Journal: Resuscitation

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Abstract

Interobserver Variability Among Experienced Electrocardiogram Readers To Diagnose Acute Thrombotic Coronary Occlusion In Patients with Out of Hospital Cardiac Arrest: Impact of Metabolic Milieu and Angiographic Culprit.

Sharma A, Miranda DF, Rodin H, Bart BA, Smith SW, Shroff GR
Objectives
We sought to evaluate interobserver concordance among experienced electrocardiogram (ECG) readers in predicting acute thrombotic coronary occlusion (ATCO) in the context of abnormal metabolic milieu (AMM) following resuscitated out of hospital cardiac arrest (OHCA).
Methods
OHCA patients with initial shockable rhythm who underwent invasive coronary angiography (ICA) were included. AMM was defined as one of: pH < 7.1, lactate > 2 mmol/L, serum potassium < 2.8 or > 6.0 mEq/L. The initial ECG following ROSC but prior to ICA was adjudicated by 2 experienced readers using classic ST elevation myocardial infarction [STEMI] and expanded criteria and their combination to predict ATCO on ICA.
Results
152 consecutive patients (mean age 58 years, 76% male) met inclusion criteria. AMM was present in 77%; and 42% had ATCO on ICA. Sensitivity, specificity, PPV, NPV using classic STEMI criteria were 50%, 98%, 94%, 72% (c-statistic 0.74); whereas for combined (STEMI + expanded) criteria they were 69%, 88%, 81%, 79% respectively (c-statistic 0.79). Inter-observer agreement (kappa) was 0.7 for classic STEMI criteria, and 0.66 for combined criteria. Agreement between readers was consistently higher when ATCO was absent and with NMM (kappa 0.78), but lower in AMM (kappa 0.6).
Conclusions
Despite experienced ECG readers, there was only modest overall concordance in predicting ATCO in the context of resuscitated OHCA. Significant interobserver variations were noted dependent on metabolic milieu and angiographic ATCO. These observations fundamentally question the role of the 12-lead ECG as primary triaging tool for early angiography among patients with OHCA.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 14 Jan 2022; epub ahead of print
Sharma A, Miranda DF, Rodin H, Bart BA, Smith SW, Shroff GR
Resuscitation: 14 Jan 2022; epub ahead of print | PMID: 35041876
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Abstract

Deep learning of early brain imaging to predict post-arrest electroencephalography.

Elmer J, Liu C, Pease M, Arefan D, ... Barot N, Wu S
Introduction
Guidelines recommend use of computerized tomography (CT) and electroencephalography (EEG) in post-arrest prognostication. Strong associations between CT and EEG might obviate the need to acquire both modalities. We quantified these associations via deep learning.
Methods
We performed a single-center, retrospective study including comatose patients hospitalized after cardiac arrest. We extracted brain CT DICOMs, resized and registered each to a standard anatomical atlas, performed skull stripping and windowed images to optimize contrast of the gray-white junction. We classified initial EEG as generalized suppression, other highly pathological findings or benign activity. We extracted clinical information available on presentation from our prospective registry. We trained three machine learning (ML) models to predict EEG from clinical covariates. We used three state-of-the-art approaches to build multi-headed deep learning models using similar model architectures. Finally, we combined the best performing clinical and imaging models. We evaluated discrimination in test sets.
Results
We included 500 patients, of whom 218 (44%) had benign EEG findings, 135 (27%) showed generalized suppression and 147 (29%) had other highly pathological findings that were most commonly (93%) burst suppression with identical bursts. Clinical ML models had moderate discrimination (test set AUCs 0.73 - 0.80). Image-based deep learning performed worse (test set AUCs 0.51 - 0.69), particularly discriminating benign from highly pathological findings. Adding image-based deep learning to clinical models improved prediction of generalized suppression due to accurate detection of severe cerebral edema.
Discussion
CT and EEG provide complementary information about post-arrest brain injury. Our results do not support selective acquisition of only one of these modalities, except in the most severely injured patients.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 14 Jan 2022; epub ahead of print
Elmer J, Liu C, Pease M, Arefan D, ... Barot N, Wu S
Resuscitation: 14 Jan 2022; epub ahead of print | PMID: 35041875
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Abstract

Utilization and cost-effectiveness of school and community center AED deployment models in Canadian cities.

Danny Liang L, C Y Chan T, Benjamin Leung KH, Scheuermeyer F, ... Al Assil R, Grunau B
Background
The optimal locations and cost-effectiveness of placing automated external defibrillators(AEDs) for out-of-hospital cardiac arrest(OHCAs) in urban residential neighbourhoods are unclear.
Methods
We used prospectively collected data from 2016 to 2018 from the British Columbia OHCA Registry to examine the utilization and cost-effectiveness of hypothetical AED deployment in municipalities with a population of over 100 000. We geo-plotted OHCA events using seven hypothetical deployment models where AEDs were placed at the exteriors of public schools and community centers and fetched by bystanders. We calculated the \"radius of effectiveness\" around each AED within which it could be retrieved and applied to an individual prior to EMS arrival, comparing automobile and pedestrian-based retrieval modes. For each deployment model, we estimated the number of OHCAs within the \"radius of effectiveness\".
Results
We included 4017 OHCAs from ten urban municipalities. The estimated radius of effectiveness around each AED was 625 m for automobile and 240m for pedestrian retrieval. With AEDs placed outside each school and community center, 2567(64%) and 605(15%) of OHCAs fell within the radii of effectiveness for automobile and pedestrian retrieval, respectively. For each AED, there was an average of 1.20-2.66 and 0.25-0.61 in-range OHCAs per year for automobile retrieval and pedestrian retrieval, respectively, depending on the deployment model. All of our proposed surpassed the cost-effectiveness threshold of 0.125 OHCA/AED/year provided >5.3-11.6% in-range AEDs were brought-to-scene.
Conclusions
The systematic deployment of AEDs at schools and community centers in urban neighbourhoods may result in increased application and be a cost-effective public health intervention.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 10 Jan 2022; epub ahead of print
Danny Liang L, C Y Chan T, Benjamin Leung KH, Scheuermeyer F, ... Al Assil R, Grunau B
Resuscitation: 10 Jan 2022; epub ahead of print | PMID: 35031391
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Abstract

Cardiorenal Function and Survival in In-Hospital Cardiac Arrest: A Nationwide Study of 22,819 Cases.

Berglund S, Andreasson A, Rawshani A, Hirlekar G, ... Herlitz J, Rawshani A
Background
We studied the association between cardiorenal function and survival, neurological outcome and trends in survival after in-hospital cardiac arrest (IHCA).
Methods
We included cases aged ≥18 years in the Swedish Cardiopulmonary Resuscitation Registry during 2008 to 2020. The CKD-EPI equation was used to calculate estimated glomerular filtration rate (eGFR). A history of heart failure was defined according to contemporary guideline criteria. Logistic regression was used to study survival. Neurological outcome was assessed using cerebral performance category (CPC).
Results
We studied 22,819 patients with IHCA. The 30-day survival was 19.3%, 16.6%, 22.5%, 28.8%, 39.3%, 44.8% and 38.4% in cases with eGFR <15, 15-29, 30-44, 45-59, 60-89, 90-130 and 130-150 ml/min/1.73 m2, respectively. All eGFR levels below and above 90 ml/min/1.73 m2 were associated with increased mortality. Probability of survival at 30 days was 62% lower in cases with eGFR <15 ml/min/1.73 m2, compared with normal kidney function. At every level of eGFR, presence of heart failure increased mortality markedly; patients without heart failure displayed higher mortality only at eGFR below 30 ml/min/1.73 m2. Among survivors with eGFR <15 ml/min/1.73 m2, good neurological outcome was noted in 87.2%. Survival increased in most groups over time, but most for those with eGFR <15 ml/min/1.73 m2, and least for those with normal eGFR.
Conclusions
All eGFR levels below and above normal range are associated with increased mortality and this association is modified by the presence of heart failure. Neurological outcome is good in the majority of cases, across kidney function levels and survival is increasing.

Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 10 Jan 2022; epub ahead of print
Berglund S, Andreasson A, Rawshani A, Hirlekar G, ... Herlitz J, Rawshani A
Resuscitation: 10 Jan 2022; epub ahead of print | PMID: 35031390
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Abstract

Delayed head CT in out-of-hospital cardiac arrest survivors: Does this improve predictive performance of neurological outcome?

Nam In Y, Ho Lee I, Soo Park J, Mi Kim Data Acquisition D, ... Kang C, Kook Lee B
Background
We compared the ability of head computed tomography (HCT) and MRI, respectively, obtained before or after target temperature management to predict neurologic outcomes in out-of-hospital cardiac arrest (OHCA) survivors.
Methods
This retrospective study included adult comatose OHCA survivors who underwent neuroimaging scans within 6 h (first HCT) or 72-96 h (second HCT and MRI) after the return of spontaneous circulation (ROSC). We calculated the gray-white matter ratio (GWR), hypoxic-ischemic brain injury presence (loss of boundary at the basal ganglia level [LOB at BG], sulcal effacement at the centrum semiovale [SE at CS], and pseudo-SAH sign), and the overall score based on MRI findings (a total score of 21 brain regions individually scored according to the degree of signal abnormality).
Results
Overall, 78 patients were included in this analysis, of whom 45 (58%) showed poor outcomes. The second HCT scan showed greater prognostic performance than the first HCT scan for GWR (area under curve 0.92 vs. 0.70), LOB at BG (0.93 vs. 0.65), SE at CS (0.89 vs. 0.64), and pseudo-SAH sign (0.75 vs. 0.51). The overall score on MRI (0.99) showed the highest prognostic performance. However, on the second HCT scan, the combination of GWR and LOB at BG showed prognostic performance (0.96) comparable to the overall score on MRI (P=0.12); the corresponding sensitivity and specificity values were 85.7% and 100%.
Conclusions
Overall score on MRI and the combination of GWR and LOB at BG findings on second HCT scans may help predict poor outcomes in OHCA survivors.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 09 Jan 2022; epub ahead of print
Nam In Y, Ho Lee I, Soo Park J, Mi Kim Data Acquisition D, ... Kang C, Kook Lee B
Resuscitation: 09 Jan 2022; epub ahead of print | PMID: 35026330
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Abstract

Physicians\' cognitive approach to prognostication after cardiac arrest.

Steinberg A, Grayek E, Arnold RM, Callaway C, ... White DB, Elmer J
Objective
Elucidate how physicians formulate a neurological prognosis after cardiac arrest and compare differences between experts and general providers.
Methods
We performed semi-structured interviews with experts in post-arrest care and general physicians. We created an initial model and interview guide based on professional society guidelines. Two authors independently coded interviews based on this initial model, then identified new topics not included in it. To describe individual physicians\' cognitive approach to prognostication, we created a graphical representation. We summarized these individual \"mental models\" into a single overall model, as well as two models stratified by expertise.
Results
We performed 36 interviews (17 experts and 19 generalists), most of whom practice in Europe (23) or North America (12). Participants described their approach to prognosis formulation as complex and iterative, with sequential and repeated data acquisition, interpretation, and prognosis formulation. Eventually, this cycle results in a final prognosis and treatment recommendation. Commonly mentioned factors were diagnostic test performance, time from arrest, patient characteristics. Participants also discussed factors rarely discussed in prognostication research including physician and hospital characteristics. We found no substantial differences between experts and general physicians.
Conclusion
Physicians\' cognitive approach to neurologic prognostication is complex and influenced by many factors, including some rarely considered in current research. Understanding these processes better could inform interventions designed to aid physicians in prognostication.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 07 Jan 2022; epub ahead of print
Steinberg A, Grayek E, Arnold RM, Callaway C, ... White DB, Elmer J
Resuscitation: 07 Jan 2022; epub ahead of print | PMID: 35017011
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Abstract

Chest compression fraction calculation: A new, automated, robust method to identify periods of chest compressions from defibrillator data - Tested in Zoll X Series.

Orlob S, Kern WJ, Alpers B, Schörghuber M, ... Gräsner JT, Wnent J
Aim
To introduce and evaluate a new, open-source algorithm to detect chest compression periods automatically by the rhythmic, high amplitude signals from an accelerometer, without processing single chest compression events, and to consecutively calculate the chest compression fraction (CCF).
Methods
A consecutive sample of defibrillator records from the German Resuscitation Registry was obtained and manually annotated in consensus as ground truth. Chest compression periods were determined by different automatic approaches, including the new algorithm. The diagnostic performance of these approaches was assessed. Further, using the different approaches in conjunction with different granularities of manual annotation, several CCF versions were calculated and compared by intraclass correlation coefficient (ICC).
Results
131 defibrillator recordings with a total duration of 5755 minutes were analysed. The new algorithm had a sensitivity of 99.39 (95% CI 99.38, 99.41)% and specificity of 99.17 (95% CI 99.15; 99.18)% to detect chest compressions at any given timepoint. The ICC compared to ground truth was 0.998 for the new algorithm and 0.999 for manual annotation, while the ICC of the proposed algorithm compared to the proprietary software was 0.978. The time required for manual annotation to calculate CCF was reduced by 70.48 (22.55, [94.35, 14.45])%.
Conclusion
The proposed algorithm reliably detects chest compressions in defibrillator recordings. It can markedly reduce the workload for manual annotation, which may facilitate uniform reporting of measured quality of cardiopulmonary resuscitation. The algorithm is made freely available and may be used in big data analysis and machine learning approaches.

