outcome for pediatric OHCA patients.<br /><b>Methods</b><br />From a nationwide population-based observational cohort study, we extracted data of consecutive pediatric OHCA patients (0-17 years old) from January 1, 2005, to December 31, 2011. The BLS TOR rule has three criteria, whereas the ALS TOR rule includes two additional criteria. We selected pediatric OHCA patients that met all criteria for each TOR rule and calculated the specificity and positive predictive value (PPV) of each TOR rule for identifying pediatric OHCA patients who did not have neurologically favorable one-month outcome.<br /><b>Results</b><br />Of the 12,740 pediatric OHCA patients eligible for the evaluation of the BLS TOR rule, 10,803 patients met the BLS TOR rule, with a specificity of 0.785 and a PPV of 0.987 for predicting a lack of neurologically favorable one-month survival. Of the 2,091 for the ALS TOR rule, 381 patients met the ALS TOR rule, with a specificity of 0.986 and a PPV of 0.997 for predicting neurologically unfavorable one-month outcome.<br /><b>Conclusions</b><br />The adult BLS and ALS TOR rules had a high PPV for predicting pediatric OHCA patients without a neurologically favorable survival at one month after onset.<br /><br />Copyright © 2022 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 28 Dec 2022:109684; epub ahead of print</small></div>
Matsui S, Kitamura T, Kurosawa H, Kiyohara K, ... Sobue T, Nitta M
Resuscitation: 28 Dec 2022:109684; epub ahead of print | PMID: 36586503
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<div><h4>Comparison of prehospital resuscitation quality during scene evacuation and early ambulance transport in out-of-hospital cardiac arrest between residential location and non-residential location.</h4><i>Choi S, Han Kim T, Jeong Hong K, Gyung Won Lee S, ... Jun Song K, Do Shin S</i><br /><b>Background</b><br />High-quality prehospital cardiopulmonary resuscitation (CPR) is important for out-of-hospital cardiac arrest (OHCA). We aimed to evaluate prehospital CPR quality during scene evacuation and early ambulance transport in patients with OHCA according to the type of cardiac arrest location.<br /><b>Methods</b><br />This retrospective observational cohort study enrolled patients with non-traumatic adult OHCA in Seoul between July 2020 and March 2022. Prehospital CPR quality data extracted from defibrillators were merged with the national OHCA database. The location of cardiac arrest was categorized into two groups (residential and non-residential). CPR quality indices including no-flow (any pause > 1.5 sec) fraction were compared according to the type of arrest location at each minute of EMS scene evacuation and early ambulance transport (5 min prior to 5 min after ambulance departure).<br /><b>Results</b><br />A total of 1,222 OHCAs were enrolled in the final analysis after serial exclusion. A total of 966 OHCAs (79.1%) occurred in the residential areas. The CPR quality deteriorated during the scene evacuation in both location type. The mean no-flow fractions were significantly higher in residential places than in non-residential places. The mean proportion of adequate compression depth and rate was lower in cardiac arrests in residential places. The discrepancy in EMS CPR quality during scene evacuation was more prominent when mechanical CPR devices were not used.<br /><b>Conclusion</b><br />Deterioration of CPR quality was observed just before and during early ambulance transport, especially when the cardiac arrest location was a residential area or when only manual CPR was provided.<br /><br />Copyright © 2022 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 27 Dec 2022:109680; epub ahead of print</small></div>
Choi S, Han Kim T, Jeong Hong K, Gyung Won Lee S, ... Jun Song K, Do Shin S
Resuscitation: 27 Dec 2022:109680; epub ahead of print | PMID: 36584964
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<div><h4>Predicting Recurrent Cardiac Arrest in Individuals Surviving Out-of-Hospital Cardiac Arrest.</h4><i>Hellsén G, Rawshani A, Skoglund K, Bergh N, ... Engdahl J, Rawshani A</i><br /><b>Background</b><br />Despite improvements in short-term survival for Out-of-Hospital Cardiac Arrest (OHCA) in the past two decades, long-term survival is still not well studied. Furthermore, the contribution of different variables on long-term survival have not been fully investigated.<br /><b>Aim</b><br />Examine the 1-year prognosis of patients discharged from hospital after an OHCA. Furthermore, identify factors predicting re-arrest and/or death during 1-year follow-up.<br /><b>Methods</b><br />All patients 18 years or older surviving an OHCA and discharged from the hospital were identified from the Swedish Register for Cardiopulmonary Resuscitation (SRCR). Data on diagnoses, medications and socioeconomic factors was gathered from other Swedish registers. A machine learning model was constructed with 886 variables and evaluated for its predictive capabilities. Variable importance was gathered from the model and new models with the most important variables were created.<br /><b>Results</b><br />Out of the 5098 patients included, 902 (∼18%) suffered a recurrent cardiac arrest or death within a year. For the outcome death or re-arrest within 1 year from discharge the model achieved an ROC (receiver operating characteristics) AUC (area under the curve) of 0.73. A model with the 15 most important variables achieved an AUC of 0.69.<br /><b>Conclusions</b><br />Survivors of an OHCA have a high risk of suffering a re-arrest or death within 1 year from hospital discharge. A machine learning model with 15 different variables, among which age, socioeconomic factors and neurofunctional status at hospital discharge, achieved almost the same predictive capabilities with reasonable precision as the full model with 886 variables.<br /><br />Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 26 Dec 2022:109678; epub ahead of print</small></div>
Hellsén G, Rawshani A, Skoglund K, Bergh N, ... Engdahl J, Rawshani A
Resuscitation: 26 Dec 2022:109678; epub ahead of print | PMID: 36581182
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<div><h4>Modulation of inflammation by treatment with tocilizumab after out-of-hospital cardiac arrest and associations with clinical status, myocardial- and brain injury.</h4><i>Abild Stengaard Meyer M, Bjerre M, Wiberg S, Grand J, ... Kjaergaard J, Hassager C</i><br /><b>Aim</b><br />To investigate how the inflammatory response after out-of-hospital cardiac arrest (OHCA) is modulated by blocking IL-6-mediated signalling with tocilizumab, and to relate induced changes to clinical status, myocardial- and brain injury.<br /><b>Methods</b><br />This is a preplanned substudy of the IMICA trial (ClinicalTrials.gov, NCT03863015). Upon admission 80 comatose OHCA patients were randomized to infusion of tocilizumab or placebo. Inflammation was characterized by a cytokine assay, CRP, and leukocyte differential count; myocardial injury by TnT and NT-proBNP; brain injury by neuron-specific enolase (NSE) and Neurofilament Light chain (NFL), while sequential organ assessment (SOFA) score and Vasopressor-Inotropic Score (VIS) represented overall clinical status.<br /><b>Results</b><br />Cytokine responses for IL-5, IL-6, IL-17, and neutrophil as well as monocyte counts were affected by tocilizumab treatment (all p<0.05), while there was no effect on levels of NFL. IL-5 and IL-6 were substantially increased by tocilizumab, while IL-17 was lowered. Neutrophils and monocytes were lower at 24 and 48 hours for the tocilizumab group compared to placebo. Multiple correlations were identified for markers of organ injury and clinical status versus inflammatory markers; this included correlations of neutrophils and monocytes with TnT, NSE, NFL, SOFA- and VIS score for the tocilizumab but not the placebo group. NT-proBNP, NFL and SOFA score correlated with CRP in both groups.<br /><b>Conclusions</b><br />Treatment with tocilizumab after OHCA modulated the inflammatory responses with notable increases for IL-5, IL-6, and decreases for neutrophils and monocytes, as well as reduced vasopressor requirements.<br /><br />Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 23 Dec 2022:109676; epub ahead of print</small></div>
Abild Stengaard Meyer M, Bjerre M, Wiberg S, Grand J, ... Kjaergaard J, Hassager C
Resuscitation: 23 Dec 2022:109676; epub ahead of print | PMID: 36572373
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<div><h4>Methods for Calculating Ventilation Rates During Resuscitation from Out-of-Hospital Cardiac Arrest.</h4><i>Wang H, Jaureguibeitia X, Aramendi E, Nassal M, ... Carlson J, Idris A</i><br /><b>Objective</b><br />Ventilation control is important during resuscitation from out-of-hospital cardiac arrest (OHCA). We compared different methods for calculating ventilation rates (VR) during OHCA.<br /><b>Methods</b><br />We analyzed data from the Pragmatic Airway Resuscitation Trial, identifying ventilations through capnogram recordings. We determined VR by: 1) counting the number of breaths within a time epoch (\"counted\" VR), and 2) calculating the mean of the inverse of measured time between breaths within a time epoch (\"measured\" VR). We repeated the VR estimates using different time epochs (10, 20, 30, 60 seconds). We defined hypo- and hyperventilation as VR <6 and >12 breaths/min, respectively. We assessed differences in estimated hypo- and hyperventilation with each VR measurement technique.<br /><b>Results</b><br />Of 3,004 patients, data were available for 1,010. With the counted method, total hypoventilation increased with longer time epochs ([10-second epoch: 75 seconds hypoventilation] to [60-second epoch: 97 seconds hypoventilation]). However, with the measured method, total hypoventilation decreased with longer time epochs ([10-second epoch: 223 seconds hypoventilation] to [60-second epoch: 150 seconds hypoventilation]). With the counted method, the total duration of hyperventilation decreased with longer time epochs ([10-second epochs: 35 seconds hyperventilation] to [60-second epoch: 0 seconds hyperventilation]). With the measured method, total hyperventilation decreased with longer time epochs ([10-second epoch: 78 seconds hyperventilation] to [60-second epoch: 0 seconds hyperventilation]). Differences between the measured and counted estimates were smallest with a 60-second time epoch.<br /><b>Conclusions</b><br />Quantifications of hypo- and hyperventilation vary with the applied measurement methods. Measurement methods are important when characterizing ventilation rates in OHCA.<br /><br />Copyright © 2022. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 23 Dec 2022:109679; epub ahead of print</small></div>
Wang H, Jaureguibeitia X, Aramendi E, Nassal M, ... Carlson J, Idris A
Resuscitation: 23 Dec 2022:109679; epub ahead of print | PMID: 36572374
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<div><h4>Calcium Use during Paediatric In-hospital Cardiac Arrest is Associated with Worse Outcomes.</h4><i>Cashen K, Sutton RM, Reeder RW, Ahmed T, ... Zuppa AF, Meert KL</i><br /><b>Aim</b><br />To evaluate associations between calcium administration and outcomes among children with in-hospital cardiac arrest and among specific subgroups in which calcium use is hypothesized to provide clinical benefit.<br /><b>Methods</b><br />This is a secondary analysis of observational data collected prospectively as part of the ICU-RESUScitation project. Children 37 weeks post-conceptual age to 18 years who received chest compressions in one of 18 intensive care units from October 2016-March 2021 were eligible. Data included child and event characteristics, pre-arrest laboratory values, pre- and intra-arrest haemodynamics, and outcomes. Outcomes included sustained return of spontaneous circulation (ROSC), survival to hospital discharge, and survival to hospital discharge with favourable neurologic outcome. A propensity score weighted cohort was used to evaluate associations between calcium use and outcomes. Subgroups included neonates, and children with hyperkalaemia, sepsis, renal insufficiency, cardiac surgery with cardiopulmonary bypass, and calcium-avid cardiac diagnoses.<br /><b>Results</b><br />Of 1,100 in-hospital cardiac arrests, median age was 0.63 years (IQR 0.19, 3.81); 450 (41%) received calcium. Among the weighted cohort, calcium use was not associated with sustained ROSC (aOR, 0.87; CI95 0.61-1.24; p=0.445), but was associated with lower rates of both survival to hospital discharge (aOR, 0.68; CI95 0.52-0.89; p=0.005) and survival with favourable neurologic outcome at hospital discharge (aOR, 0.75; CI95 0.57-0.98; p=0.038). Among subgroups, calcium use was associated with lower rates of survival to hospital discharge in children with sepsis and renal insufficiency.<br /><b>Conclusions</b><br />Calcium use was common during paediatric in-hospital cardiac arrest and associated with worse outcomes at hospital discharge.<br /><br />Copyright © 2022 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 21 Dec 2022:109673; epub ahead of print</small></div>
Cashen K, Sutton RM, Reeder RW, Ahmed T, ... Zuppa AF, Meert KL
Resuscitation: 21 Dec 2022:109673; epub ahead of print | PMID: 36565948
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<div><h4>Brain injury markers in blood predict signs of hypoxic ischaemic encephalopathy on head computed tomography after cardiac arrest.</h4><i>Lagebrant A, Lang M, Nielsen N, Blennow K, ... Cronberg T, Moseby Knappe M</i><br /><b>Background</b><br />/aim: Signs of hypoxic ischaemic encephalopathy (HIE) on head computed tomography (CT) predicts poor neurological outcome after cardiac arrest. We explore whether levels of brain injury markers in blood could predict the likelihood of HIE on CT.<br /><b>Methods</b><br />Retrospective analysis of CT performed at 24-168 hours post cardiac arrest on clinical indication within the Target Temperature Management after out-of-hospital cardiac arrest-trial. Biomarkers prospectively collected at 24- and 48 hours post-arrest were analysed for neuron specific enolase (NSE), neurofilament light (NFL), total-tau and glial fibrillary acidic protein (GFAP). HIE was assessed through visual evaluation and quantitative grey-white-matter ratio (GWR) was retrospectively calculated on Swedish subjects with original images available.<br /><b>Results</b><br />In total, 95 patients were included. The performance to predict HIE on CT (performed at IQR 73-116 h) at 48 hours was similar for all biomarkers, assessed as area under the receiving operating characteristic curve (AUC) NSE 0.82 (0.71-0.94), NFL 0.79 (0.67-0.91), total-tau 0.84 (0.74-0.95), GFAP 0.79 (0.67-0.90). The predictive performance of biomarker levels at 24 hours was AUC 0.72-0.81. At 48 hours biomarker levels below Youden Index accurately excluded HIE in 77.3-91.7% (negative predictive value) and levels above Youden Index correctly predicted HIE in 73.3-83.7% (positive predictive value). NSE cut-off at 48 hours was 48 ng/ml. Elevated biomarker levels irrespective of timepoint significantly correlated with lower GWR.<br /><b>Conclusion</b><br />Biomarker levels can assess the likelihood of a patient presenting with HIE on CT and could be used to select suitable patients for CT-examination during neurological prognostication in unconscious cardiac arrest patients.<br /><br />Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 20 Dec 2022; epub ahead of print</small></div>
Lagebrant A, Lang M, Nielsen N, Blennow K, ... Cronberg T, Moseby Knappe M
Resuscitation: 20 Dec 2022; epub ahead of print | PMID: 36563954
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<div><h4>Extracorporeal cardiopulmonary resuscitation (eCPR) and cerebral perfusion: A narrative review.</h4><i>Justice CN, Halperin HR, Vanden Hoek TL, Geocadin RG</i><br /><AbstractText>Extracorporeal cardiopulmonary resuscitation (eCPR) is emerging as an effective, lifesaving resuscitation strategy for select patients with prolonged or refractory cardiac arrest. Currently, a paucity of evidence-based recommendations is available to guide clinical management of eCPR patients. Despite promising results from initial clinical trials, neurological injury remains a significant cause of morbidity and mortality. Neuropathology associated with utilization of an extracorporeal circuit may interact significantly with the consequences of a prolonged low-flow state that typically precedes eCPR. In this narrative review, we explore current gaps in knowledge about cerebral perfusion over the course of cardiac arrest and resuscitation with a focus on patients treated with eCPR. We found no studies which investigated regional cerebral blood flow or cerebral autoregulation in human cohorts specific to eCPR. Studies which assessed cerebral perfusion in clinical eCPR were small and limited to near-infrared spectroscopy. Furthermore, no studies prospectively or retrospectively evaluated the relationship between epinephrine and neurological outcomes in eCPR patients. In summary, the field currently lacks a comprehensive understanding of how regional cerebral perfusion and cerebral autoregulation are temporally modified by factors such as pre-eCPR low-flow duration, vasopressors, and circuit flow rate. Elucidating these critical relationships may inform future strategies aimed at improving neurological outcomes in patients treated with lifesaving eCPR.</AbstractText><br /><br />Copyright © 2022 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 19 Dec 2022; epub ahead of print</small></div>
Justice CN, Halperin HR, Vanden Hoek TL, Geocadin RG
Resuscitation: 19 Dec 2022; epub ahead of print | PMID: 36549433
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<div><h4>Annual improvement trends in resuscitation outcome of patients defibrillated by laypersons after out-of-hospital cardiac arrests and compression-only resuscitation of laypersons.</h4><i>Yoshimoto H, Fukui K, Nishimoto Y, Kuboyama K, ... Sekine K, Hiraide A</i><br /><b>Aim</b><br />We aimed to investigate the effect of compression-only cardiopulmonary resuscitation (CPR) with conventional CPR in patients who were defibrillated by laypersons.<br /><b>Methods</b><br />This is a population-based, nationwide observational study. Adult and children who sustained a witnessed out-of-hospital cardiac arrest and defibrillated by laypersons between 2005 to 2019 were identified on the national database. The study used trend analyses, multivariate logistic regression and inverse probability weighting using propensity score to explore changes in one-month survival and survival with a good neurological outcome over time and the influence of compression-only CPR compared to conventional CPR.<br /><b>Results</b><br />In total 11,402 patients defibrillated by laypersons were enrolled in this study. Percentages of compression-only resuscitation increased dramatically and beyond 50% from 2012 (P<0.001). The percentages of cases with favorable resuscitation outcomes also increased annually (P<0.001). By regression analysis, favorable outcomes were associated with recent years, male sex, younger age, and shorter resuscitation start time. In addition, adjusted odds ratio of compression-only CPR to conventional CPR was 1.23 with a 95% confident interval 1.13-1.34. By inverse probability weighting, compression-only CPR was superior to conventional CPR for the favorable outcomes (P<0.001). The adjusted outcomes in each year were better in compression-only resuscitation in most of years. Overall relative risk reduction and number needed to treat for compression-only resuscitation compared to conventional resuscitation were 7.6% and 22.1, respectively.<br /><b>Conclusions</b><br />In Japan, outcomes of out-of-hospital cardiac arrest patients who were defibrillated by laypersons were considerably better in compression-only resuscitation of laypersons every year.<br /><br />Copyright © 2022 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 19 Dec 2022; epub ahead of print</small></div>