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

Resuscitation: 03 Jan 2022; epub ahead of print
Orlob S, Kern WJ, Alpers B, Schörghuber M, ... Gräsner JT, Wnent J
Resuscitation: 03 Jan 2022; epub ahead of print | PMID: 34995686
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Abstract

CPR-related injuries after non-traumatic out-of-hospital cardiac arrest: survivors versus non-survivors.

Karasek J, Slezak J, Stefela R, Topinka M, ... Polasek R, Ostadal P
Aim
There have been no direct comparisons of cardiopulmonary resuscitation (CPR)-related injuries between those who die during CPR and those who survive to intensive care unit (ICU) admission. This study aimed to compare the incidence, severity, and impact on survival rate of these injuries and potential influencing factors.
Method
This retrospective multicenter study analyzed autopsy reports of patients who experienced out-of-hospital cardiac arrest (OHCA) and were not admitted to hospital. CPR-related injuries were compared to OHCA patients with clinical suspicion of CPR-related injury confirmed on imaging when admitted to the ICU.
Results
A total of 859 out-of-hospital cardiac arrests (OHCA) were divided into 2 groups: those who died during CPR and underwent autopsy (DEAD [n=628]); and those who experienced return of spontaneous circulation and admitted to the ICU (ICU [n=231]). Multivariable analyses revealed that independent factors of 30-day mortality included no bystander arrest, cardiac etiology, no shockable rhythm, and CPR-related injury. Trauma was independently associated with older age, bystander CPR, cardiac etiology, duration of CPR, and no defibrillation. CPR-related injury occurred in 30 (13%) patients in the ICU group and 547 (87%) in the DEAD group (p<0.0001). Comparison of injuries revealed that those in the DEAD group experienced more thoracic injuries, rib(s) and sternal fractures, and fewer liver injuries compared to those in the ICU group, without differences in injury severity.
Conclusion
CPR-related injuries were observed more frequently in those who died compared with those who survived to ICU admission. Injury was an independent factor of 30-day mortality.

Copyright © 2022 Elsevier B.V. All rights reserved.

Resuscitation: 03 Jan 2022; epub ahead of print
Karasek J, Slezak J, Stefela R, Topinka M, ... Polasek R, Ostadal P
Resuscitation: 03 Jan 2022; epub ahead of print | PMID: 34995685
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Abstract

Vasopressin and glucocorticoids for in-hospital cardiac arrest: A systematic review and meta-analysis of individual participant data.

Holmberg MJ, Granfeldt A, Mentzelopoulos SD, Andersen LW
Aim
To perform a systematic review and individual participant data meta-analysis of vasopressin and glucocorticoids for the treatment of cardiac arrest.
Methods
The PRISMA-IPD guidelines were followed. We searched Medline, Embase, and the Cochrane Library for randomized trials comparing vasopressin and glucocorticoids to placebo during cardiac arrest. The population included adults with cardiac arrest in any setting. Pairs of investigators reviewed studies for relevance, extracted data, and assessed risk of bias. Meta-analyses were conducted using individual participant data. A Bayesian framework was used to estimate posterior treatment effects assuming various prior beliefs. The certainty of evidence was evaluated using GRADE.
Results
Three trials were identified including adult in-hospital cardiac arrests only. Individual participant data were obtained from all trials yielding a total of 869 patients. There was some heterogeneity in post-cardiac arrest interventions between the trials. The results favored vasopressin and glucocorticoids for return of spontaneous circulation (odds ratio: 2.09, 95%CI: 1.54 to 2.84, moderate certainty). Estimates for survival at discharge (odds ratio: 1.39, 95%CI: 0.90 to 2.14, low certainty) and favorable neurological outcome (odds ratio: 1.64, 95%CI, 0.99 to 2.72, low certainty) were more uncertain. The Bayesian estimates for return of spontaneous circulation were consistent with the primary analyses, whereas the estimates for survival at discharge and favorable neurological outcome were more dependent on the prior belief.
Conclusions
Among adults with in-hospital cardiac arrest, vasopressin and glucocorticoids compared to placebo, improved return of spontaneous circulation. Larger trials are needed to determine whether there is an effect on longer-term outcomes.

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

Resuscitation: 02 Jan 2022; 171:48-56
Holmberg MJ, Granfeldt A, Mentzelopoulos SD, Andersen LW
Resuscitation: 02 Jan 2022; 171:48-56 | PMID: 34990764
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Impact:
Abstract

International multi-center real world implementation trial to increase out-of-hospital cardiac arrest survival with a dispatcher-assisted cardio-pulmonary resuscitation package (Pan-Asian resuscitation outcomes study phase 2).

Ong MEH, Shin SD, Ko PC, Lin X, ... Al Qahtani S, Tanaka H
Background
Dispatcher-assisted CPR (DA-CPR) has the potential to deliver early bystander CPR (BCPR) and improve out-of-hospital cardiac arrest (OHCA) survival. This study in the Asia-Pacific evaluated the impact of a DA-CPR program on BCPR rates and survival.
Methods
This was a three-arm, prospective, multi-national, population-based, community-level, implementation trial. Cases between January 2009 and June 2018 from the Pan-Asian Resuscitation Outcomes Study were included. Sites either implemented a comprehensive (with quality improvement tool) or a basic DA-CPR package, or served as controls. Primary outcome was survival-to-discharge/30th day post-arrest. Secondary outcomes were BCPR and favorable neurological outcome. A before-after comparison was made within each country; this before-after change was then compared across the three groups using logistic regression.
Results
170,687 cases were analyzed. Before-after comparison showed that survival to discharge was higher in the \'implementation\' period in all three groups: comprehensive odds ratio (OR) 1.09, 95% confidence interval (CI; [1.0-1.19]); basic OR 1.14, 95% CI (1.08-1.2); and control OR 1.25, 95% CI (1.02-1.53). Comparing between groups, the comprehensive group had significantly higher change in BCPR (comprehensive vs control ratio of OR 1.86, 95% CI [1.66-2.09]; basic vs control ratio of OR 0.94, 95% CI [0.85-1.05]; and comprehensive vs basic ratio of OR 1.97, 95% CI [1.87-2.08]) and survival with favorable neurological outcome (comprehensive vs basic ratio of OR 1.2, 95% CI [1.04-1.39]).
Conclusion
We evaluated the impact of a DA-CPR program across heterogeneous EMS systems and demonstrated that a comprehensive DA-CPR program had the most impact on BCPR and favorable neurological outcome.

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

Resuscitation: 29 Dec 2021; 171:80-89
Ong MEH, Shin SD, Ko PC, Lin X, ... Al Qahtani S, Tanaka H
Resuscitation: 29 Dec 2021; 171:80-89 | PMID: 34974143
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Impact:
Abstract

Long-term outcomes after out-of-hospital cardiac arrest: A systematic review and meta-analysis.

Chin YH, Yaow CYL, Teoh SE, Foo MZQ, ... Ong MEH, Ho AFW
Aims
Long term outcomes after out-of-hospital cardiac arrest (OHCA) are not well understood. This study aimed to evaluate the long-term (1-year and beyond) survival outcomes, including overall survival and survival with favorable neurological status and the quality-of-life (QOL) outcomes, among patients who survived the initial OHCA event (30 days or till hospital discharge).
Methods
Embase, Medline and PubMed were searched for primary studies (randomized controlled trials, cohort and cross-sectional studies) which reported the long-term survival outcomes of OHCA patients. Data abstraction and quality assessment was conducted, and survival at predetermined timepoints were assessed via single-arm meta-analyses of proportions, using generalized linear mixed models. Comparative meta-analyses were conducted using the Mantel-Haenszel Risk Ratio (RR) estimates, using the DerSimonian and Laird model.
Results
67 studies were included, and among patients that survived to hospital discharge or 30-days, 77.3% (CI = 71.2-82.4), 69.6% (CI = 54.5-70.3), 62.7% (CI = 54.5-70.3), 46.5% (CI = 32.0-61.6), and 20.8% (CI = 7.8-44.9) survived to 1-, 3-, 5-, 10- and 15-years respectively. Compared to Asia, the probability of 1-year survival was greater in Europe (RR = 2.1, CI = 1.8-2.3), North America (RR = 2.0, CI = 1.7-2.2) and Oceania (RR = 1.9, CI = 1.6-2.1). Males had a higher 1-year survival (RR:1.41, CI = 1.25-1.59), and patients with initial shockable rhythm had improved 1-year (RR = 3.07, CI = 1.78-5.30) and 3-year survival (RR = 1.45, CI = 1.19-1.77). OHCA occurring in residential locations had worse 1-year survival (RR = 0.42, CI = 0.25-0.73).
Conclusion
Our study found that up to 20.8% of OHCA patients survived to 15-years, and survival was lower in Asia compared to the other regions. Further analysis on the differences in survival between the regions are needed to direct future long-term treatment of OHCA patients.

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

Resuscitation: 28 Dec 2021; 171:15-29
Chin YH, Yaow CYL, Teoh SE, Foo MZQ, ... Ong MEH, Ho AFW
Resuscitation: 28 Dec 2021; 171:15-29 | PMID: 34971720
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Abstract

Outcomes of Out-of-hospital Cardiac Arrests After a Decade of System-wide Initiatives Optimising Community Chain of Survival in Taipei City.

Lin HY, Chien YC, Lee BC, Wu YL, ... Huei-Ming Ma M, Taipei City Fire Department Quality Assurance Team
Objective
A strengthened chain of survival benefits patient outcomes after out-of-hospital cardiac arrest (OHCA).2 Over the past decade, the Taipei Fire Department (TFD) has continuously implemented system-wide initiatives on this issue.We hypothesised that for adult, non-trauma OHCA patients, the bundle of these system-wide initiatives are associated with better outcomes.
Methods
We conducted a registry-based, retrospective study to examine the association between consecutive system-level initiatives and OHCA survival on a two-yearly basis using trend analysis and multivariable logistic regression. The primary outcome was survival to hospital discharge (STHD) and favourable neurological status.
Results
We analysed 18,076 cases from 2008 to 2017. The numbers of two-yearly cases of OHCA with resuscitation attempts from 2008 to 2017 were 3,576, 3,456, 3,822, 3,811, and 3,411. There was a significant trend of improved STHD (Two-fold) and favourable neurological outcome (Six-fold) over the past decade. Similar trends were observed in the shockable and non-shockable groups. Considering the first 2 years as baseline, the odds of STHD and favourable neurological status in the end of the initiatives increased significantly after adjusting for universally recognised predictors for OHCA survival.
Conclusion
For non-trauma adult OHCA in Taipei, continuous, multifaceted system-wide initiatives on the community chain of survival were associated with improved odds of STHD and favourable neurologic outcomes.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 27 Dec 2021; epub ahead of print
Lin HY, Chien YC, Lee BC, Wu YL, ... Huei-Ming Ma M, Taipei City Fire Department Quality Assurance Team
Resuscitation: 27 Dec 2021; epub ahead of print | PMID: 34971722
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Abstract

Drones Delivering Automated External Defibrillators-Integrating Unmanned Aerial Systems into the Chain of Survival: A Simulation Study in Rural Germany.

Carolina Baumgarten M, Röper J, Hahnenkamp K, Thies KC
Background
Community first responders (CFR) improve survival in out-of-hospital cardiac arrest (OHCA) but are often hampered by limited availability of public access defibrillation. Unmanned aerial systems (UAS) delivering automated external defibrillators (AED) directly to an OHCA site could help overcome this. We evaluated the feasibility of integrating UAS into the chain of survival in rural Northeast Germany.
Methods
This simulation study explored UAS-AED delivery combined with a smartphone-based CFR dispatch. Five OHCA locations (A-E) were randomly selected. We routed a flight corridor to each of these sites from a corresponding UAS base; 50 OHCA scenarios with 10 flights per corridor were scheduled. All steps were accurately simulated, from a bystander finding the patient, making an emergency call, conducting dispatcher-assisted cardiopulmonary resuscitation, and simultaneous CFR plus UAS deployment, to the bystander and CFR interacting with UAS and AED. This process was time-tracked and video-recorded until defibrillation.
Results
We performed 46 OHCA simulations. Missions were flown autonomously but needed pilot assistance during landing. Distances (km) and average time intervals from alert to defibrillation (td in min:sec±SD) were 0.4 (6:02±0:56), 2.29 (6:53±0:19), 4.0 (8:54±0:25), 7.43 (14:51±1:055), and 9.79 (15:51±1:16) for routes A to E, respectively. All participants were able to retrieve the AED within seconds after UAS landing and interacted safely with the UAS and AED.
Conclusions
Integrating airborne AED delivery into the chain of survival appeared feasible and safe but remains an experimental technology. Linking this with CFR potentially improves the availability of early public-access defibrillation, particularly in rural regions.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 27 Dec 2021; epub ahead of print
Carolina Baumgarten M, Röper J, Hahnenkamp K, Thies KC
Resuscitation: 27 Dec 2021; epub ahead of print | PMID: 34971721
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Impact:
Abstract

A risk-adjustment model for patients presenting to hospitals with out-of-hospital cardiac arrest and ST-elevation myocardial infarction.