Yoshimoto H, Fukui K, Nishimoto Y, Kuboyama K, ... Sekine K, Hiraide A
Resuscitation: 19 Dec 2022; epub ahead of print | PMID: 36549434
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<div><h4>Drones delivering automated external defibrillators: a new strategy to improve the prognosis of out-of-hospital cardiac arrest.</h4><i>Liu X, Yuan Q, Wang G, Bian Y, Xu F, Chen Y</i><br /><b>Background</b><br />Out-of-hospital cardiac arrest (OHCA) is a serious threat to human life and health, characterized by high morbidity and mortality. However, given the limitations of the current emergency medical system (EMS), it is difficult to immediately treat patients who experience OHCA. It is well known that rapid defibrillation after cardiac arrest is essential for improving the survival rate of OHCA, yet automated external defibrillators (AED) are difficult to obtain in a timely manner.<br /><b>Objective</b><br />This review illustrates the feasibility and advantages of AED delivery by drones by surveying current studies on drones, explains that drones are a new strategy in OHCA, and finally proposes novel strategies to address existing problems with drone systems.<br /><b>Results</b><br />The continuous development of drone technology has been beneficial for patients who experience OHCA, as drones have demonstrated powerful capabilities to provide rapid delivery of AED. Drones have great advantages over traditional EMS, and the delivery of AED by drones for patients with OHCA is a new strategy. However, the application of this new strategy in real life still has many challenges.<br /><b>Conclusion</b><br />Drones are promising and innovative tools. Many studies have demonstrated that AED delivery by drones is feasible and cost-effective; however, as a new strategy to improve the survival rate of OHCA patients, there remain problems to be solved. In the future, more in-depth investigations need to be conducted.<br /><br />Copyright © 2022 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 16 Dec 2022; epub ahead of print</small></div>
Liu X, Yuan Q, Wang G, Bian Y, Xu F, Chen Y
Resuscitation: 16 Dec 2022; epub ahead of print | PMID: 36535307
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<div><h4>Characteristics, Therapies, and Outcomes of In-Hospital vs Out-of-Hospital Cardiac Arrest in Patients Presenting to Cardiac Intensive Care Units: From the Critical Care Cardiology Trials Network (CCCTN).</h4><i>Carnicelli AP, Keane R, Brown KM, Loriaux DB, ... Katz JN, Morrow DA</i><br /><b>Background</b><br />Cardiac arrest (CA) is a common reason for admission to the cardiac intensive care unit (CICU), though the relative burden of morbidity, mortality, and resource use between admissions with in-hospital (IH) and out-of-hospital (OH) CA is unknown. We compared characteristics, care patterns, and outcomes of admissions to contemporary CICUs after IHCA or OHCA.<br /><b>Methods</b><br />The Critical Care Cardiology Trials Network is a multicenter network of tertiary CICUs in the US and Canada. Participating centers contributed data from consecutive admissions during 2-month annual snapshots from 2017 to 2021. We analyzed characteristics and outcomes of admissions by IHCA vs OHCA.<br /><b>Results</b><br />We analyzed 2,075 admissions across 29 centers (50.3% IHCA, 49.7% OHCA). Admissions with IHCA were older (median 66 vs 62 years), more commonly had coronary disease (38.3% vs 29.7%), atrial fibrillation (26.7% vs 15.6%), and heart failure (36.3% vs 22.1%), and were less commonly comatose on CICU arrival (34.2% vs 71.7%), p<0.001 for all. IHCA admissions had lower lactate (median 4.3 vs 5.9) but greater utilization of invasive hemodynamics (34.3% vs 23.6%), mechanical circulatory support (28.4% vs 16.8%), and renal replacement therapy (15.5% vs 9.4%); p<0.001 for all. Comatose IHCA patients underwent targeted temperature management less frequently than OHCA patients (63.3% vs 84.9%, p<0.001). IHCA admissions had lower unadjusted CICU (30.8% vs 39.0%, p<0.001) and in-hospital mortality (36.1% vs 44.1%, p<0.001).<br /><b>Conclusion</b><br />Despite a greater burden of comorbidities, CICU admissions after IHCA have lower lactate, greater invasive therapy utilization, and lower crude mortality than admissions after OHCA.<br /><br />Copyright © 2022 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 12 Dec 2022; epub ahead of print</small></div>
Carnicelli AP, Keane R, Brown KM, Loriaux DB, ... Katz JN, Morrow DA
Resuscitation: 12 Dec 2022; epub ahead of print | PMID: 36521683
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<div><h4>Extracorporeal Cardiopulmonary Resuscitation for Cardiac Arrest: An Updated Systematic Review.</h4><i>Holmberg MJ, Granfeldt A, Guerguerian AM, Sandroni C, ... Johannsen CM, Andersen LW</i><br /><b>Objectives</b><br />To provide an updated systematic review on the use of extracorporeal cardiopulmonary resuscitation (ECPR) compared with manual or mechanical cardiopulmonary resuscitation during cardiac arrest.<br /><b>Methods</b><br />This was an update of a systematic review published in 2018. OVID Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched for randomized trials and observational studies between January 1, 2018, and June 21, 2022. The population included adults and children with out-of-hospital or in-hospital cardiac arrest. Two investigators reviewed studies for relevance, extracted data, and assessed bias. The certainty of evidence was evaluated using GRADE.<br /><b>Results</b><br />The search identified 3 trials, 27 observational studies, and 6 cost-effectiveness studies. All trials included adults with out-of-hospital cardiac arrest and were terminated before enrolling the intended number of subjects. One trial found a benefit of ECPR in survival and favorable neurological status, whereas two trials found no statistically significant differences in outcomes. There were 23 observational studies in adults with out-of-hospital cardiac arrest or in combination with in-hospital cardiac arrest, and 4 observational studies in children with in-hospital cardiac arrest. Results of individual studies were inconsistent, although many studies favored ECPR. The risk of bias was intermediate for trials and critical for observational studies. The certainty of evidence was very low to low. Study heterogeneity precluded meta-analyses. The cost-effectiveness varied depending on the setting and the analysis assumptions.<br /><b>Conclusions</b><br />Recent randomized trials suggest potential benefit of ECPR, but the certainty of evidence remains low. It is unclear which patients might benefit from ECPR.<br /><br />Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 12 Dec 2022; epub ahead of print</small></div>
Holmberg MJ, Granfeldt A, Guerguerian AM, Sandroni C, ... Johannsen CM, Andersen LW
Resuscitation: 12 Dec 2022; epub ahead of print | PMID: 36521684
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<div><h4>Outcome of extracorporeal membrane oxygenation use in severe accidental hypothermia with cardiac arrest and circulatory instability: a multicentre, prospective, observational study in Japan (ICE-CRASH study).</h4><i>Takauji S, Hayakawa M, Yamada D, Tian T, ... Nitta K, Sato Y</i><br /><b>Aim</b><br />To elucidate the effectiveness of extracorporeal membrane oxygenation (ECMO) in accidental hypothermia (AH) patients with and without cardiac arrest (CA), including details of complications.<br /><b>Methods</b><br />This study was a multicentre, prospective, observational study of AH in Japan. All adult (aged ≥ 18 years) AH patients with body temperature ≤ 32 °C who presented to the emergency department between December 2019 and March 2022 were included. Among the patients, those with CA or circulatory instability, defined as severe AH, were selected and divided into the ECMO and non-ECMO groups. We compared 28-day survival and favourable neurological outcomes at discharge between the ECMO and non-ECMO groups by adjusting for the patients\' background characteristics using multivariable logistic regression analysis.<br /><b>Results</b><br />Among the 499 patients in this study, 242 patients with severe AH were included in the analysis: 41 in the ECMO group and 201 in the non-ECMO group. Multivariable analysis showed that the ECMO group was significantly associated with better 28-day survival and favourable neurological outcomes at discharge in patients with CA compared to the non-ECMO group (odds ratio [OR] 0.17, 95% confidence interval [CI]: 0.05-0.58, and OR 0.22, 95%CI: 0.06-0.81). However, in patients without CA, ECMO not only did not improve 28-day survival and neurological outcomes, but also decreased the number of event-free days (ICU-, ventilator-, and catecholamine administration-free days) and increased the frequency of bleeding complications.<br /><b>Conclusions</b><br />ECMO improved survival and neurological outcomes in AH patients with CA, but not in AH patients without CA.<br /><br />Copyright © 2022 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 09 Dec 2022; epub ahead of print</small></div>
Abstract
<div><h4>Mechanical chest compression and extracorporeal life support for out-of-hospital cardiac arrest. A 30-month observational study in the metropolitan area of Milan, Italy.</h4><i>Mistraletti G, Lancioni A, Bassi G, Nespoli F, ... Pesenti A, mechCPR-ECLS investigators</i><br /><b>Background</b><br />Return of spontaneous circulation (ROSC) is achieved in 25% of out-of-hospital cardiac arrest (OHCA) patients. Mechanical chest compression (mechCPR) may maintain better perfusion during transport, allowing hospital treatments like extracorporeal circulation life support (ECLS). We aim to assess the effectiveness of a pre-hospital protocol introduction.<br /><b>Methods</b><br />Observational, retrospective study assessing all OHCA patients aged 12-75, with no-flow time <20 minutes in a metropolitan area (Milan, Italy, 2013-2016).<br /><b>Primary outcomes</b><br />ROSC and Cerebral Performance Category score (CPC) ≤2 at hospital discharge. Logistic regressions with multiple comparison adjustments balanced with propensity scores calculated with inverse probability of treatment weighting were performed.<br /><b>Results</b><br />1366 OHCA were analysed; 305 received mechCPR, 1061 manual chest compressions (manCPR), and 108 ECLS. ROSC and CPC ≤2 were associated with low-flow minutes (odds ratio [95% confidence interval] 0.90 [0.88-0.91] and 0.90 [0.87-0.93]), shockable rhythm (2.52 [1.71-3.72] and 10.68 [5.63-20.28]), defibrillations number (1.15 [1.07-1.23] and 1.15 [1.04-1.26]), and mechCPR (1.86 [1.17-2.96] and 2.06 [1.11-3.81]). With resuscitation times >13 minutes, mechCPR achieved more frequently ROSC compared to manCPR. Among ECLS patients, 70% had time exceeding protocol: 8 (7.5%) had CPC ≤2 (half of them with low-flow times between 45 and 90 minutes), 2 (1.9%) survived with severe neurological disabilities, and 13 brain-dead (12.0%) became organ donors.<br /><b>Conclusions</b><br />MechCPR patients achieved ROSC more frequently than manual CPR patients; mechCPR was a crucial factor in an ECLS protocol for refractory OHCA. ECLS offered a chance of survival to patients who would otherwise die.<br /><br />Copyright © 2022. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 08 Dec 2022; epub ahead of print</small></div>
Mistraletti G, Lancioni A, Bassi G, Nespoli F, ... Pesenti A, mechCPR-ECLS investigators
Resuscitation: 08 Dec 2022; epub ahead of print | PMID: 36503025
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<div><h4>The incidence and outcomes of out-of-hospital cardiac arrest in metropolitan versus rural locations: A systematic review and meta-analysis.</h4><i>Smith A, Masters S, Ball S, Finn J</i><br /><b>Background/aims</b><br />Rurality poses a unique challenge to the management of out-of-hospital cardiac arrest (OHCA) when compared to metropolitan (metro) locations. We conducted a systematic review of published literature to understand how OHCA incidence, management and survival outcomes vary between metro and rural areas.<br /><b>Methods</b><br />We included studies comparing the incidence or survival of ambulance attended OHCA in metropolitan and rural areas, from a search of five databases from inception until 9<sup>th</sup> March 2022. The primary outcomes of interest were cumulative incidence and survival (return of spontaneous circulation, survival to hospital discharge (or survival to 30 days)). Meta-analyses of OHCA survival were undertaken.<br /><b>Results</b><br />We identified 28 studies (30 papers- total of 823,253 patients) across 13 countries of origin. The definition of rurality varied markedly. There was no clear difference in OHCA incidence between metro and rural locations. Whilst there was considerable statistical heterogeneity between studies, the likelihood of return of spontaneous circulation on arrival at hospital was lower in rural than metro locations (OR=0.53, 95% CI 0.40, 0.70; I<sup>2</sup>=89%; 5 studies; 90,934 participants), as was survival to hospital discharge/survival to 30 days (OR= 0.52, 95% CI 0.38, 0.71; I<sup>2</sup>=95%; 15 studies; 18,837 participants).<br /><b>Conclusions</b><br />Overall, while incidence did not vary, the odds of OHCA survival to hospital discharge were approximately 50% lower in rural areas compared to metro areas. This suggests an opportunity for improvement in the prehospital management of OHCA within rural locations. This review also highlighted major challenges in standardising the definition of rurality in the context of cardiac arrest research.<br /><br />Copyright © 2022 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 07 Dec 2022; epub ahead of print</small></div>
Smith A, Masters S, Ball S, Finn J
Resuscitation: 07 Dec 2022; epub ahead of print | PMID: 36496107
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<div><h4>Intra-aortic Balloon Pump Use in Out-of-hospital Cardiac Arrest Patients Who Underwent Extracorporeal Cardiopulmonary Resuscitation.</h4><i>Kashiura M, Kishihara Y, Ozawa H, Amagasa S, Yasuda H, Moriya T</i><br /><b>Aim</b><br />To investigate the effect of intra-aortic balloon pump (IABP) use after extracorporeal membrane oxygenation-assisted cardiopulmonary resuscitation (ECPR) on short-term neurological outcomes and survival in patients with out-of-hospital cardiac arrest (OHCA).<br /><b>Methods</b><br />We retrospectively analysed data collected between June 2014 and December 2019 from the Japanese OHCA registry. Adult patients (aged ≥18 years) who underwent ECPR were included. We divided the patients into those who received IABP and those who did not receive IABP. The primary outcome was the 30-day favourable neurological outcomes in survived patients. The secondary outcome was the 30-day survival. We performed propensity score matching (PSM) to adjust for confounding factors after multiple imputations of missing data. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated using logistic regression analysis after PSM to adjust for confounding factors after IABP initiation.<br /><b>Results</b><br />Among 2,135 adult patients who underwent ECPR, 1,173 received IABP. In 842 matched patients, IABP use was associated with survival (aOR, 1.98; 95% CI, 1.39-2.83; p < 0.001). However, IABP use was not significantly associated with the 30-day neurologically favourable outcome in 190 survived patients (aOR, 1.22; 95% CI, 0.79-1.89; p = 0.36).<br /><b>Conclusion</b><br />The use of IABP in patients with OHCA who underwent ECPR was associated with 30-day survival. Among survived patients, there was no significant association between IABP use and 30-day neurological outcome. A further well-designed prospective study is needed.<br /><br />Copyright © 2022 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 05 Dec 2022; epub ahead of print</small></div>
Kashiura M, Kishihara Y, Ozawa H, Amagasa S, Yasuda H, Moriya T
Resuscitation: 05 Dec 2022; epub ahead of print | PMID: 36481238
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<div><h4>Ventilation Rates Measured by Capnography during Out-of-Hospital Cardiac Arrest Resuscitations and their Association with Return of Spontaneous Circulation.</h4><i>Benoit JL, Lakshmanan S, Farmer SJ, Sun Q, ... Tadesse DG, McMullan JT</i><br /><b>Background</b><br />Clinical guidelines for adult out-of-hospital cardiac arrest (OHCA) recommend a ventilation rate of 8-10 per minute yet acknowledge that few data exist to guide recommendations. The goal of this study was to evaluate the utility of continuous capnography to measure ventilation rates and the association with return of spontaneous circulation (ROSC).<br /><b>Methods</b><br />This was a retrospective observational cohort study. We included all OHCA during a two-year period and excluded traumatic and pediatric patients. Ventilations were recorded using non-invasive continuous capnography. Blinded medically trained team members manually annotated all ventilations. Four techniques were used to analyze ventilation rate. The primary outcome was sustained prehospital ROSC. Secondary outcomes were vital status at the end of prehospital care and survival to hospital admission. Univariable and multivariable logistic regression models were constructed.<br /><b>Results</b><br />A total of 790 OHCA were analyzed. Only 386 (49%) had useable capnography data. After applying inclusion and exclusion criteria, the final study cohort was 314 patients. The median ventilation rate per minute was 7 (IQR 5.4-8.5). Only 70 (22%) received a guideline-compliant ventilation rate of 8-10 per minute. Sixty-two (20%) achieved the primary outcome. No statistically significant associations were observed between any of the ventilation parameters and patient outcomes in both univariable and multivariable logistic regression models.<br /><b>Conclusions</b><br />We failed to detect an association between intra-arrest ventilation rates measured by continuous capnography and proximal patient outcomes after OHCA. Capnography has poor reliability as a measure of ventilation rate. Achieving guideline-compliant ventilation rates remains challenging.<br /><br />Copyright © 2022 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 05 Dec 2022; epub ahead of print</small></div>