Tran AT, Hart AJ, Spertus JA, Jones PG, ... Malik AO, Chan PS
Background
Patients with ST-elevation myocardial infarction (STEMI) complicated by an out-of-hospital-cardiac-arrest (OHCA) may vary widely in their probability of dying. Large variation in mortality may have implications for current national efforts to benchmark operator and hospital mortality rates for coronary angiography. We aimed to build a risk-adjustment model of in-hospital mortality among OHCA survivors with concurrent STEMI.
Methods
Within the Cardiac Arrest Registry to Enhance Survival (CARES), we included adults with OHCA and STEMI who underwent emergent angiography within 2 hours of hospital arrival between January 2013 and December 2019. Using multivariable logistic regression to adjust for patient and cardiac arrest factors, we developed a risk-adjustment model for in-hospital mortality and examined variation in patients\' predicted mortality.
Results
Of 2,999 patients (mean age 61.2 ± 12.0, 23.1% female, 64.6% white), 996 (33.2%) died during their hospitalization. The final risk-adjustment model included higher age (OR per 10-year increase, 1.50 [95% CI: 1.39-1.63]), unwitnessed OHCA (OR, 2.51 [1.99-3.16]), initial non-shockable rhythm [OR, 5.66 [4.52-7.13]), lack of sustained pulse for > 20 minutes (OR, 2.52 [1.88-3.36]), and longer resuscitation time (increased with each 10-minute interval) (c-statistic = 0.804 with excellent calibration). There was large variability in predicted mortality: median, 25.2%, inter-quartile-range: 14.0% to 47.8%, 10th-90th percentile: 8.2 % to 74.1%.
Conclusions
In a large national registry, we identified 5 key predictors for mortality in patients with STEMI and OHCA and found wide variability in mortality risk. Our findings suggest that current national benchmarking efforts for coronary angiography, which simply adjusts for the presence of OHCA, may not adequately capture patient case-mix severity.

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

Resuscitation: 26 Dec 2021; 171:41-47
Tran AT, Hart AJ, Spertus JA, Jones PG, ... Malik AO, Chan PS
Resuscitation: 26 Dec 2021; 171:41-47 | PMID: 34968532
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Impact:
Abstract

External Validation of Pittsburgh Cardiac Arrest Category Illness Severity Score.

Nassal MMJ, Nichols D, Demasi S, Rittenberger JC, ... White C, UAB Post-Cardiac Arrest Service
Early prognostication post-cardiac arrest can help determine appropriate medical management and help evaluate effectiveness of post-arrest interventions. The Pittsburgh Cardiac Arrest Category (PCAC) severity score is a 4-level illness severity score found to strongly predict patient outcomes in both in- (IHCA) and out-of-hospital cardiac arrests (OHCA). We aimed to validate the PCAC severity score in an external cohort of cardiac arrest patients.
Methods
We retrospectively assigned PCAC scores to both IHCA and OHCA patients treated by our hypothermia team from July 1, 2009 to July 1 2016. Our primary outcome was survival to hospital discharge. Secondary outcomes were favorable functional status defined as favorable discharge disposition (home or acute rehabilitation), discharge Cerebral Performance Category (CPC); and discharge modified Rankin Scale (mRS). We tested the association of PCAC and outcomes using a multivariable adjusted logistic regression model.
Results
We included 317 subjects in our model. PCAC was strongly associated with survival I Reference; II adjusted odds ratio (OR) 0.20 95% confidence interval (CI) 0.35-0.66, III (OR 0.14 CI 0.3-0.73, p<0.05); IV (OR 0.05 CI 0.01-0.24, p<0.01). PCAC was similarly associated with favorable functional outcomes: favorable discharge disposition II (OR 0.12 CI 0.02-0.68), III (OR 0.19 CI 0.05-0.74, p<0.05) IV (OR 0.05 CI 0.01-0.22, p<0.01); favorable CPC score II (OR 0.25 CI 0.06-1.03), III (OR 0.14 CI 0.03-0.57, p<0.01), IV (OR 0.05 CI 0.01-0.20, p<0.01) and favorable mRS (OR 0.47 CI (0.33-0.68)).
Conclusion
Early (<6hr post-arrest) PCAC severity scoring strongly predicts patient outcomes from cardiac arrest in both OHCA and IHCA.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 26 Dec 2021; epub ahead of print
Nassal MMJ, Nichols D, Demasi S, Rittenberger JC, ... White C, UAB Post-Cardiac Arrest Service
Resuscitation: 26 Dec 2021; epub ahead of print | PMID: 34968531
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Impact:
Abstract

Effect of resuscitation training and implementation of continuous electronic heart rate monitoring on identification of stillbirth.

Patterson J, Berkelhamer S, Ishoso D, Iyer P, ... Tshefu A, Bose C
Aim
To evaluate the effect of resuscitation training and continuous electronic heart rate (HR) monitoring of non-breathing newborns on identification of stillbirth.
Methods
We conducted a pre-post interventional trial in three health facilities in the Democratic Republic of the Congo. We collected data on a retrospective control group of newborns that reflected usual resuscitation practice (Epoch 1). In the prospective, interventional group, skilled birth attendants received resuscitation training in Helping Babies Breathe and implemented continuous electronic HR monitoring of non-breathing newborns (Epoch 2). Our primary outcome was the incidence of stillbirth with secondary outcomes of fresh or macerated stillbirth, neonatal death before discharge and perinatal death. Among a subset, we conducted expert review of electronic HR data to estimate misclassification of stillbirth in Epoch 2. We used a generalized estimating equation, adjusted for variation within-facility, to compare risks between EPOCHs.
Results
There was no change in total stillbirths following resuscitation training and continuous electronic HR monitoring of non-breathing newborns (aRR 1.15 [0.95, 1.39]). We observed an increased rate of macerated stillbirth (aRR 1.58 [1.24, 2.02]), death before discharge (aRR 3.31 [2.41, 4.54]), and perinatal death (aRR 1.61 [1.38, 1.89]) during the intervention period. In expert review, 20% of newborns with electronic HR data that were classified by SBAs as stillborn were liveborn.
Conclusion
Resuscitation training and use of continuous electronic HR monitoring did not reduce stillbirths nor eliminate misclassification.

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

Resuscitation: 25 Dec 2021; 171:57-63
Patterson J, Berkelhamer S, Ishoso D, Iyer P, ... Tshefu A, Bose C
Resuscitation: 25 Dec 2021; 171:57-63 | PMID: 34965451
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Impact:
Abstract

The Montreal Cognitive Assessment is a valid cognitive screening tool for cardiac arrest survivors.

van Gils P, van Heugten C, Hofmeijer J, Keijzer H, Nutma S, Duits A
Aim
The survival rate of out-of-hospital cardiac arrest (OHCA) patients has increased over the past decades. This gives rise to a growing number of patients with hypoxic-ischemic brain damage and cognitive impairment. Currently, cognitive impairment is underdiagnosed in OHCA patients. There is a need for a validated cognitive screening instrument to identify patients with cognitive impairment. This study aimed to examine the diagnostic value of the Montreal Cognitive Assessment (MoCA) in patients after OHCA.
Methods
Survivors (age ≥ 18 years) of OHCA completed the MoCA and a gold standard neuropsychological test battery, including tests for memory, attention, perception, language, reasoning, and executive functioning, at around one year after OHCA. Results of the MoCA are related to the results of the neuropsychological test battery. Analyses of diagnostic accuracy included receiver operating characteristics and calculation of predictive values.
Results
We included 54 OHCA survivors (mean age = 57.3, 74% male). The area under the curve (AUC) was 0.8, 95% CI [0.67, 0.93]. The MoCA showed excellent sensitivity of 86%, 95% CI [57, 98] and adequate specificity of 70.0%, 95% CI [53, 83] to detect cognitive impairment at the regular cut-off score of 26. The positive predictive value of the MoCA was 50%, 95% CI [30, 70] and the negative predictive value was 93%, 95% CI [76, 99].
Conclusion
This study shows that the MoCA may be a valid cognitive screening instrument for use in the OHCA patient population.

Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.

Resuscitation: 24 Dec 2021; epub ahead of print
van Gils P, van Heugten C, Hofmeijer J, Keijzer H, Nutma S, Duits A
Resuscitation: 24 Dec 2021; epub ahead of print | PMID: 34958880
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Impact:
Abstract

Evaluation of outcomes after EMS-witnessed traumatic out-of-hospital cardiac arrest caused by traffic collisions.

Kitano S, Fujimoto K, Suzuki K, Harada S, ... Ogawa S, Yokota H
Aim
The survival rate of patients with traumatic cardiac arrest is 3% or lower. Cardiac arrest witnessed by emergency medical services (EMS) accounts for approximately 16% of prehospital traumatic cardiac arrests, but the prognosis is unknown. We aimed to compare the 1-month survival rate of cardiac arrest witnessed by EMS with that of cardiac arrest witnessed by bystanders and unwitnessed cardiac arrest in traffic trauma victims; further, the time from injury to cardiac arrest was assessed.
Methods
This analysis used the Utstein Registry in Japan and included data of 3883 patients with traumatic cardiac arrest caused by traffic collisions registered between 2014 and 2019 in Japan.
Results
The 1-month survival rate was 10.9% in the EMS-witnessed cardiac arrest group; this was significantly higher than that in the bystander-witnessed (7.2%) and unwitnessed (5.6%) cardiac arrest groups (P < 0.01). The median time from injury to cardiac arrest was 18 min (25% quartile: 12, 75% quartile: 26).
Conclusion
The 1-month survival rate was significantly higher in the EMS-witnessed cardiac arrest group than in the bystander-witnessed and unwitnessed cardiac arrest groups. It is important to prevent progression to cardiac arrest in trauma patients with intact respiratory function and pulse rate at the time of contact with EMS. A system for early recognition of severe trauma is needed, and a doctor\'s car or helicopter can be requested as needed. We believe that early recognition and prompt intervention will improve the prognosis of prehospital traumatic cardiac arrest.

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

Resuscitation: 23 Dec 2021; 171:64-70
Kitano S, Fujimoto K, Suzuki K, Harada S, ... Ogawa S, Yokota H
Resuscitation: 23 Dec 2021; 171:64-70 | PMID: 34958879
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Impact:
Abstract

Paramedic rhythm interpretation misclassification is associated with poor survival from out-of-hospital cardiac arrest.

Stoecklein HH, Pugh A, Johnson MA, Tonna JE, ... Drakos S, Youngquist ST
Background
Early recognition and rapid defibrillation of shockable rhythms is strongly associated with survival in out of hospital cardiac arrest (OHCA). Little is known about the accuracy of paramedic rhythm interpretation and its impact on survival. We hypothesized that inaccurate paramedic interpretation of initial rhythm would be associated with worse survival.
Methods
This is a retrospective cohort analysis of prospectively collected OHCA data over a nine-year period within a single, urban, fire-based EMS system that utilizes manual defibrillators equipped with rhythm-filtering technology. We compared paramedic-documented initial rhythm with a reference standard of post-event physician interpretation to estimate sensitivity and specificity of paramedic identification of and shock delivery to shockable rhythms. We assessed the association between misclassification of initial rhythm and neurologically intact survival to hospital discharge using multivariable logistic regression.
Results
A total of 863 OHCA cases were available for analysis with 1,756 shocks delivered during 542 (63%) resuscitation attempts. Eleven percent of shocks were delivered to pulseless electrical activity (PEA). Sensitivity and specificity for paramedic initial rhythm interpretation were 176/197 (0.89, 95% CI 0.84-0.93) and 463/504 (0.92, 95% CI 0.89-0.94) respectively. No patient survived to hospital discharge when paramedics misclassified the initial rhythm.
Conclusions
Paramedics achieved high sensitivity for shock delivery to shockable rhythms, but with an 11% shock delivery rate to PEA. Misclassification of initial rhythm was associated with poor survival. Technologies that assist in rhythm identification during CPR, rapid shock delivery, and minimal hands-off time may improve outcomes.

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

Resuscitation: 20 Dec 2021; 171:33-40
Stoecklein HH, Pugh A, Johnson MA, Tonna JE, ... Drakos S, Youngquist ST
Resuscitation: 20 Dec 2021; 171:33-40 | PMID: 34952179
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Impact:
Abstract

Validation of ICD-10 codes for the identification of paediatric out-of-hospital cardiac arrest patients.

Gray K, Cameron S, McKenzie K, Miller M, Odoardi N, Tijssen JA
Aim
There is a need for large-scale epidemiological studies of paediatric out-of-hospital cardiac arrest (POHCA). To enable this, we developed and validated international classification of disease (ICD-10) search algorithms for the identification of POHCA patients from health administrative data.
Methods
We validated the algorithms with a registry of POHCA (CanRoc) as the reference standard. The reference standard included all atraumatic POHCA in Middlesex-London region for January 2012-June 2020. All algorithms included 1 day to <18-year-old patients transported to emergency department (ED) by ambulance and excluded trauma. We tested three algorithms, which were applied to the National Ambulatory Care Reporting System and Discharge Abstract Database. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR) and negative likelihood ration (NLR) were calculated for each algorithm.
Results
During the study period, 17,688 children presented to the ED by ambulance. The reference standard included 51 POHCA patients. The algorithm using only ICD-10 code for cardiac arrest had a sensitivity of 65.5% and PPV of 90%. The algorithm with the highest sensitivity of 87.3% added sudden infant death syndrome, drowning or asphyxiation with CPR in addition to the cardiac arrest codes for inpatient and ED records. This algorithm had a specificity of 99.9%, PPV of 81.4% and NPV of ∼100.0%.
Conclusion
It is important that algorithms used for cohort identification are validated prior to use. The ICD-10 code for cardiac arrest alone misses many POHCA cases but the use of additional codes can improve the sensitivity while maintaining specificity.

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

Resuscitation: 20 Dec 2021; 171:73-79
Gray K, Cameron S, McKenzie K, Miller M, Odoardi N, Tijssen JA
Resuscitation: 20 Dec 2021; 171:73-79 | PMID: 34952178
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Impact:
Abstract

Clinical Significance of Early Echocardiographic Changes after Resuscitated Out-of-Hospital Cardiac Arrest.