Benoit JL, Lakshmanan S, Farmer SJ, Sun Q, ... Tadesse DG, McMullan JT
Resuscitation: 05 Dec 2022; epub ahead of print | PMID: 36481240
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<div><h4>The use of 100% compared to 50% oxygen during ineffective experimental cardiopulmonary resuscitation improves brain oxygenation.</h4><i>Nelskylä A, Humaloja J, Litonius E, Pekkarinen P, ... Heinonen JA, Skrifvars MB</i><br /><b>Introduction</b><br />Perfusion pressure and chest compression quality are generally considered key determinants of brain oxygenation during cardiopulmonary resuscitation (CPR) and the impact of oxygen administration is less clear. We compared ventilation with 100% and 50% oxygen during ineffective manual chest compressions and hypothesized that 100% oxygen would improve brain oxygenation.<br /><b>Methods</b><br />Ventricular fibrillation (VF) was induced electrically in anaesthetized pigs and left untreated for 5 minutes, followed by randomization to ineffective manual CPR with ventilation of 50% or 100% oxygen. The first defibrillation was performed 10 minutes after induction of VF, and CPR continued with mechanical chest compressions (LUCAS2™) and defibrillation every 2 minutes until 36 minutes or return of spontaneous circulation (ROSC). Brain oxygenation was measured with near-infrared spectroscopy (rSO<sub>2</sub>) and invasive brain tissue oxygen (PbtO<sub>2</sub>) with a probe (NEUROVENT-PTO, RAUMEDIC) inserted into frontal brain tissue. Cerebral oxygenation was compared between groups with Mann-Whitney U tests and linear mixed models.<br /><b>Results</b><br />Twenty-eight pigs were included in the study: 14 subjects in each group. During ineffective chest compressions relative PbtO<sub>2</sub> was higher in the group ventilated with 100% compared to 50% oxygen (5.2mmHg [1.4-20.5] vs 2.2 [0.8-6.8], p=0.001), but there was no difference in rSO<sub>2</sub> (22% [16-28] vs 18 [15-25], p=0.090). The use of 50% or 100% oxygen showed no difference in relative PbtO<sub>2</sub> (p=1.00) and rSO<sub>2</sub> (p=0.206) during mechanical CPR.<br /><b>Conclusions</b><br />The use of 100% compared to 50% oxygen during ineffective manual CPR improved brain oxygenation measured invasively in brain tissue, but there was no difference in rSO<sub>2.</sub><br /><br />Copyright © 2022. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 02 Dec 2022; epub ahead of print</small></div>
Nelskylä A, Humaloja J, Litonius E, Pekkarinen P, ... Heinonen JA, Skrifvars MB
Resuscitation: 02 Dec 2022; epub ahead of print | PMID: 36470536
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<div><h4>The association of duration of resuscitation and long-term survival and functional outcomes after out-of-hospital cardiac arrest.</h4><i>Chai J, Fordyce CB, Guan M, Humphries K, ... Christenson J, Grunau B</i><br /><b>Aim</b><br />Longer emergency medical system cardiopulmonary-resuscitation-to-return of-spontaneous-circulation (EMS CPR-to-ROSC) interval has been associated with worse hospital discharge outcomes after out-of-hospital cardiac arrest (OHCA). We hypothesized that this association extends post-discharge in hospital survivors. We investigated whether pre-arrest co-morbidities influence the duration of resuscitation.<br /><b>Methods</b><br />We included EMS-treated adult OHCA (January 2009 - December 2016) from British Columbia Cardiac Arrest Registry linked to provincial databases. Pre-OHCA characteristics were compared by ≤ 10, 10-20, and >20 minute interval categories. Outcomes included survival and functional outcomes at hospital discharge and 1- and 3-year survival. We examined the relationship between CPR-to-ROSC intervals and survival using Kaplan-Meier. We examined the relationship between the CPR-to-ROSC interval (continuous variable) with all outcomes using regression models.<br /><b>Results</b><br />Among 10,241 OHCA, 4604 (45%) achieved ROSC, with a median CPR-to-ROSC interval of 15.5 (IQR 9.0- 22.9) minutes. Diabetes, chronic kidney disease, and prior myocardial infarction were associated with longer CPR-to-ROSC intervals. 1245 (12.2%) survived to hospital discharge. Among hospital survivors, Kaplan-Meier survival at 1- and 3- years were 92% [95% CI 90-93%] and 84% [95% CI 82-86%] respectively; survival curves stratified by CPR-to-ROSC intervals were not statistically different. Longer CPR-to-ROSC interval was non-linearly associated with lower survival and functional outcomes at hospital discharge but not with post-discharge outcomes <br /><b>Conclusion:</b><br/>Longer CPR-to-ROSC interval was associated with lower survival at hospital discharge and was influenced by pre-arrest co-morbidities. However, these intervals were not associated with long-term survival or functional outcome among hospital survivors, suggesting early risk of longer CPR-to-ROSC intervals does not persist.<br /><br />Copyright © 2022 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 29 Nov 2022; epub ahead of print</small></div>
Chai J, Fordyce CB, Guan M, Humphries K, ... Christenson J, Grunau B
Resuscitation: 29 Nov 2022; epub ahead of print | PMID: 36460196
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<div><h4>Does time heal fatigue, psychological, cognitive and disability problems in people who experience an out-of-hospital cardiac arrest? Results from the DANCAS survey study.</h4><i>Joshi VL, Hermann Tang L, Broby Mikkelsen T, Feldbæk Nielsen J, ... Hassager C, Zwisler AD</i><br /><b>Aims</b><br />Out-of-hospital cardiac arrest (OHCA) survivors may suffer short-term fatigue, psychological, cognitive and disability problems, but we lack information on the proportion of survivors with these problems in the long-term. Hence, we investigated these problems in survivors 1-5 years post-OHCA and whether the results are different at different time points post-OHCA.<br /><b>Methods</b><br />All adults who survived an OHCA in Denmark from 2016 to 2019 were identified using the Danish Cardiac Arrest Registry and invited to participate in a survey between October 2020 and March 2021. The survey included the Modified Fatigue Impact Scale, Hospital Anxiety and Depression Scale, \"Two simple questions\" (everyday activities and mental recovery), and the 12-item World Health Organisation Disability Assessment Schedule 2.0. To investigate results at different time points, survivors were divided into four time-groups (12-24, 25-36, 37-48 and 49-56 months post-OHCA). Differences between time-groups were determined using the Kruskall-Wallis test for the mean scores and Chi-square test for the proportion of survivors with symptoms.<br /><b>Results</b><br />Total eligible survey population was 2116, of which 1258 survivors (60%) responded. Overall, 29% of survivors reported fatigue, 20% anxiety, 15% depression, and 27% disability. When survivors were sub-divided by time since OHCA, no significant difference was found on either means scores or proportion between time groups (p=0.28 to 0.88).<br /><b>Conclusion</b><br />Up to a third of survivors report fatigue, anxiety, depression, reduced mental function and disability 1-5 years after OHCA. This proportion is the same regardless of how much time has passed supporting early screening and tailored post-OHCA interventions to help survivors adapt to their new situation.<br /><br />Copyright © 2022. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 28 Nov 2022; epub ahead of print</small></div>
Joshi VL, Hermann Tang L, Broby Mikkelsen T, Feldbæk Nielsen J, ... Hassager C, Zwisler AD
Resuscitation: 28 Nov 2022; epub ahead of print | PMID: 36455704
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<div><h4>Acute Lung Injury and Recovery in Patients with Refractory VT/VF Cardiac Arrest Treated with Prolonged CPR and Veno-Arterial Extracorporeal Membrane Oxygenation.</h4><i>Gutierrez A, Kalra R, Elliott AM, Marquez A, Yannopoulos D, Bartos JA</i><br /><b>Aim</b><br />Describe the lung injury patterns among patients presenting with refractory ventricular tachycardia/ventricular fibrillation out-of-hospital cardiac arrest (VT/VF OHCA) supported with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) facilitated resuscitation.<br /><b>Methods</b><br />In this retrospective single-center cohort study including VT/VF OHCA patients supported with VA ECMO, we compared OHCA characteristics, post-arrest computed tomography (CT) scans, ventilator parameters, and other lung-related pathology between survivors, patients who developed brain death, and those with other causes of death.<br /><b>Results</b><br />Among 138 patients, 48/138 (34.8%) survived, 31/138 (22.4%) developed brain death, and 59/138 (42.7%) died of other causes. Successful extubation was achieved in 39/138 (28%) with a median time to extubation of 8.0 days (6.0, 11.0) in those who survived. Tracheostomy was required in 15/48 (31.3%) survivors. Chest CT obtained on all patients showed lung injury in at least one lung area in 124/135 (91.8%) patients, predominantly in the dependent posterior areas. There was no association between the number of affected areas and survival. Lung compliance was low on admission [26 (19,33) ml/cmH<sub>2</sub>0], improved throughout hospitalization (p=0.03), and recovered faster in survivors compared to those who died (p<0.001). VA-ECMO allowed the use of lung-protective ventilation while maintaining normalized PaO<sub>2</sub> and PaCO<sub>2</sub>. Patients treated with V-A ECMO and either IABP or Impella had lower pulmonary compliance and more affected areas on their CT compared to those treated with V-A ECMO alone.<br /><b>Conclusions</b><br />Lung injury is common among patients with refractory VT/VF OHCA requiring V-A ECMO, but imaging severity is not associated with survival. Reductions in lung compliance accompany post-arrest lung injury while compliance recovery is associated with survival.<br /><br />Published by Elsevier B.V.<br /><br /><small>Resuscitation: 25 Nov 2022; epub ahead of print</small></div>