Sarma D, Pareek N, Kanyal R, Cannata A, ... MacCarthy P, Byrne J
Background
Left Ventricular Systolic Dysfunction (LVSD) is common after out-of-hospital cardiac arrest (OOHCA) and can manifest globally or regionally, although its clinical significance has not been robustly studied. This study evaluates the association between LVSD, extent of coronary artery disease (CAD) and outcome in those undergoing early echocardiography and coronary angiography after OOHCA.
Methods
Trans-thoracic echocardiography (TTE) was performed in OOHCA patients on arrival to our centre between May 2012 and December 2017. Rates of cardiogenic shock and extent of CAD, respectively classified by SCAI grade and the SYNTAX score, were measured. The primary end-point was 12-month mortality.
Results
From 398 patients in the King\'s Out of Hospital Cardiac Arrest Registry (KOCAR), 266 patients (median age 61 [53-71], 76% male) underwent both TTE and coronary angiography on arrival. 96 patients (36%) had significant LVSD (Left Ventricular Ejection Fraction [LVEF] <40%) and 139 (52.2%) patients had regional wall motion abnormalities (RWMAs). Patients with LVEF <40% had more SCAI grade C-E shock (65.3% vs. 34.5%, p <0.001) and higher 12-month mortality (55.2% vs 31.8%, p <0.001) which was more likely to be due to a cardiac aetiology (27.3% vs 5.3%, p <0.001). Patients with RWMAs had higher median SYNTAX scores (14.75 vs 7, p=0.001), culprit coronary lesions (83.5% vs. 45.3%, p <0.001) and lower 12-month mortality (29.5% vs 52%, p <0.001).
Conclusions
Patients with LVEF <40% at presentation have an increased mortality, driven by cardiac aetiology death, while the presence of RWMAs is associated with a higher rate of culprit coronary lesions, representing a potentially reversible cause of the arrest, and improved survival at 1 year.

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

Resuscitation: 15 Dec 2021; epub ahead of print
Sarma D, Pareek N, Kanyal R, Cannata A, ... MacCarthy P, Byrne J
Resuscitation: 15 Dec 2021; epub ahead of print | PMID: 34923035
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Impact:
Abstract

Rationale for withholding professional resuscitation in emergency medical system-attended out-of-hospital cardiac arrest.

Yap J, Haines M, Nowroozpoor A, Armour R, ... Christenson J, Grunau B
Background
Half of out-of-hospital cardiac arrests (OHCA) are deemed inappropriate for resuscitation by emergency medical services (EMS). We investigated patient characteristics and reasons for non-treatment of OHCAs, and determined the proportion involving illicit drug use.
Methods
We reviewed consecutive EMS-untreated OHCA from the British Columbia Cardiac Arrest Registry (2019-2020). We abstracted patient characteristics and categorized reasons for EMS non-treatment: (1) prolonged interval from the OHCA to EMS arrival (\"non-recent OHCA\") with or without signs of \"obvious death\"; (2) do-not-resuscitate (DNR) order; (3) terminal disease; (4) verbal directive; and (5) unspecified. We abstracted clinical details regarding a history of, or evidence at the scene of, illicit drug use.
Results
Of 13 331 cases, 5959 (45%) were not treated by EMS. The median age was 67 (IQR 54-81) and 1903 (32%) were female. EMS withheld resuscitation due to: non-recent OHCA, with and without signs of \"obvious death\" in 4749 (80%) and 108 (1.8%), respectively; DNR order in 952 (16%); terminal disease in 77 (1.3%); family directive in 41 (0.69%); and unspecified in 32 (0.54%). Overall and among those with non-recent OHCA, 695/5959 (12%) and 691/4857 (14%) had either a history of or evidence of recent illicit drug use, respectively.
Conclusion
A prolonged interval from the OHCA until EMS assessment was the predominant reason for withholding treatment. Innovative solutions to decrease this interval may increase the proportion of OHCA that are treated by EMS and overall outcomes. Targeted interventions for illicit-drug use-related OHCAs may add additional benefit.

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

Resuscitation: 13 Dec 2021; 170:201-206
Yap J, Haines M, Nowroozpoor A, Armour R, ... Christenson J, Grunau B
Resuscitation: 13 Dec 2021; 170:201-206 | PMID: 34920017
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Impact:
Abstract

Palliative care consultation and end-of-life outcomes in hospitalized COVID-19 patients.

Cheruku SR, Barina A, Kershaw CD, Goff K, ... Society of Critical Care Medicine Discovery Viral Infection, Respiratory Illness Universal Study VIRUS: COVID-19 Registry Investigator Group
Rationale
The impact of palliative care consultation on end-of-life care has not previously been evaluated in a multi-center study.
Objectives
To evaluate the impact of palliative care consultation on the incidence of cardiopulmonary resuscitation (CPR) performed and comfort care received at the end-of-life in hospitalized patients with COVID-19.
Methods
We used the Society of Critical Care Medicine\'s COVID-19 registry to extract clinical data on patients hospitalized with COVID-19 between March 31st, 2020 to March 17th, 2021 and died during their hospitalization. The proportion of patients who received palliative care consultation was assessed in patients who did and did not receive CPR (primary outcome) and comfort care (secondary outcome). Propensity matching was used to account for potential confounding variables.
Measurements and main results
3,227 patients were included in the analysis. There was no significant difference in the incidence of palliative care consultation between the CPR and no-CPR groups (19.9% vs. 19.4%, p = 0.8334). Patients who received comfort care at the end-of-life were significantly more likely to have received palliative care consultation (43.3% vs. 7.7%, p < 0.0001). After propensity matching for comfort care on demographic characteristics and comorbidities, this relationship was still significant (43.2% vs. 8.5%; p < 0.0001).
Conclusion
Palliative care consultation was not associated with CPR performed at the end-of-life but was associated with increased incidence of comfort care being utilized. These results suggest that utilizing palliative care consultation at the end-of-life may better align the needs and value of patients with the care they receive.

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

Resuscitation: 13 Dec 2021; 170:230-237
Cheruku SR, Barina A, Kershaw CD, Goff K, ... Society of Critical Care Medicine Discovery Viral Infection, Respiratory Illness Universal Study VIRUS: COVID-19 Registry Investigator Group
Resuscitation: 13 Dec 2021; 170:230-237 | PMID: 34920014
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Impact:
Abstract

Tidal volumes and pressures delivered by the NeoPuff T-piece resuscitator during resuscitation of term newborns.

Peder Aleksander B, Hege Langli E, Joanna H, Anastasia U, Knut Ø, Siren IR
Aim
T-piece resuscitators are commonly used for respiratory support during newborn resuscitation. This study aimed to describe delivered pressures and tidal volumes when resuscitating term newborns immediately after birth, using the NeoPuff T-piece resuscitator.
Method
Observational study from June 2019 through March 2021 at Stavanger University Hospital, Norway, including term newborns ventilated with a T-piece resuscitator after birth, with consent to participate. Ventilation parameters of the first 100 inflations from each newborn were recorded by respiration monitors and divided into an early (inflation 1-20) and a late (inflation 21-100) phase.
Results
Of the 7730 newborns born, 232 term newborns received positive pressure ventilation. Of these, 129 newborns were included. In the early and the late phase, the median (interquartile range) peak inflating pressure was 30 (28-31) and 30 (27-31) mbar, and tidal volume was 4.5 (1.6-7.8) and 5.7 (2.2-9.8) ml/kg, respectively. Increased inflation times were associated with an increase in volume before plateauing at an inflation time of 0.41 s in the early phase and 0.50 s in the late phase. Inflation rates exceeding 32 per minute in the early phase and 41 per minute in the late phase were associated with lower tidal volumes.
Conclusion
There was a substantial variation in tidal volumes despite a relatively stable peak inflating pressure. Delivered tidal volumes were at the lower end of the recommended range. Our results indicate that an inflation time of approximately 0.5 s and rates around 30-40 per minute are associated with the highest delivered tidal volumes.

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

Resuscitation: 12 Dec 2021; 170:222-229
Peder Aleksander B, Hege Langli E, Joanna H, Anastasia U, Knut Ø, Siren IR
Resuscitation: 12 Dec 2021; 170:222-229 | PMID: 34915085
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Impact:
Abstract

The accuracy of various neuro-prognostication algorithms and the added value of neurofilament light chain dosage for patients resuscitated from shockable cardiac arrest: An ancillary analysis of the ISOCRATE study.

Pouplet C, Colin G, Guichard E, Reignier J, ... Lascarrou JB, AfterROSC network
Purpose
In current guidelines, neurological prognostication after cardiopulmonary resuscitation is based on a multimodal approach bundled in algorithms. Biomarkers are of particular interest because they are unaffected by interpretation bias. We assessed the predictive value of serum neurofilament light chains (NF-L) in patients with a shockable rhythm who received cardiopulmonary resuscitation, and evaluated the predictive value of a modified algorithm where NF-L dosage is included.
Methods
All patients who were included participated in the randomized ISOCRATE trial. NF-L values 48 h after ROSC were compared for patients with a good (Cerebral Performance Category (CPC) 1 or 2) and a poor prognosis (CPC 3 to 5 or death). The benefit of adding NF-L dosage to the current guideline algorithm was then assessed for NF-L thresholds of 500 and 1,200 pg/ml as previously described.
Results
NF-L was assayed for 49 patients. In patients with good versus those with poor outcomes, median NF-L values at 48 h were 72 ± 78 and 7,755 ± 9,501 pg/ml respectively (P < 0.0001; AUC [95 %CI] = 0.87 [0.74;0.99]). The sensitivity of the modified ESICM/ERC 2021 algorithm after adding NF-L with thresholds of 500 and 1,200 pg/ml was 0.74 (CI 95% 0.51-0.88) and 0.68 (CI 95% 0.46-0.86), respectively, versus 0.53 (CI 95% 0.32-0.73) for the unmodified algorithm. In three instances the specificity was 1.
Conclusion
High NF-L plasma levels 48 h after cardiac arrest was significantly associated with a poor outcome. Adjunction to the current guideline algorithm of an NF-L assay with a 500 pg/ml threshold 48 h after cardiac arrest provided the best sensitivity compared to the algorithm alone, while specificity remained excellent.

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

Resuscitation: 12 Dec 2021; 171:1-7
Pouplet C, Colin G, Guichard E, Reignier J, ... Lascarrou JB, AfterROSC network
Resuscitation: 12 Dec 2021; 171:1-7 | PMID: 34915084
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Impact:
Abstract

Hyperoxia after pediatric cardiac arrest: Association with survival and neurological outcomes.

Barreto JA, Weiss NS, Nielsen KR, Farris R, Roberts JS
Objective
To evaluate the association between hyperoxia in the first 24 hours after in-hospital pediatric cardiac arrest and mortality and poor neurological outcome.
Methods
This is a retrospective cohort study of inpatients in a freestanding children\'s hospital. We included all patients younger than 18 years of age with in-hospital cardiac arrest between December 2012 and December 2019, who achieved return of circulation (ROC) for longer than 20 minutes, survived at least 24 hours after cardiac arrest, and had documented PaO2 or SpO2 during the first 24 hours after ROC. Hyperoxia was defined as having at least one level of PaO2 above 200 mmHg in the first 24 hours after cardiac arrest.
Results
There were 187 patients who met eligibility criteria, of whom 48% had hyperoxia during the first 24 hours after cardiac arrest. In-hospital mortality was 41%, with similar mortality between oxygenation groups (hyperoxia 45% vs no hyperoxia 38%). We did not observe an association between hyperoxia and in-hospital mortality or poor neurological outcome after adjusting for confounders (odds ratio 1.2, 95% confidence interval 0.5-2.8). On sensitivity analysis using two additional cutoffs of PaO2 (>150 mmHg and > 300 mmHg), there was also no association with in-hospital mortality or poor neurological outcome after adjusting for confounders. Similarly, on multivariable logistic regression using SpO2 > 99% as the exposure, there was no difference in the frequency of death or poor neurological outcome at hospital discharge.
Conclusion
Hyperoxia after pediatric cardiac arrest was common and was not associated with worse in-hospital outcomes.

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

Resuscitation: 10 Dec 2021; 171:8-14
Barreto JA, Weiss NS, Nielsen KR, Farris R, Roberts JS
Resuscitation: 10 Dec 2021; 171:8-14 | PMID: 34906621
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Impact:
Abstract

Medical futility regarding cardiopulmonary resuscitation in in-hospital cardiac arrests of adult patients: A systematic review and Meta-analysis.

Beck K, Vincent A, Cam H, Becker C, ... Bassetti S, Hunziker S
Aim
For some patients, survival with good neurologic function after cardiopulmonary resuscitation (CPR) is highly unlikely, thus CPR would be considered medically futile. Yet, in clinical practice, there are no well-established criteria, guidelines or measures to determine futility. We aimed to investigate how medical futility for CPR in adult patients is defined, measured, and associated with do-not-resuscitate (DNR) code status as well as to evaluate the predictive value of clinical risk scores through meta-analysis.
Methods
We searched Embase, PubMed, CINAHL, and PsycINFO from the inception of each database up to January 22, 2021. Data were pooled using a fixed-effects model. Data collection and reporting followed the PRISMA guidelines.
Results
Thirty-one studies were included in the systematic review and 11 in the meta-analysis. Medical futility defined by risk scores was associated with a significantly higher risk of in-hospital mortality (5 studies, 3102 participants with Pre-Arrest Morbidity (PAM) and Prognosis After Resuscitation (PAR) score; overall RR 3.38 [95% CI 1.92-5.97]) and poor neurologic outcome/in-hospital mortality (6 studies, 115,213 participants with Good Outcome Following Attempted Resuscitation (GO-FAR) and Prediction of Outcome for In-Hospital Cardiac Arrest (PIHCA) score; RR 6.93 [95% CI 6.43-7.47]). All showed high specificity (>90%) for identifying patients with poor outcome.
Conclusion
There is no international consensus and a lack of specific definitions of CPR futility in adult patients. Clinical risk scores might aid decision-making when CPR is assumed to be futile. Future studies are needed to assess their clinical value and reliability as a measure of futility regarding CPR.