Gutierrez A, Kalra R, Elliott AM, Marquez A, Yannopoulos D, Bartos JA
Resuscitation: 25 Nov 2022; epub ahead of print | PMID: 36442595
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<div><h4>Time in Therapeutic Range for Targeted Temperature Management and Outcomes Following Out-of-Hospital Cardiac Arrest.</h4><i>Wheelock KM, Chan PS, Chen L, de Lemos JA, ... Girotra S, Khera R</i><br /><b>Objective</b><br />For comatose survivors of out-of-hospital cardiac arrest (OHCA), current guidelines recommend targeted temperature management (TTM) with a goal temperature of 32°C - 36°C for at least 24 hours. We examined adherence to temperature targets, quantified as time-in-therapeutic range (TTR), and association of TTR with survival and neurologic outcomes.<br /><b>Methods</b><br />We conducted a retrospective cohort study of the Resuscitation Outcomes Consortium-Continuous Chest Compressions trial, including adults with OHCA who underwent TTM for >12 hours. We imputed continuous temperatures between consecutive temperature measurements using the linear interpolation method and calculated TTR for multiple target temperatures. The association of TTR with survival to hospital discharge and favorable neurological outcome was evaluated using hierarchical regression models.<br /><b>Main results</b><br />Among 2,637 patients (mean age 62.3 years, 29.9% female), the median duration of TTR for TTM between 32°C - 36°C was 23 (IQR: 21-24) hours with a median time outside therapeutic range of 0.9 (IQR: 0.0 - 4.2) hours. In risk-adjusted analyses, there was no association of TTR of 32°C - 36°C with overall survival (OR 1.00 [95% CI, 0.90 - 1.10]) or favorable neurologic outcome (1.02 [95% CI, 0.90 - 1.14]). However, in assessments of TTR 33°C - 36°C, there was a significant association with favorable neurologic survival (OR 1.12 [1.01 - 1.25]) but not overall survival (OR 1.04 [0.94 - 1.15]).<br /><b>Conclusions</b><br />Among patients with OHCA who underwent TTM, we found variability in adherence to guideline-recommended treatment targets. Higher TTR was not associated with overall survival, but for certain temperature thresholds, TTR was associated with favorable neurologic outcome.<br /><br />Copyright © 2022. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 25 Nov 2022; epub ahead of print</small></div>
Wheelock KM, Chan PS, Chen L, de Lemos JA, ... Girotra S, Khera R
Resuscitation: 25 Nov 2022; epub ahead of print | PMID: 36442596
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<div><h4>External validation of the TiPS65 score for predicting good neurological outcomes in patients with out-of-hospital cardiac arrest treated with extracorporeal cardiopulmonary resuscitation.</h4><i>Makino Y, Okada Y, Irisawa T, Yamada T, ... Kitamura T, Iwami T</i><br /><b>Aim</b><br />Estimating prognosis of patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) is essential for selecting candidates. The TiPS65 score can predict neurological outcomes of patients with out-of-hospital cardiac arrest (OHCA) treated with ECPR. We aimed to perform an external validation of this score.<br /><b>Methods</b><br />Data from the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest registry, a multicentred, nationwide, prospectively registered database, were analysed. All adult patients with OHCA and shockable rhythm and treated with ECPR between January 2018 to December 2019 were included. In the TiPS65 score, age, call-to-hospital arrival time, initial cardiac rhythm at hospital arrival, and initial pH value were used as predictors. The primary outcome was 30-day survival with favourable neurological outcomes (Cerebral Performance Category 1 or 2). Discrimination, using the C-statistic, and predictive performances of each score, such as sensitivity and specificity, were investigated.<br /><b>Results</b><br />Of 590 included patients (517 [81.6%] men; median [interquartile range] age, 60 [50-69] years), 64 (10.8%) reported favourable neurological outcomes. The C-statistic of the TiPS65 score was 0.729 (95% confidence interval (CI): 0.672-0.786). When the cut-off of TiPS65 score was set to >1, the sensitivity and specificity were 0.906 (95%CI: 0.807-0.965) and 0.430 (95%CI: 0.387-0.473), respectively; conversely, when the cut-off was set to >3, they were 0.172 (95%CI: 0.089-0.287) and 0.971 (95%CI: 0.953-0.984), respectively.<br /><b>Conclusions</b><br />The TiPS65 score shows reasonable discrimination and predictive performances. This score can be supportive in the decision-making process for the selection of eligible patients for ECPR in clinical settings.<br /><br />Copyright © 2022. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 25 Nov 2022; epub ahead of print</small></div>
Makino Y, Okada Y, Irisawa T, Yamada T, ... Kitamura T, Iwami T
Resuscitation: 25 Nov 2022; epub ahead of print | PMID: 36442597
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<div><h4>Development of the epidemiology and outcomes of out-of-hospital cardiac arrest using data from the German Resuscitation Register over a 15-year period (EpiCPR study).</h4><i>Hubar I, Fischer M, Monaco T, Gräsner JT, Westenfeld R, Bernhard M</i><br /><b>Background</b><br />Sudden cardiac arrest is a relevant problem with a significant number of deaths in Europe.<br /><b>Aim</b><br />Using data from the German Resuscitation Register (GRR), we examined changes in epidemiology and therapeutic interventions over a 15-year period in order to identify key factors contributing to favourable outcome in out-of-hospital cardiac arrest (OHCA) patients.<br /><b>Methods</b><br />GRR data were analysed in 5-year periods (2006-2010 vs. 2011-2015 vs. 2016-2020) representing changes in the European Resuscitation Council (ERC) guidelines. Group comparison of OHCA patients was made for epidemiological and resuscitation-associated factors. Endpoints included 30-day survival and hospital discharge with a good neurological outcome (CPC 1,2). Matched-pair analysis compared outcomes, and multivariate binary logistic regression analysis identified variables with effects on survival.<br /><b>Results</b><br />A total of 42,997 GRR patients were studied (2006-2010: n=3,471, 2011-2015: n=16,122, 2016-2020: n=23,404). Proportion of patients over 80 years, use of intraosseous (IO) access and supraglottic airway devices, rate of bystander CPR, and the proportion of telephone CPR increased over the study period. The 30-day survival, and hospital discharge rates with CPC1/2 were unchanged. After adjusting cohorts using matched pairs, a higher CPC1,2 rate was observed (8.8 vs. 10.2%, p<0.03). Logistic regression analysis showed that IO and SAD had an unfavourable impact on outcome.<br /><b>Conclusion</b><br />Despite a significant increase in bystander and telephone CPR rates, no improvement in 30-day survival and hospital discharge rate with CPC1,2 was observed. Initial rhythm (VF/VT), cardiac and hypoxic cause of CA, bystander CPR and IV access were identified as factors associated with a favourable neurological outcome.<br /><br />Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 21 Nov 2022; epub ahead of print</small></div>
Hubar I, Fischer M, Monaco T, Gräsner JT, Westenfeld R, Bernhard M
Resuscitation: 21 Nov 2022; epub ahead of print | PMID: 36423737
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Abstract
<div><h4>Outcomes Associated with Intra-Arrest Hyperoxaemia in Out-of-Hospital Cardiac Arrest: A Registry-Based Cohort Study.</h4><i>Izawa J, Komukai S, Nishioka N, Kiguchi T, Kitamura T, Iwami T</i><br /><b>Background</b><br />An association between post-arrest hyperoxaemia and worse outcomes has been reported for out-of-hospital cardiac arrest (OHCA) patients, but little is known about the relationship between intra-arrest hyperoxaemia and clinically relevant outcomes. This study aimed to investigate the association between intra-arrest hyperoxaemia and outcomes for OHCA patients.<br /><b>Methods</b><br />This was an observational study using a registry database of OHCA cases that occurred between 2014 and 2017 in Japan. We included adult, non-traumatic OHCA patients who were in cardiac arrest at the time of hospital arrival and for whom partial pressure of arterial oxygen (PaO<sub>2</sub>) levels was measured during resuscitation. Main exposure was intra-arrest PaO<sub>2</sub> level, which was divided into three categories: hypoxaemia, PaO<sub>2</sub> <60 mmHg; normoxaemia, 60-300; or hyperoxaemia, ≥300. Primary outcome was favourable functional survival at one month or at hospital discharge. Multivariable logistic regression was performed to adjust for clinically relevant variables.<br /><b>Results</b><br />Among 16,013 patients who met the eligibility criteria, the proportion of favourable functional survival increased as the PaO<sub>2</sub> categories became higher: 0.5% (57/11,484) in hypoxaemia, 1.1% (48/4243) in normoxaemia, and 5.2% (15/286) in hyperoxaemia (p-value for trend <0.001). Higher PaO<sub>2</sub> categories were associated with favourable functional survival and the adjusted odds ratios increased as the PaO<sub>2</sub> categories became higher: 2.09 (95% CI: 1.39-3.14) in normoxaemia and 5.04 (95% CI: 2.62-9.70) in hyperoxaemia when compared to hypoxaemia as a reference.<br /><b>Conclusion</b><br />In this observational study of adult OHCA patients, intra-arrest normoxaemia and hyperoxaemia were associated with better functional survival, compared to hypoxaemia.<br /><br />Copyright © 2022 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 18 Nov 2022; epub ahead of print</small></div>
Izawa J, Komukai S, Nishioka N, Kiguchi T, Kitamura T, Iwami T
Resuscitation: 18 Nov 2022; epub ahead of print | PMID: 36410603
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Abstract
<div><h4>Evaluating Novel Methods of Outcome Assessment following Cardiac Arrest.</h4><i>Krampe N, Case N, Rittenberger JC, Condle JP, ... Elmer J, University of Pittsburgh Post-Cardiac Arrest Service</i><br /><b>Introduction</b><br />We compared novel methods of long-term follow-up after resuscitation from cardiac arrest to a query of the National Death Index (NDI). We hypothesized use of the electronic health record (EHR), and internet-based sources would have high sensitivity for identifying decedents identified by the NDI.<br /><b>Methods</b><br />We performed a retrospective study including patients treated after cardiac arrest at a single academic center from 2010 to 2018. We evaluated two novel methods to ascertain long-term survival and modified Rankin Scale (mRS): 1) a structured chart review of our health system\'s EHR; and 2) an internet-based search of: a) local newspapers, b) Ancestry.com, c) Facebook, d) Twitter, e) Instagram, and f) Google. If a patient was not reported deceased by any source, we considered them to be alive. We compared results of these novel methods to the NDI to calculate sensitivity. We queried the NDI for 200 in-hospital decedents to evaluate sensitivity against a true criterion standard.<br /><b>Results</b><br />We included 1,097 patients, 897 (82%) alive at discharge and 200 known decedents (18%). NDI identified 197/200 (99%) of known decedents. The EHR and local newspapers had highest sensitivity compared to the NDI (87% and 86% sensitivity, respectively). Online sources identified 10 likely decedents not identified by the NDI. Functional status estimated from EHR, and internet sources at follow up agreed in 38% of alive patients.<br /><b>Conclusions</b><br />Novel methods of outcome assessment are an alternative to NDI for determining patients\' vital status. These methods are less reliable for estimating functional status.<br /><br />Copyright © 2022 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 18 Nov 2022; epub ahead of print</small></div>
Krampe N, Case N, Rittenberger JC, Condle JP, ... Elmer J, University of Pittsburgh Post-Cardiac Arrest Service
Resuscitation: 18 Nov 2022; epub ahead of print | PMID: 36410604
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Abstract
<div><h4>Anteroposterior pacer pad position is better than anterolateral for transcutaneous cardiac pacing.</h4><i>Moayedi S, Patel P, Brady N, Witting M, Dickfeld TL</i><br /><b>Introduction</b><br />Transcutaneous cardiac pacing (TCP) is a lifesaving procedure for patients with certain types of unstable bradycardia. We aimed to assess the difference in the pacing thresholds between the anteroposterior (AP) and anterolateral (AL) pacer pad positions. The second aim was to characterize the severity of chest wall muscle contractions during TCP.<br /><b>Methods</b><br />In this prospective crossover trial, we enrolled patients presenting to the electrophysiology laboratory for elective cardioversion. After successful cardioversion, sedated participants were sequentially paced in both positions. The study procedure concluded after successful capture or inability to achieve capture by 140 mA (the pacer\'s maximum output) in both positions. Pacing thresholds were compared between positions, using a student\'s paired t-test, assigning a value of 141 mA to any trials with non-capture.<br /><b>Results</b><br />Forty-one patients were screened; 20 were enrolled in the study. Seven participants were excluded from the paired analysis (three were prevented from pacing in the second position at the anesthesiologist\'s discretion, and 4 did not capture in either position). The study population consisted of 14 men and 6 women with a median age of 65 years. The mean pacing threshold was 33 mA lower (P=0.001, 95% CI 20-45) in the AP (93 mA) versus the AL (126 mA) position. The median contraction severity score was 3 in the AL position versus 4 in the AP position (P=0.005).<br /><b>Conclusions</b><br />Placing pacer pads in the AP position requires less energy to capture. Major resuscitation guidelines may favor the AP position for TCP.<br /><br />Copyright © 2022 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 18 Nov 2022; epub ahead of print</small></div>
Moayedi S, Patel P, Brady N, Witting M, Dickfeld TL
Resuscitation: 18 Nov 2022; epub ahead of print | PMID: 36410605
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Abstract
<div><h4>Effect of Calcium in Patients with Pulseless Electrical Activity and Electrocardiographic Characteristics Potentially Associated with Hyperkalemia and Ischemia-Sub-study of the Calcium for Out-of-hospital Cardiac Arrest (COCA) trial.</h4><i>Fink Vallentin M, Ling Povlsen A, Granfeldt A, Juhl Terkelsen C, Andersen LW</i><br /><b>Objective</b><br />The Calcium for Out-of-hospital Cardiac Arrest (COCA) trial was recently conducted and published. This pre-planned sub-study evaluated the effect of calcium in patients with pulseless electrical activity (PEA) including subgroup analyses based on electrocardiographic characteristics potentially associated with hyperkalemia and ischemia.<br /><b>Methods</b><br />Patients aged ≥ 18 years were included if they had a non-traumatic out-of-hospital cardiac arrest and received adrenaline. The trial drug consisted of calcium chloride (5 mmol) or saline placebo given after the first, and again after the second, dose of adrenaline for a maximum of two doses. This sub-study analyzed patients with PEA as their last known rhythm prior to receiving the trial drug. Outcomes were return of spontaneous circulation and survival at 30 days.<br /><b>Results</b><br />104 patients were analyzed. In the calcium group, 9 patients (20%) achieved return of spontaneous circulation vs. 23 patients (39%) in the placebo group (risk ratio 0.51; 95%CI 0.26, 1.00). Subgroup analyses based on electrocardiographic characteristics potentially associated with hyperkalemia and ischemia showed similar results. At 30 days, 1 patient (2.2%) was alive in the calcium group while 8 patients (13.6%) were alive in the placebo group (risk ratio 0.16; 95%CI 0.02, 1.26).<br /><b>Conclusion</b><br />In adults with out-of-hospital cardiac arrest presenting with PEA, effect estimates suggested harm of calcium administration as compared to placebo but with wide confidence intervals. Results were consistent for electrocardiographic characteristics potentially associated with hyperkalemia and ischemia. The results do not support calcium administration based strictly on electrocardiographic findings seen during out-of-hospital cardiac arrest.<br /><br />Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 17 Nov 2022; epub ahead of print</small></div>
Abstract
<div><h4>Sodium Bicarbonate Administration is Associated with Improved Survival in Asystolic and PEA Out-of-Hospital Cardiac Arrest.</h4><i>Niederberger SM, Crowe RP, Salcido DD, Menegazzi JJ</i><br /><b>Background</b><br />Sodium bicarbonate (\"bicarb\") administration in out-of-hospital cardiac arrest (OHCA) is intended to counteract acidosis, although there is limited clinical evidence to support its routine administration. We sought to analyze the association of bicarb with resuscitation outcomes in non-traumatic OHCA.<br /><b>Methods</b><br />Records were obtained from the 2019-2020 ESO Data Collaborative prehospital electronic health record database, spanning 1,322 agencies in 50 states. OHCAs with resuscitations lasting 5-40 minutes were stratified by presenting ECG rhythm (VF/VT, pulseless electrical activity (PEA), asystole) for analysis. The outcomes of any prehospital ROSC and survival to discharge were compared by bicarb status using propensity score matching and logistic regressions with/without adjustment.<br /><b>Results</b><br />We analyzed 23,567 records, 6,663 (28.3%) of which included bicarb administration. Most patients presented in asystole (67.4%), followed by PEA (16.6%), and VF/VT (15.1%). In the propensity-matched cohort, ROSC was higher in the bicarb group for the asystole group (bicarb 10.6% vs control 8.8%; p=0.013), without differences in the PEA or VF/VT groups. Survival was higher in the bicarb group for asystole (bicarb 3.3% vs control 2.4%; p=0.020) and for PEA (bicarb 8.1% vs control 5.4%; p=0.034), without differences in the VF/VT group. These results were consistent across adjusted/unadjusted logistic regression analyses: bicarb was associated with ROSC and survival in asystole [uOR (95% CI): ROSC 1.23 (1.04-1.44), survival 1.40 (1.05-1.87)] and with survival in PEA (1.54 (1.03-2.31).<br /><b>Conclusions</b><br />Bicarb was associated with survival in non-shockable rhythms and ROSC in asystole. Findings from this observational study should be corroborated with prospective randomized work.<br /><br />Copyright © 2022 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 17 Nov 2022; epub ahead of print</small></div>