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

Resuscitation: 08 Dec 2021; epub ahead of print
Beck K, Vincent A, Cam H, Becker C, ... Bassetti S, Hunziker S
Resuscitation: 08 Dec 2021; epub ahead of print | PMID: 34896244
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Impact:
Abstract

Dispatcher-assisted CPR can it do harm as well as good?

Ferguson C
Outcomes for patients with out-of-hospital cardiac arrest can be improved by bystander cardiopulmonary resuscitation (CPR). Dispatcher-assisted CPR increases both the likelihood of CPR being performed, and the chance of survival for the arrested patient. Due to the urgency of the situation, CPR may be advised in patients who are subsequently found not to be in cardiac arrest. Ng and colleagues look at whether bystander CPR causes harm in this group of patients.

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

Resuscitation: 08 Dec 2021; epub ahead of print
Ferguson C
Resuscitation: 08 Dec 2021; epub ahead of print | PMID: 34896243
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Impact:
Abstract

Maximum expected survival rate model for public access defibrillator placement.

Pourghaderi AR, Kogtikov N, Lees MH, Cai W, ... Shao Wei Lam S, Eng Hock Ong M
Aim
Mathematical optimization of automated external defibrillator (AED) placement has demonstrated potential to improve survival of out-of-hospital cardiac arrest (OHCA). Existing models mostly aim to improve accessibility based on coverage radius and do not account for detailed impact of delayed defibrillation on survival. We aimed to predict OHCA survival based on time to defibrillation and developed an AED placement model to directly maximize the expected survival rate.
Methods
We stratified OHCAs occurring in Singapore (2010-2017) based on time to defibrillation and developed a regression model to predict the Utstein survival rate. We then developed a novel AED placement model, the maximum expected survival rate (MESR) model. We compared the performance of MESR with a maximum coverage model developed for Canada that was shown to be generalizable to other settings (Denmark). The survival gain of MESR was assessed through 10-fold cross-validation for placement of 20 to 1000 new AEDs in Singapore. Statistical analysis was performed using χ2 and McNemar\'s tests.
Results
During the study period, 15,345 OHCAs occurred. The power-law approximation with R2 of 91.33% performed best among investigated models. It predicted a survival of 54.9% with defibrillation within the first two minutes after collapse that was reduced by more than 60% without defibrillation within the first 4 minutes. MESR outperformed the maximum coverage model with P-value < 0.05 (<0.0001 in 22 of 30 experiments).
Conclusion
We developed a novel AED placement model based on the impact of time to defibrillation on OHCA outcomes. Mathematical optimization can improve OHCA survival.

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

Resuscitation: 05 Dec 2021; 170:213-221
Pourghaderi AR, Kogtikov N, Lees MH, Cai W, ... Shao Wei Lam S, Eng Hock Ong M
Resuscitation: 05 Dec 2021; 170:213-221 | PMID: 34883217
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Impact:
Abstract

Rearrest during hospitalisation in adult comatose out-of-hospital cardiac arrest patients: Risk factors and prognostic impact, and predictors of favourable long-term outcomes.

Jung YH, Jeung KW, Lee HY, Lee BK, ... Kim YM, Korean Hypothermia Network investigators
Background
Rearrest occurs commonly after initial resuscitation following out-of-hospital cardiac arrest (OHCA). We determined (1) the predictors of rearrest during hospitalisation that can be identified in the hours immediately after OHCA, (2) the association between rearrest and favourable long-term outcomes, and (3) the predictors of favourable long-term outcomes in rearrest patients.
Methods
Conditional multivariable logistic regression analyses were performed using the Korean Hypothermia Network prospective registry data, which included details of adult OHCA patients treated with targeted temperature management at 22 teaching hospitals in South Korea.
Results
Among the 1,233 patients, 260 (21.1%) experienced rearrest. Of the 192 patients resuscitated from first rearrest, 33 (17.2%) achieved 6-month favourable outcomes. Arrhythmia, heart failure, ST-segment elevation, lower initial Glasgow coma scale (GCS) motor score, higher initial lactate level, and antiarrhythmic drug use within 1 h were independently associated with rearrest. Higher lactate level and antiarrhythmic drug use were associated with shockable first rearrest, while arrhythmia, heart failure, ST-segment elevation, and lower GCS motor score were associated with non-shockable first rearrest. Rearrest was independently associated with a lower likelihood of 6-month favourable outcomes (P = 0.003). Initial shockable rhythm after OHCA, absence of diabetes, shorter cumulative time to restoration of spontaneous circulation, coronary angiography, and hypophosphataemia within 7 d were independently associated with 6-month favourable outcomes in the patients resuscitated from first rearrest.
Conclusions
Rearrest during hospitalisation after OHCA was inversely associated with 6-month favourable outcomes. We identified several risk factors for rearrest and prognostic factors for patients resuscitated from first rearrest.

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

Resuscitation: 02 Dec 2021; 170:150-159
Jung YH, Jeung KW, Lee HY, Lee BK, ... Kim YM, Korean Hypothermia Network investigators
Resuscitation: 02 Dec 2021; 170:150-159 | PMID: 34871759
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Impact:
Abstract

Impact of dispatcher-assisted cardiopulmonary resuscitation on performance of termination of resuscitation criteria.

Limkakeng AT, Ye JJ, Staton C, Ng YY, ... Ong MEH, Singapore PAROS Investigators
Background
Current Advanced Life Support Termination of Resuscitation (TOR) guidelines suggest when to cease cardiopulmonary resuscitation (CPR). With the significant increase of Dispatch-Assisted CPR (DA-CPR) programs, the impact of DA-CPR on the TOR criteria performance is not clear.
Methods
We conducted a secondary analysis of a prospectively collected registry, the Pan-Asian Resuscitation Outcomes Study. We included patients >15 years old with out-of-hospital cardiac arrest between 2014 and 2017 (after implementation of Singapore\'s DA-CPR program). We excluded patients with non-cardiac etiology, known do-not-resuscitate status, and healthcare provider bystanders. All cases were collected in accordance to Utstein standards. We evaluated the addition of DA-CPR to the diagnostic performance of TOR criteria using logistic regression modeling. The primary outcome was performance for predicting non-survival at 30 days. Sensitivity, specificity, and positive and negative predictive values were calculated.
Results
Of the 6009 cases, 319 (5.3%) were still alive at 30 days. Patients had a mean age of 67.9 (standard deviation 15.7) years and were mostly male and Chinese. Almost half of patients had no bystander CPR. The TOR criteria differentiating DA-CPR from unassisted bystander CPR has a specificity of 94% and predictive value of death of 99%, which was not significantly different from undifferentiated CPR criteria. There were differences in adjusted association with survival between unassisted and DA-CPR.
Conclusion
Advanced life support TOR criteria retain high specificity and predictive value of death in the context of DA-CPR. Further research should explore the differences between unassisted CPR and DA-CPR to understand differential survival outcomes.

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

Resuscitation: 02 Dec 2021; 170:160-166
Limkakeng AT, Ye JJ, Staton C, Ng YY, ... Ong MEH, Singapore PAROS Investigators
Resuscitation: 02 Dec 2021; 170:160-166 | PMID: 34871758
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Impact:
Abstract

Aetiology of resuscitated out-of-hospital cardiac arrest treated at hospital.

Wittwer MR, Zeitz C, Beltrame JF, Arstall MA
Introduction
Precipitating aetiology of out-of-hospital cardiac arrest (OHCA), as confirmed by diagnostic testing or autopsy, provides important insights into burden of OHCA and has potential implications for improving OHCA survivorship. This study aimed to describe the aetiology of non-traumatic resuscitated OHCAs treated at hospital within a local health network according to available documentation, and to investigate differences in outcome between aetiologies.
Methods
Observational retrospective cohort study of consecutive OHCA treated at hospital within a local health network between 2011-2016. Cases without sustained ROSC (≥20 minutes), unverified cardiac arrest, and retrievals to external acute care facilities were excluded. A single aetiology was determined from the hospital medical record and available autopsy results. Survival to hospital discharge was compared between adjudicated aetiologies.
Results
In the 314 included cases, distribution of precipitating aetiology was 53% cardiac, 18% respiratory, 3% neurological, 6% toxicological, 9% other, and 11% unknown. A presumed cardiac pre-hospital diagnosis was assigned in 235 (84%) cases, 20% of which were incorrect after exclusion of unknown cases. Rates of survival to hospital discharge varied significantly across aetiologies: cardiac 64%, respiratory 21%, neurological 0%, toxicological 58%, other 32% (p < 0.001). A two-fold difference in survival was observed between cardiac and non-cardiac aetiologies (64% versus 29%, excluding unknown, p < 0.001).
Conclusions
Non-cardiac aetiologies represented a substantial burden of resuscitated OHCA treated at hospital within a local health network and were associated with poor outcome. The results confirmed that true aetiology was not evident on initial examination in 1 in 5 cases with a pre-hospital cardiac diagnosis.

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

Resuscitation: 02 Dec 2021; 170:178-183
Wittwer MR, Zeitz C, Beltrame JF, Arstall MA
Resuscitation: 02 Dec 2021; 170:178-183 | PMID: 34871757
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Impact:
Abstract

Biomarkers associated with mortality in pediatric patients with cardiac arrest and acute respiratory distress syndrome.

Gardner MM, Kirschen MP, Wong HR, McKeone DJ, ... Topjian AA, Yehya N
Aims
To identify plasma biomarkers associated with cardiac arrest in a cohort of children with acute respiratory distress syndrome (ARDS), and to assess the association of these biomarkers with mortality in children with cardiac arrest and ARDS (ARDS + CA).
Methods
This was a secondary analysis of a single-center prospective cohort study of children with ARDS from 2014-2019 with 17 biomarkers measured. Clinical characteristics and biomarkers were compared between subjects with ARDS + CA and ARDS with univariate analysis. In a sub-cohort of ARDS + CA subjects, the association between biomarker levels and mortality was tested using univariate and bivariate logistic regression.
Results
Biomarkers were measured in 333 subjects: 301 with ARDS (median age 5.3 years, 55.5% male) and 32 ARDS + CA (median age 8 years, 53.1% male). More arrests (69%) occurred out-of-hospital with a median CPR duration of 11 (IQR 5.5, 25) minutes. ARDS severity, PRISM III score, vasoactive-ionotropic score and extrapulmonary organ failures were worse in the ARDS + CA versus ARDS group. Eight biomarkers were elevated in the ARDS + CA versus ARDS cohort: sRAGE, nucleosomes, SP-D, CCL22, IL-6, HSP70, IL-8, and MIP-1b. sRAGE, SP-D, and CCL22 remained elevated when the cohorts were matched for illness severity. When controlling for severity of ARDS and cardiac arrest characteristics, sRAGE, IL-6 and granzyme B were associated with mortality in the ARDS + CA group.
Conclusion
sRAGE, IL-6 and granzyme B were associated with cardiac arrest mortality when controlling for illness severity. sRAGE was consistently higher in the ARDS + CA cohort compared to ARDS and retained independent association with mortality.

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

Resuscitation: 02 Dec 2021; 170:184-193
Gardner MM, Kirschen MP, Wong HR, McKeone DJ, ... Topjian AA, Yehya N
Resuscitation: 02 Dec 2021; 170:184-193 | PMID: 34871756
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Impact:
Abstract

The association of race with CPR quality following out-of-hospital cardiac arrest.

Schmicker RH, Blewer A, Lupton JR, Aufderheide TP, ... Colella MR, Daya MR
Introduction
Previous studies have shown racial disparities in outcomes after out-of-hospital cardiac arrest. Although several treatment factors may account for these differences, there is limited information regarding differences in CPR quality and its effect on survival in underrepresented racial populations.
Methods
We conducted a secondary analysis of data from patients enrolled in the Pragmatic Airway Resuscitation Trial (PART). We calculated compliance rates with AHA 2015 high quality CPR metrics as well as compliance to intended CPR strategy (30:2 or continuous chest compression) based on the protocol in place for the first responding EMS agency. The primary analysis used general estimating equations logistic regression to examine differences between black and white patients based on EMS-assessed race after adjustment for potential confounders. Sensitivity analyses examined differences using alternate race definitions.
Results
There were 3004 patients enrolled in PART of which 1734 had > 2 minutes of recorded CPR data and an EMS-assessed race (1003 white, 555 black, 176 other). Black patients had higher adjusted odds of compression rate compliance (OR: 1.36, 95% CI: 1.02-1.81) and lower adjusted odds of intended CPR strategy compliance (OR: 0.78, 95% CI: 0.63-0.98) compared to white patients. Of 974 transported to the hospital, there was no difference in compliance metric estimates based on ED-reported race.
Conclusion
Compression rate compliance was higher in black patients however compliance with intended strategy was lower based on EMS-assessed race. The remaining metrics showed no difference suggesting that CPR quality differences are not important contributors to the observed outcome disparities by race.