Niederberger SM, Crowe RP, Salcido DD, Menegazzi JJ
Resuscitation: 17 Nov 2022; epub ahead of print | PMID: 36403821
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<div><h4>The amount of calcium in calcium chloride - is there a need to clarify emergency treatment of hyperkalaemia algorithm?</h4><i>Mateusz P, Jerzy J, Jarosław W</i><br /><AbstractText>European Resuscitation Council (ERC) and American Heart Association (AHA) guidelines emphasize a rapid administration of calcium chloride (10ml 10% CaCl2) to protect the myocardium in the hyperkalaemia algorithm. However, calcium chloride preparations available in European markets vary from country to country. In our opinion, the drug dose recommended in the guidelines should not raise questions about the volume and amount of calcium in the intravenous supply and should be unambiguous to minimize the risk of error. Calcium dose should be given in terms of mmol/L or mEq or mg of calcium ions.</AbstractText><br /><br />Copyright © 2022 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 17 Nov 2022; epub ahead of print</small></div>
Mateusz P, Jerzy J, Jarosław W
Resuscitation: 17 Nov 2022; epub ahead of print | PMID: 36403822
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<div><h4>Specific theorical and practical education on mechanical chest compression during Advanced Life Support training courses - results from a local experience.</h4><i>D\'Agostino F, Eugenio Agrò F, Fusco P, Ferri C, Ristagno G, training group collaborators</i><br /><AbstractText>Specific training modules focusing on mechanical chest compression and device use might be considered in a structured manner during the standard advanced life support (ALS) courses. The aim of this study was to evaluate the impact of a specific brief 15 min training on the use of a specific mechanical CPR device during Advanced Cardiac Life Support courses on its correct use and on attendees\' satisfaction.</AbstractText><br /><br />Copyright © 2022 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 14 Nov 2022; epub ahead of print</small></div>
D'Agostino F, Eugenio Agrò F, Fusco P, Ferri C, Ristagno G, training group collaborators
Resuscitation: 14 Nov 2022; epub ahead of print | PMID: 36396010
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<div><h4>Benign EEG for prognostication of favorable outcome after cardiac arrest: a reappraisal.</h4><i>Fenter H, Ben-Hamouda N, Novy J, Rossetti AO</i><br /><b>Aim</b><br />The current EEG role for prognostication after cardiac arrest (CA) essentially aims at reliably identifying patients with poor prognosis (\"highly malignant\" patterns, defined by Westhall et al. in 2014). Conversely, \"benign EEGs\", defined by the absence of elements of \"highly malignant\" and \"malignant\" categories, has limited sensitivity in detecting good prognosis. We postulate that a less stringent \"benign EEG\" definition would improve sensitivity to detect patients with favorable outcomes.<br /><b>Methods</b><br />Retrospectively assessing our registry of unconscious adults after CA (1.2018 - 8.2021), we scored EEGs within 72h after CA using a modified \"benign EEG\" classification (allowing discontinuity, low-voltage, or reversed anterio-posterior amplitude development), versus Westhall\'s \"benign EEG\" classification (not allowing the former items). We compared predictive performances towards good outcome (Cerebral Performance Category 1-2 at 3 months), using 2x2 tables (and binomial 95% confidence intervals) and proportions comparisons.<br /><b>Results</b><br />Among 381 patients (mean age 61.9±15.4 years, 104 (27.2%) females, 240 (62.9%) having cardiac origin), the modified \"benign EEG\" definition identified a higher number of patients with good outcome (230, 54.3%). Sensitivity of the modified EEG definition was 0.97 (95% CI: 0.92-0.97) vs 0.71 (95% CI: 0.62-0.78) (p<0.001). Positive predictive values (PPV) were 0.53 (95% CI: 0.46-0.59) versus 0.59 (95% CI: 0.51-0.67; p=0.17). Similar statistics were observed at definite recording times, and for survivors.<br /><b>Discussion</b><br />The modified \"benign EEG\" classification demonstrated a markedly higher sensitivity towards favorable outcome, with minor impact on PPV. Adaptation of \"benign EEG\" criteria may improve efficient identification of patients who may reach a good outcome.<br /><br />Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 14 Nov 2022; epub ahead of print</small></div>
Fenter H, Ben-Hamouda N, Novy J, Rossetti AO
Resuscitation: 14 Nov 2022; epub ahead of print | PMID: 36396011
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<div><h4>Performance of the Medical Priority Dispatch System in Correctly Classifying Out-of-Hospital Cardiac Arrests as Appropriate for Resuscitation.</h4><i>Yap J, Helmer J, Gessaroli M, Hutton J, ... Christenson J, Grunau B</i><br /><b>Background</b><br />Emergency dispatch centres receive emergency calls and assign resources. Out-of-hospital cardiac arrests (OHCA) can be classified as appropriate (requiring emergent response) or inappropriate (requiring non-emergent response) for resuscitation. We sought to determine system accuracy in emergency medical services (EMS) OHCA response allocation.<br /><b>Methods</b><br />We analyzed EMS-assessed non-traumatic OHCA records from the British Columbia (BC) Cardiac Arrest registry (January 1, 2019-June 1, 2021), excluding EMS-witnessed cases. In BC the \"Medical Priority Dispatch System\" is used. We classified EMS dispatch as \"emergent\" or \"non-emergent\" and compared to the gold standard of whether EMS personnel decided treatment was appropriate upon scene arrival. We calculated sensitivity, specificity, and positive and negative predictive values (PPV, NPV), with 95% CI\'s.<br /><b>Results</b><br />Of 15,371 non-traumatic OHCAs, the median age was 65 (inter quartile range 51-78), and 4834 (31%) were women; 7152 (47%) were EMS-treated, of whom 651 (9.1%) survived). Among EMS-treated cases 6923/7152 had an emergent response (sensitivity=97%, 95% CI 96-97) and among EMS-untreated cases 3951/8219 had a non-emergent response (specificity=48%, 95% CI, 47 to 49). Among cases with emergent dispatch, 6923/11191 were EMS-treated (PPV=62%, 95% CI 61-62), and among those with non-emergent dispatch, 3951/4180 were EMS-untreated (NPV=95%, 95% CI 94-95); 229/4180 (5.5%) with a non-emergent dispatch were treated by EMS.<br /><b>Conclusion</b><br />The dispatch system in BC has a high sensitivity and moderate specificity in sending the appropriate responses for OHCAs deemed appropriate for treatment by paramedics. Future research may address strategies to increase system specificity, and decrease the incidence of non-emergent dispatch to EMS-treated cases.<br /><br />Copyright © 2022 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 11 Nov 2022; epub ahead of print</small></div>
Yap J, Helmer J, Gessaroli M, Hutton J, ... Christenson J, Grunau B
Resuscitation: 11 Nov 2022; epub ahead of print | PMID: 36375652
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<div><h4>Do changes in SSEP amplitude over time predict the outcome of comatose survivors of cardiac arrest?</h4><i>Scarpino M, Lolli F, Lanzo G, Carrai R, ... Sandroni C, ProNeCA Study Group</i><br /><b>Aim</b><br />To assess if the amplitude of the N20 wave (N20Amp) of somatosensory evoked potentials (SSEPs) changes between 12-24h and 72h from the return of spontaneous circulation (ROSC) after cardiac arrest and if an N20Amp decrease predicts poor neurological outcome (CPC 3-5) at six months. Setting retrospective analysis of the ProNeCA multicentre prognostication study dataset. (NCT03849911).<br /><b>Methods</b><br />In adult comatose cardiac arrest survivors whose SSEPs were recorded at both 12-24h and 72h after ROSC, we measured the median N20Amp at each timepoint and the individual change in N20Amp across the two timepoints. We identified their cutoffs for predicting poor outcome with 0% false positive rate (FPR) and compared their sensitivities.<br /><b>Results</b><br />We included 236 patients. The median [IQR] N20Amp increased from 1.90 [0.78-4.22] µV to 2.86 [1.52-5.10] µV between 12-24h and 72h (p = 0.0019). The N20Amp cutoff for 0% FPR increased from 0.6 µV at 12-24h to 1.23 µV at 72h, and its sensitivity increased from 56[48-64]% to 71[63-77]%. Between 12-24h and 72h, an N20Amp decrease >53% predicted poor outcome with 0[0-5]% FPR and 26[19-35]% sensitivity. Its combination with an N20Amp<1.23µV at 72h increased sensitivity by 1% to 72[64-79]%.<br /><b>Conclusion</b><br />In comatose cardiac arrest survivors, the median N20Amp and its cutoff for predicting poor neurological outcome increase between 12-24 and 72h after ROSC. An N20Amp decrease greater than 53% between these two timepoints predicts poor outcome with 0% FPR, confirming the unfavourable prognostic signal of a low N20Amp at 72h.<br /><br />Copyright © 2022 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 11 Nov 2022; epub ahead of print</small></div>
Scarpino M, Lolli F, Lanzo G, Carrai R, ... Sandroni C, ProNeCA Study Group
Resuscitation: 11 Nov 2022; epub ahead of print | PMID: 36375653
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This program is still in alpha version.