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

Resuscitation: 02 Dec 2021; 170:194-200
Schmicker RH, Blewer A, Lupton JR, Aufderheide TP, ... Colella MR, Daya MR
Resuscitation: 02 Dec 2021; 170:194-200 | PMID: 34871755
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Impact:
Abstract

GFAp and tau protein as predictors of neurological outcome after out-of-hospital cardiac arrest: A post hoc analysis of the COMACARE trial.

Humaloja J, Lähde M, Ashton NJ, Matti R, ... Skrifvars MB, COMACARE Study Groups
Aim
To determine the ability of serum glial fibrillary acidic protein (GFAp) and tau protein to predict neurological outcome after out-of-hospital cardiac arrest (OHCA).
Methods
We measured plasma concentrations of GFAp and tau of patients included in the previously published COMACARE trial (NCT02698917) on intensive care unit admission and at 24, 48, and 72 h after OHCA, and compared them to neuron specific enolase (NSE). NSE concentrations were determined already during the original trial. We defined unfavourable outcome as a cerebral performance category (CPC) score of 3-5 six months after OHCA. We determined the prognostic accuracy of GFAp and tau using the receiver operating characteristic curve and area under the curve (AUROC).
Results
Overall, 39/112 (35%) patients had unfavourable outcomes. Over time, both markers were evidently higher in the unfavourable outcome group (p < 0.001). At 48 h, the median (interquartile range) GFAp concentration was 1514 (886-4995) in the unfavourable versus 238 (135-463) pg/ml in the favourable outcome group (p < 0.001). The corresponding tau concentrations were 99.6 (14.5-352) and 3.0 (2.2-4.8) pg/ml (p < 0.001). AUROCs at 48 and 72 h were 0.91 (95% confidence interval 0.85-0.97) and 0.91 (0.85-0.96) for GFAp and 0.93 (0.86-0.99) and 0.95 (0.89-1.00) for tau. Corresponding AUROCs for NSE were 0.86 (0.79-0.94) and 0.90 (0.82-0.97). The difference between the prognostic accuracies of GFAp or tau and NSE were not statistically significant.
Conclusions
At 48 and 72 h, serum both GFAp and tau demonstrated excellent accuracy in predicting outcomes after OHCA but were not superior to NSE.
Clinical trial registration
NCT02698917 (https://www.clinicaltrials.gov/ct2/show/NCT02698917).

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

Resuscitation: 30 Nov 2021; 170:141-149
Humaloja J, Lähde M, Ashton NJ, Matti R, ... Skrifvars MB, COMACARE Study Groups
Resuscitation: 30 Nov 2021; 170:141-149 | PMID: 34863908
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Impact:
Abstract

Feasibility of early waking cardiac arrest patients whilst receiving therapeutic hypothermia: The therapeutic hypothermia and early waking (THAW) trial.

Watson N, Karamasis G, Stathogiannis K, Potter M, ... Davies JR, Keeble TR
Aim
To determine the safety and feasibility of an early (12 h) waking and extubation protocol for out-of-hospital cardiac arrest (OHCA) patients receiving targeted temperature management (TTM).
Methods
This was a single-centre, prospective, non-randomised, observational, safety and feasibility pilot study which included successfully resuscitated OHCA patients, of presumed cardiac cause. Inclusion criteria were: OHCA patients aged over 18 years with a return of spontaneous circulation, who were going to receive TTM33 (TTM at 33 °C for 24 h and prevention of hyperthermia for 72 h) as part of their post cardiac arrest care. Clinical stability was measured against physiological and neurological parameters as well as clinical assessment.
Results
50 consecutive patients were included (median age 65.5 years, 82% male) in the study. Four (8%) patients died within the first twelve hours and were excluded from the final cohort (n = 46). Twenty-three patients (46%) were considered clinically stable and suitable for early waking based on the intention to treat analysis; 12 patients were extubated early based on a variety of clinical factors (21.4 ± 8.6 h) whilst continuing to receive TTM33 with a mean core temperature of 34.2 °C when extubated. Of these, five patients were discharged from the intensive care unit (ICU) <48 h after admission with a mean ICU length of stay 1.8 ± 0.4 days. Twenty-eight patients (56%) were discharged from the ICU with a modified Rankin Score of 0-2. The overall intra-hospital mortality was 50% (n = 25).
Conclusions
It is safe and feasible to wake selected comatose OHCA patients at 12 h, allowing for earlier positive neuro-prognostication and reduced ICU stay.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 26 Nov 2021; epub ahead of print
Watson N, Karamasis G, Stathogiannis K, Potter M, ... Davies JR, Keeble TR
Resuscitation: 26 Nov 2021; epub ahead of print | PMID: 34848275
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Impact:
Abstract

Development and validation of the SARICA score to predict survival after return of spontaneous circulation in out of hospital cardiac arrest using an interpretable machine learning framework.

Wong XY, Ang YK, Li K, Chin YH, ... Ho AFW, PAROS Singapore Investigators
Background
Accurate and timely prognostication of patients with out-of-hospital cardiac arrest (OHCA) who achieved the return of spontaneous circulation (ROSC) is crucial in clinical decision-making, resource allocation, and communications with next-of-kins. We aimed to develop the Survival After ROSC in Cardiac Arrest (SARICA), a practical clinical decision tool to predict survival in OHCA patients who attained ROSC.
Methods
We utilized real-world Singapore data from the population-based Pan-Asian Resuscitation Outcomes Study between 2010-2018. We excluded patients without ROSC. The dataset was segmented into training (60%), validation (20%) and testing (20%) cohorts. The primary endpoint was survival (to 30-days or hospital discharge). AutoScore, an interpretable machine-learning based clinical score generation algorithm, was used to develop SARICA. Candidate factors were chosen based on objective demographic and clinical factors commonly available at the time of admission. Performance of SARICA was evaluated based on receiver-operating curve (ROC) analyses.
Results
5970 patients were included, of which 855 (14.3%) survived. A three-variable model was determined to be most parsimonious. Prehospital ROSC, age, and initial heart rhythm were identified for inclusion via random forest selection. Finally, SARICA consisted of these 3 variables and ranged from 0 to 10 points, achieving an area under the ROC (AUC) of 0.87 (95% confidence interval: 0.84-0.90) within the testing cohort.
Conclusion
We developed and internally validated the SARICA score to accurately predict survival of OHCA patients with ROSC at the time of admission. SARICA is clinically practical and developed using an interpretable machine-learning framework. SARICA has unknown generalizability pending external validation studies.

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

Resuscitation: 25 Nov 2021; 170:126-133
Wong XY, Ang YK, Li K, Chin YH, ... Ho AFW, PAROS Singapore Investigators
Resuscitation: 25 Nov 2021; 170:126-133 | PMID: 34843878
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Impact:
Abstract

Impact of the three COVID-19 surges in 2020 on in-hospital cardiac arrest survival in the United States.

Gupta K, Girotra S, Nallamothu BK, Kennedy K, ... Chan PS, American Heart Association\'s Get With the Guidelines®-Resuscitation Investigators (listed in Supplementary Appendix)
Background
Studies have reported lower survival for in-hospital cardiac arrest (IHCA) during the initial COVID-19 surge. Whether the pandemic reduced IHCA survival during subsequent surges and in areas with lower COVID-19 rates is unknown.
Methods
Within Get-With-The-Guidelines®-Resuscitation, we identified 22,899 and 79,736 IHCAs during March to December in 2020 and 2015-2019, respectively. Using hierarchical regression, we compared risk-adjusted rates of survival to discharge in 2020 vs. 2015-19 during five COVID-19 periods: Surge 1 (March to mid-May), post-Surge 1 (mid-May to June), Surge 2 (July to mid-August), post-Surge 2 (mid-August to mid-October), and Surge 3 (mid-October to December). Monthly COVID-19 mortality rates for each hospital\'s county were categorized, per 1,000,000 residents, as very low (0-10), low (11-50), moderate (51-100), or high (>100).
Results
During each COVID-19 surge period in 2020, rates of survival to discharge for IHCA were lower, as compared with the same period in 2015-2019: Surge 1: adjusted OR: 0.81 (0.75-0.88); Surge 2: adjusted OR: 0.88 (0.79-0.97), Surge 3: adjusted OR: 0.79 (0.73-0.86). Lower survival was most pronounced at hospitals located in counties with moderate to high monthly COVID-19 mortality rates. In contrast, during the two post-surge periods, survival rates were similar in 2020 vs. 2015-2019: post-Surge 1: adjusted OR 0.93 (0.83-1.04) and post-Surge 2: adjusted OR 0.94 (0.86-1.03), even at hospitals with the highest county-level COVID-19 mortality rates.
Conclusions
During the three COVID-19 surges in the U.S. during 2020, rates of survival to discharge for IHCA dropped substantially, especially in communities with moderate to high COVID-19 mortality rates.

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

Resuscitation: 23 Nov 2021; 170:134-140
Gupta K, Girotra S, Nallamothu BK, Kennedy K, ... Chan PS, American Heart Association's Get With the Guidelines®-Resuscitation Investigators (listed in Supplementary Appendix)
Resuscitation: 23 Nov 2021; 170:134-140 | PMID: 34838661
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Impact:
Abstract

The inflammatory response is related to circulatory failure after out-of-hospital cardiac arrest: A prospective cohort study.

Langeland H, Damås JK, Mollnes TE, Ludviksen JK, ... Skjærvold NK, Klepstad P
Background
Whole body ischemia and reperfusion injury after cardiac arrest leads to the massive inflammation clinically manifested in the post-cardiac arrest syndrome. Previous studies on the inflammatory effect on circulatory failure after cardiac arrest have either investigated a selected patient group or a limited part of the inflammatory mechanisms. We examined the association between cardiac arrest characteristics and inflammatory biomarkers, and between inflammatory biomarkers and circulatory failure after cardiac arrest, in an unselected patient cohort.
Methods
This was a prospective study of 50 consecutive patients with out-of-hospital cardiac arrest. Circulation was invasively monitored from admission until day five, whereas inflammatory biomarkers, i.e. complement activation, cytokines and endothelial injury, were measured daily. We identified predictors for an increased inflammatory response, and associations between the inflammatory response and circulatory failure.
Results
We found a marked and broad inflammatory response in patients after cardiac arrest, which was associated with clinical outcome. Long time to return of spontaneous circulation and high lactate level at admission were associated with increased complement activation (TCC and C3bc), pro-inflammatory cytokines (IL-6, IL-8) and endothelial injury (syndecan-1) at admission. These biomarkers were in turn significantly associated with lower mean arterial blood pressure, lower cardiac output and lower systemic vascular resistance, and increased need of circulatory support in the initial phase. High levels of TCC and IL-6 at admission were significantly associated with increased 30-days mortality.
Conclusion
Inflammatory biomarkers, including complement activation, cytokines and endothelial injury, were associated with increased circulatory failure in the initial period after cardiac arrest.

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

Resuscitation: 23 Nov 2021; 170:115-125
Langeland H, Damås JK, Mollnes TE, Ludviksen JK, ... Skjærvold NK, Klepstad P
Resuscitation: 23 Nov 2021; 170:115-125 | PMID: 34838662
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Impact:
Abstract

Prevalence of anxiety, depression, and post-traumatic stress disorder after cardiac arrest: A systematic review and meta-analysis.

Yaow CYL, Teoh SE, Lim WS, Wang RSQ, ... Ng QX, Ho AFW
Aim
Quality of life after surviving out-of-hospital cardiac arrest (OHCA) is poorly understood, and the risk to mental health is not well understood. We aimed to estimate the prevalence of anxiety, depression, and post-traumatic stress disorder (PTSD) following OHCA.
Methods
In this systematic review and meta-analysis, databases (MEDLINE, EMBASE, and PsycINFO) were searched from inception to July 3, 2021, for studies reporting the prevalence of depression, anxiety, and PTSD among OHCA survivors. Data abstraction and quality assessment were conducted by two authors independently, and a third resolved discrepancies. A single-arm meta-analysis of proportions was conducted to pool the proportion of patients with these conditions at the earliest follow-up time point in each study and at predefined time points. Meta-regression was performed to identify significant moderators that contributed to between-study heterogeneity.
Results
The search yielded 15,366 articles. 13 articles were included for analysis, which comprised 186,160 patients. The pooled overall prevalence at the earliest time point of follow-up was 19.0% (11 studies; 95% confidence interval [CI] = 11.0-30.0%) for depression, 26.0% (nine studies; 95% CI = 16.0-39.0%) for anxiety, and 20.0% (three studies; 95% CI = 3.0-65.0%) for PTSD. Meta-regression showed that the age of patients and proportion of female sex were non-significant moderators.
Conclusion
The burden of mental health disorders is high among survivors of OHCA. There is an urgent need to understand the predisposing risk factors and develop preventive strategies.

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

Resuscitation: 22 Nov 2021; 170:82-91
Yaow CYL, Teoh SE, Lim WS, Wang RSQ, ... Ng QX, Ho AFW
Resuscitation: 22 Nov 2021; 170:82-91 | PMID: 34826580
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Impact:
Abstract

Percutaneous angio-guided versus surgical veno-arterial ECLS implantation in patients with cardiogenic shock or cardiac arrest.

Saiydoun G, Gall E, Boukantar M, Fiore A, ... Teiger E, Gallet R
Background
Veno-arterial Extracorporeal Life Support (V-A ECLS) has gained increasing place into the management of patients with refractory cardiogenic shock or cardiac arrest. Both surgical and percutaneous approach can be used for cannulation, but percutaneous approach has been associated with fewer complications. Angio-guided percutaneous cannulation and decannulation may further decrease the rate of complication. We aimed to compare outcome and complication rates in patients supported with V-A ECLS through percutaneous angio-guided versus surgical approach.
Methods
We included all patients with emergent peripheral femoro-femoral V-A ECLS implantation for refractory cardiogenic shock or cardiac arrest in our center from March 2018 to March 2021. Survival and major complications (major bleeding, limb ischemia and groin infection) rates were compared between the percutaneous angio-guided and the surgical groups.
Results
One hundred twenty patients received V-A ECLS, 59 through surgical approach and 61 through angio-guided percutaneous approach. Patients\' baseline characteristics and severity scores were equally balanced between the 2 groups. Thirty-day mortality was not significantly different between the 2 approaches. However, angio-guided percutaneous cannulation was associated with fewer major vascular complications (42% vs. 11%, p > 0.0001) and a higher rate of V-A ECLS decannulation. In multivariate analysis, percutaneous angio-guided implantation of V-A ECLS was independently associated with a lower probability of major complications.
Conclusion
Compared to surgical approach, angio-guided percutaneous V-A ECLS implantation is associated with fewer major vascular complications. Larger studies are needed to confirm those results and address their impact on mortality.

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

Resuscitation: 22 Nov 2021; 170:92-99
Saiydoun G, Gall E, Boukantar M, Fiore A, ... Teiger E, Gallet R
Resuscitation: 22 Nov 2021; 170:92-99 | PMID: 34826577
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Impact:
Abstract

Serum levels of the cold stress hormones FGF21 and GDF-15 after cardiac arrest in infants and children enrolled in single center therapeutic hypothermia clinical trials.

Herrmann JR, Fink EL, Fabio A, Au AK, ... Kochanek PM, Jackson TC
Objective
Fibroblast Growth Factor 21 (FGF21) and Growth Differentiation Factor-15 (GDF-15) are putative neuroprotective cold stress hormones (CSHs) provoked by cold exposure that may be age-dependent. We sought to characterize serum FGF21 and GDF-15 levels in pediatric cardiac arrest (CA) patients and their association with use of therapeutic hypothermia (TH).
Methods
Secondary analysis of serum samples from clinical trials. We measured FGF21 and GDF-15 levels in pediatric patients post-CA and compared levels to both pediatric intensive care (PICU) and healthy controls. Post-CA, we compared normothermia (NT) vs TH (33 °C for 72 h) treated cohorts at < 24 h, 24 h, 48 h, 72 h, and examined the change in CSHs over 72 h. We also assessed association between hospital mortality and initial levels.
Results
We assessed 144 samples from 68 patients (27 CA [14 TH, 13 NT], 9 PICU and 32 healthy controls). Median initial FGF21 levels were higher post-CA vs. healthy controls (392 vs. 40 pg/mL, respectively, P < 0.001). Median GDF-15 levels were higher post-CA vs. healthy controls (7,089 vs. 396 pg/mL, respectively, P < 0.001). In the CA group, the median change in FGF21 from PICU day 1-3 (after 72 h of temperature control), was higher in TH vs. NT (231 vs. -20 pg/mL, respectively, P < 0.05), with no difference in GDF-15 over time. Serum GDF-15 levels were higher in CA patients that died vs. survived (19,450 vs. 5,337 pg/mL, respectively, P < 0.05), whereas serum FGF21 levels were not associated with mortality.
Conclusion
Serum levels of FGF21 and GDF-15 increased after pediatric CA, and FGF21 appears to be augmented by TH.

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

Resuscitation: 21 Nov 2021; epub ahead of print
Herrmann JR, Fink EL, Fabio A, Au AK, ... Kochanek PM, Jackson TC
Resuscitation: 21 Nov 2021; epub ahead of print | PMID: 34822938
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Impact:
Abstract

Effects of pre-hospital re-arrest on outcomes based on transfer to a heart attack centre in patients with out-of-hospital cardiac arrest.

Yoon H, Ahn KO, Park JH, Lee SY
Aim
We aimed to investigate the interaction effects between transfer to a heart attack centre [HAC] and prehospital re-arrest on the clinical outcomes of patients with out-of-hospital cardiac arrest [OHCA].
Methods
We included adult patients with OHCA of presumed cardiac aetiology from January 2012 to December 2018. The main exposure variable was prehospital re-arrest, defined as recurrence of cardiac arrest with a loss of palpable pulse upon hospital arrival. The other exposure variable was the resuscitation capacity of the receiving hospital [HAC or Non-HAC]. The outcome variable was neurological recovery. A multivariable logistic regression was performed to determine the interaction effects.
Results
The final analysis included 6935 patients. Of these, 21.9% (n = 1521) experienced prehospital re-arrest, whereas 41.3% (n = 2866) were transferred to a non-HAC. The prehospital re-arrest group associated with poor neurological recovery (adjusted odds ratio [AOR], 0.25; 95% confidence interval [CI], 0.21-0.29;). Transfer to an HAC had beneficial effects on neurological recovery (AOR, 3.40 [95% CI, 3.04-3.85]. In the interaction model, wherein prehospital re-arrest patients who were transferred to a non-HAC were used as reference, the AOR of prehospital re-arrest patients who were transferred to an HAC, non-re-arrest patients who were transferred to a non-HAC, and non-re-arrest patients who were transferred to a non-HAC was 2.41 (95% CI, 1.73-3.35), 3.09 (95% CI, 2.33-4.10), and 11.07 (95% CI, 8.40-14.59) respectively (interaction p = 0.001).
Conclusion
Transport to a heart attack centre was beneficial to the clinical outcomes of patients who achieved prehospital ROSC after OHCA. The magnitude of that benefit was significantly modified by whether prehospital re-arrest had occurred.

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

Resuscitation: 21 Nov 2021; 170:107-114
Yoon H, Ahn KO, Park JH, Lee SY
Resuscitation: 21 Nov 2021; 170:107-114 | PMID: 34822934
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Impact:
Abstract

Predictors of poor outcome after extra-corporeal membrane oxygenation for refractory cardiac arrest (ECPR): A post hoc analysis of a multicenter database.

Halenarova K, Belliato M, Lunz D, Peluso L, ... Pappalardo F, Taccone FS
Background
The objective was to assess predictors for unfavorable neurological outcome (UO) in out-of-hospital (OHCA) and in-hospital (IHCA) cardiac arrest patients treated with Extracorporeal cardiopulmonary resuscitation (ECPR).
Methods
A post hoc analysis of retrospective data from five European ECPR centers (January 2012-December 2016) was performed. The primary composite endpoint was 3-month UO defined as survival with a cerebral performance category (CPC) of 3-4 or death (CPC 5).
Results
A total of 413 patients treated with ECPR were included (median age was 57 [48-65] years, male gender 78%): 61% of patients (n = 250) suffered OHCA. The median time from collapse to ECMO placement was 63 [45-82] minutes. Overall, 81% patients (n = 333) showed unfavorable UO, which was higher in OHCA patients (90% vs 66%), as compared to IHCA. In OHCA, prolonged time from collapse to ECMO initiation (OR 1.02, p < 0.01) and higher ECMO blood flow (OR 1.99, p = 0.01) were associated with UO while initial shockable rhythm (OR 0.04, p < 0.01), previous heart disease (OR 0.20, p < 0.01) and pre-hospital hypothermia (OR 0.08, p < 0.01) had a protective role. In IHCA, prolonged time from arrest to ECMO implantation (OR 1.02, p = 0.03), high lactate level on admission (OR 1.15, p < 0.01) and higher body weight (OR 1.03, p < 0.01) were independently associated with UO.
Conclusions
IHCA and OHCA patients receiving ECPR have different predictors of UO at presentation, suggesting that selection criteria for ECPR should be decided according to the location of CA. After ECMO initiation, ECMO blood flow management and mean arterial pressure targets might also impact neurological recovery.

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

Resuscitation: 21 Nov 2021; 170:71-78
Halenarova K, Belliato M, Lunz D, Peluso L, ... Pappalardo F, Taccone FS
Resuscitation: 21 Nov 2021; 170:71-78 | PMID: 34822932
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Impact:
Abstract

Predictors and outcomes of cardiac arrest in the emergency department and in-patient settings in the United States (2016-2018).

Mir T, Qureshi WT, Uddin M, Soubani A, ... Rab T, Kakouros N
Background
Outcomes of cardiac arrest (CA) remain dismal despite therapeutic advances. Literature is limited regarding outcomes of CA in emergency departments (ED).
Objective
To study the possible causes, predictors, and outcomes of CA in ED and in-patient settings throughout the United States (US).
Methods
Data from the US national emergency department sample (NEDS) was analyzed for the episodes of CA for 2016-2018. In-hospital CA was divided into in-patient (IPCA) and in the ED (EDCA). Only patients who had cardiopulmonary resuscitation (CPR) within the hospital were included in the study (out-of-hospital were excluded).
Results
A total of 1,068,847 CA (mean age 63.7 ± 19.4 years, 24%females), of whom 325,062 (30.4%) EDCA and 177,104 (16.6%) IPCA were included in the study. Patients without CPR, 743,785 (69.6%), were excluded. Survival was higher among IPCA 55,821 (31.6%) than the EDCA 32,516 (10%). IPCA encounters had multifactorial associated etiologies including respiratory failure (73%), acidosis (38.7%) sepsis (36.8%) and ST-elevated myocardial infarction (STEMI) (7.3%). Majority of ED arrests (67.1%) had no possible identifiable cause. The predominant known causes include intoxication (7.5%), trauma (6.4%), respiratory failure (5%), and STEMI (2.7%). Cardiovascular interventions had significant survival benefits in IPCA on univariate logistic regression after coarsened exact matching for comorbidities. IPCA had higher intervention rates than EDCA. For all live discharges, a total of 40% of patients were discharged to hospice.
Conclusion
Survival remains dismal among CA patients especially those occurring in the ED. Given that there are considerable variations in the etiology between the two studied cohorts, more research is required to improve the understanding of these factors, which may improve survival outcomes.

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

Resuscitation: 18 Nov 2021; 170:100-106
Mir T, Qureshi WT, Uddin M, Soubani A, ... Rab T, Kakouros N
Resuscitation: 18 Nov 2021; 170:100-106 | PMID: 34801637
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Impact:
Abstract

Socio-demographic characteristics of basic life support course participants in Denmark.

Jensen TW, Folke F, Andersen MP, Blomberg SN, ... Torp-Pedersen C, Christensen HC
Background
Bystander-initiated basic life support (BLS) plays an important role in improving survival after out-of-hospital cardiac arrest. In 2009, laws mandating BLS course participation when acquiring a driver\'s licence were implemented in Denmark. The aim of this study was to characterise Danish BLS course participants.
Methods
This study is a Danish, registry-based, follow-up study that examined all Danish BLS course participants from 2016 to 2019. Data concerning BLS course participation were supplied by the major Danish BLS course providers. Socio-economic and healthcare data on all Danish inhabitants were assessed using national registers from Statistics Denmark.
Results
Between January 1, 2016, and January 1, 2020, 3.6% of the entire adult population of Denmark attended certified BLS courses annually. Since the implementation of a law mandating BLS course participation when acquiring a driver licence in 2009, approximately 44% of the adult population has participated in a BLS course. BLS course participants were commonly younger and healthier than the general population (mean 31.3 years old vs. 51.3 years old, P < 0.001). Furthermore, law-mandated BLS course participants had a lower disposable income (adjusted OR: 0.23; 95% CI: 0.23-0.23; P < 0.001) and were more likely to live in rural areas (adjusted OR: 0.57; 95% CI: 0.57-0.58; P < 0.001).
Conclusion
In Denmark, 3.6% of the entire adult population attend certified courses annually. BLS participants are commonly male, younger, healthier, less likely to have small children in the household, and more likely to live in rural areas. Law-mandated BLS course participation prior to acquiring a driver\'s licence has been successful in reaching segments of the society that are known to have limited participation.

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

Resuscitation: 15 Nov 2021; 170:167-177
Jensen TW, Folke F, Andersen MP, Blomberg SN, ... Torp-Pedersen C, Christensen HC
Resuscitation: 15 Nov 2021; 170:167-177 | PMID: 34798179
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Impact:
Abstract

Faster time to automated elevation of the head and thorax during cardiopulmonary resuscitation increases the probability of return of spontaneous circulation.

Moore JC, Duval S, Lick C, Holley J, ... Lurie KG, Pepe PE
Objectives
Resuscitation in the Head Up position improves outcomes in animals treated with active compression decompression cardiopulmonary resuscitation and an impedance threshold device (ACD + ITD CPR).We assessed impact of time to deployment of an automated Head Up position (AHUP) based bundle of care after out-of-hospital cardiac arrest on return of spontaneous circulation (ROSC).
Methods
Observational data were analyzed from a patient registry. Patients received treatment with 1) ACD + and/or automated CPR 2) an ITD and 3) an AHUP device. Probability of ROSC (ROSCprob) from the 9-1-1 call to AHUP device placement was assessed with a restricted cubic spline model and linear regression.
Results
Of 11 sites, 6 recorded the interval from 9-1-1 to AHUP device (n = 227). ROSCprobfor all rhythms was 34%(77/227). Median age (range) was 66 years (19-101) and 68% men. TheROSCprobfor shockable rhythms was 47%(18/38). Minutes from 9-1-1 to AHUP device (median, range) varied between sites: 1) 6.4(4,15), 2) 8.0(5,19), 3) 9.9(4, 12), 4) 14.1(6, 36), 5) 15.9(6, 34), 6) 19.0(8, 38),(p = 0.0001).ROSCprobalso varied; 1) 55.1%(16/29), 2) 60%(3/5), 3) 50%(3/6), 4) 22.7%(17/75), 5) 26.4%(9/34), and 6) 37.1%(29/78), (p = 0.019). For all rhythms between 4 and 12 min (n = 85),ROSCprobdeclined 5.6% for every minute elapsed (p = 0.024). For shockable rhythms, between 6 and 15 min (n = 23),ROSCprobdeclined 9.0% for every minute elapsed (p = 0.006).
Conclusions
Faster time to deployment of an AHUP based bundle of care is associated with higher incidence of ROSC. This must be considered when evaluating and implementing this bundle.

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

Resuscitation: 14 Nov 2021; 170:63-69
Moore JC, Duval S, Lick C, Holley J, ... Lurie KG, Pepe PE
Resuscitation: 14 Nov 2021; 170:63-69 | PMID: 34793874
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Impact:
Abstract

Temporal Trends, Predictors and Outcomes of Inpatient Palliative Care Use in Cardiac Arrest Complicating Acute Myocardial Infarction.

Kanwar A, Patlolla SH, Singh M, Murphree DH, ... Nicholson WJ, Vallabhajosyula S
Background
Utilization of inpatient palliative care services (PCS) has been infrequently studied in patients with cardiac arrest complicating acute myocardial infarction (AMI-CA).
Methods
Adult AMI-CA admissions were identified from the National Inpatient Sample (2000-2017). Outcomes of interest included temporal trends and predictors of PCS use and in-hospital mortality, length of stay, hospitalization costs and discharge disposition in AMI-CA admissions with and without PCS use. Multivariable logistic regression and propensity matching were used to adjust for confounding.
Results
Among 584,263 AMI-CA admissions, 26,919 (4.6%) received inpatient PCS. From 2000 to 2017 PCS use increased from <1% to 11.5%. AMI-CA admissions that received PCS were on average older, had greater comorbidity, higher rates of cardiogenic shock, acute organ failure, lower rates of coronary angiography (48.6% vs 63.3%), percutaneous coronary intervention (37.4% vs 46.9%), and coronary artery bypass grafting (all p < 0.001). Older age, greater comorbidity burden and acute non-cardiac organ failure were predictive of PCS use. In-hospital mortality was significantly higher in the PCS cohort (multivariable logistic regression: 84.6% vs 42.9%, adjusted odds ratio 3.62 [95% CI 3.48-3.76]; propensity-matched analysis: 84.7% vs. 66.2%, p < 0.001). The PCS cohort received a do- not-resuscitate status more often (47.6% vs. 3.7%), had shorter hospital stays (4 vs 5 days), and were discharged more frequently to skilled nursing facilities (73.6% vs. 20.4%); all p < 0.001. These results were consistent in the propensity-matched analysis.
Conclusions
Despite an increase in PCS use in AMI-CA, it remains significantly underutilized highlighting the role for further integrating of these specialists in AMI-CA care.

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

Resuscitation: 11 Nov 2021; 170:53-62
Kanwar A, Patlolla SH, Singh M, Murphree DH, ... Nicholson WJ, Vallabhajosyula S
Resuscitation: 11 Nov 2021; 170:53-62 | PMID: 34780813
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Impact:
Abstract

2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

Wyckoff MH, Singletary EM, Soar J, Olasveengen TM, ... Berg KM, COVID-19 working group
The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 10 Nov 2021; epub ahead of print
Wyckoff MH, Singletary EM, Soar J, Olasveengen TM, ... Berg KM, COVID-19 working group
Resuscitation: 10 Nov 2021; epub ahead of print | PMID: 34776269
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Impact:
Abstract

PulsePoint dispatch associated patient characteristics and prehospital outcomes in a mid-sized metropolitan area.

Smida T, Salerno J, Weiss L, Martin-Gill C, Salcido DD
Background
Mobile phone-based dispatch of volunteers to out-of-hospital cardiac arrests (OHCA) has been shown to increase the likelihood of early CPR and AED application. In the United States, limited characterization of patients encountered as a result of such systems exists.
Aims
Examine prehospital case characteristics and outcomes from a multi-year deployment of PulsePoint Respond in Pittsburgh, Pennsylvania.
Methods
PulsePoint event timing, location, and associated prehospital electronic health records (ePCRs) were obtained for EMS-encountered OHCA cases that did and did not generate PulsePoint alerts within the service area of Pittsburgh EMS from July 2016 to October 2020. ePCRs were reviewed and OHCA case characteristics were extracted according to the Utstein template. PulsePoint-associated OHCA and non-PulsePoint-associated OHCA were compared.
Results
Of 840 total PulsePoint dispatches, 64 (7.6%) were for OHCA associated with a resuscitation attempt. Forty-one (64.1%) were witnessed, 38 (59.4%) received bystander CPR, and 13 (20.0%) of these patients had an AED applied prior to EMS arrival. Twenty-seven (39.7%) had an initial shockable rhythm, and 31 (48.4%) patients achieved ROSC in the field. In the city of Pittsburgh, there were 1229 total OHCA during the study period, with an estimated 29.6% occurring in public. When PulsePoint-associated and publicly occurring non-PulsePoint-associated OHCA were compared, baseline characteristics (age, sex, witnessed status) were similar, but PulsePoint-associated OHCA received more bystander CPR (p = 0.008).
Conclusions
A minority of PulsePoint dispatches in Pittsburgh were triggered by true OHCA. The majority of OHCA during the study period occurred within private residences where PulsePoint responders are not currently dispatched. PulsePoint dispatches were associated with prognostically favorable OHCA characteristics and increased bystander CPR performance.

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

Resuscitation: 10 Nov 2021; 170:36-43
Smida T, Salerno J, Weiss L, Martin-Gill C, Salcido DD
Resuscitation: 10 Nov 2021; 170:36-43 | PMID: 34774964
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Impact:
Abstract

Wellbeing, emotional response and stress among lay responders dispatched to suspected out-of-hospital cardiac arrests.

Berglund E, Olsson E, Jonsson M, Svensson L, ... Högstedt Å, Ringh M
Background
Systems for smartphone dispatch of lay responders to perform cardio-pulmonary resuscitation (CPR) and bring automated external defibrillators to out-of-hospital cardiac arrests (OHCAs) are advocated by recent international guidelines and emerging worldwide.
Objectives
This study aimed to investigate the emotional responses, posttraumatic stress reactions and levels of wellbeing among smartphone-alerted lay responders dispatched to suspected OHCAs.
Methods
Lay responders were stratified by level of exposure: unexposed (Exp-0), tried to reach (Exp-1), and reached the suspected OHCA (Exp-2). Participants rated their emotional responses online, at 90 minutes and at 4-6 weeks after an incident. Level of emotional response was measured in two dimensions of core affect: \"alertness\" - from deactivation to activation, and \"pleasantness\" - from unpleasant to pleasant. At 4-6 weeks, WHO wellbeing index and level of posttraumatic stress (PTSD) were also rated.
Results
Altogether, 915 (28%) unexposed and 1471 (64%) exposed responders completed the survey. Alertness was elevated in the exposed groups: Exp-0: 6.7 vs. Exp-1: 7.3 and Exp-2: 7.5, (p < 0.001) and pleasantness was highest in the unexposed group: 6.5, vs. Exp-1: 6.3, and Exp-2: 6.1, (p < 0.001). Mean scores for PTSD at follow-up was below clinical cut-off, Exp-0: 9.9, Exp-1: 8.9 and Exp-2: 8.8 (p = 0.065). Wellbeing index showed no differences, Exp-0: 78.0, Exp-1: 78.5 and Exp-2: 79.9 (p = 0.596).
Conclusion
Smartphone dispatched lay responders rated the experience as high-energy and mainly positive. No harm to the lay responders was seen. The exposed groups had low posttraumatic stress scores and high-level general wellbeing at follow-up.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 09 Nov 2021; epub ahead of print
Berglund E, Olsson E, Jonsson M, Svensson L, ... Högstedt Å, Ringh M
Resuscitation: 09 Nov 2021; epub ahead of print | PMID: 34774709
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Impact:
Abstract

Geographic variation and temporal trends in management and outcomes of cardiac arrest complicating acute myocardial infarction in the United States.

Atreya AR, Patlolla SH, Devireddy CM, Jaber WA, ... King SB, Vallabhajosyula S
Background
Limited studies have evaluated regional disparities in the care of acute myocardial infarction (AMI) patients with cardiac arrest (CA). This study sought to evaluate 18-year national trends, resource utilization, and geographical variation in outcomes in AMI-CA admissions.
Methods and results
Using the National Inpatient Sample (2000-2017), we identified adults with AMI and concomitant CA admitted to the United States census regions of Northeast, Midwest, South, and West. Clinical outcomes of interest included in-hospital mortality, use of coronary angiography, percutaneous coronary intervention (PCI), mechanical circulatory support (MCS), hospitalization costs and length of stay. Of 9,680,257 admissions for AMI, 494,083 (5.1%) had concomitant CA. The West (6.0%) had higher prevalence compared to the Northeast (4.4%), Midwest (5.0%), and South (5.1%), p < 0.001. Admissions in the West had higher rates of STEMI, cardiogenic shock, multiorgan failure, mechanical ventilation, and hemodialysis. Northeast admissions had lower use of coronary angiography (52.0% vs. 67.9% vs. 60.9% vs. 61.5%), PCI (38.7% vs. 51.9% vs. 44.8% vs. 46.7%), and MCS (18.4% vs. 21.8% vs. 18.1%, vs. 20.0%) compared to the Midwest, West and South (all p < 0.001). Compared with the Northeast, adjusted in-hospital mortality was higher in the Midwest (odds ratio [OR] 1.06 [95% confidence interval {CI} 1.03-1.08]), South (OR 1.11 [95% CI 1.09-1.13]) and highest in the West (OR 1.16 [95% CI 1.13-1.18]), all p < 0.001. Temporal trends showed a decline in in-hospital mortality except in the West, which showed a slight increase.
Conclusions
There remain significant regional disparities in the management and outcomes of AMI-CA.

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

Resuscitation: 08 Nov 2021; epub ahead of print
Atreya AR, Patlolla SH, Devireddy CM, Jaber WA, ... King SB, Vallabhajosyula S
Resuscitation: 08 Nov 2021; epub ahead of print | PMID: 34767902
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Impact:
Abstract

Longer retrieval distances to the automated external defibrillator reduces survival after out-of-hospital cardiac arrest.

Sarkisian L, Mickley H, Schakow H, Gerke O, ... Jørgensen G, Henriksen FL
Aims
To evaluate and compare survival after out-of-hospital (OHCA), where an automated external defibrillator (AED) was used, in densely, moderately and thinly populated areas. Also, to evaluate the association between AED retrieval distance and survival after OHCA.
Methods
From 2014 to 2018, AEDs used during OHCA in the region of Southern Denmark were systematically collected. OHCAs were included if the OHCA address was known. OHCAs at nursing homes were excluded. To evaluate population density, a map with 1000 × 1000 meter grid cells was used with each cell color-graded according to the number of inhabitants. Densely, moderately and thinly populated areas were defined as ≥200 inhabitants, 20-199 inhabitants and 0-19 inhabitants per km2, respectively. Primary outcome was 30-day survival.
Results
A total of 423 cases of OHCA were included, of which 207 (49%) occurred in densely populated areas, while 78 (18%) and 138 (33%) occurred in moderately and thinly populated areas, respectively. AED retrieval distances were: densely populated 105 m (IQR 5-450), moderately populated 220 m (IQR 5-450) and thinly populated 350 m (IQR 5-1500) (P < 0.001). Thirty-day survival was 40%, 31% and 34%, respectively (P = 0.3). In a multivariable regression analysis, mortality increased with 10% per 100 m an AED was placed further away from the site of OHCA.
Conclusion
Survival after OHCA, where an AED was used, did not seem to differ in thinly, moderately and densely populated areas. The length of the AED retrieval distance, however, was correlated with reduced survival after adjusting for other potentially explanatory variables.

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

Resuscitation: 08 Nov 2021; 170:44-52
Sarkisian L, Mickley H, Schakow H, Gerke O, ... Jørgensen G, Henriksen FL
Resuscitation: 08 Nov 2021; 170:44-52 | PMID: 34767901
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Impact:
Abstract

Distal femur versus humeral or tibial IO, access in adult out of hospital cardiac resuscitation.

Rayas EG, Winckler C, Bolleter S, Stringfellow M, ... Lewis A, Wampler D
Background
Intraosseous (IO) vascular access is a well-established method for fluid and drug administration in the critically ill. The Food and Drug Administration has approved adult IO access at the proximal humerus, proximal tibia, and the sternum; all three sites have significant limitations. The Distal Femur is away from the chest, with high flow rates. The objective of this study was to evaluate the distal femur site during resuscitation of adult out-of-hospital cardiac arrest.
Methods
A retrospective analysis of adult out of hospital cardiac arrest patients treated by the San Antonio Fire Department. IO access was obtained by first-responders (paramedics or EMT-basic) or EMS paramedics. All resuscitation attempts from 2017 to 2018 data were analyzed. The protocol did not dictate the preference of IO site. The primary measure: number of OHCA patients in each subgroup: IO femur, IO humerus, IO tibia. Secondary measures: paramedic or basic operator, dislodgement rate, and total fluid infused.
Results
There were 2,198 patients meeting inclusion criteria: 888 femur, 696 humerus, 432 tibia. Distal femur increased 2.5 times in the 2018 cohort compared to the 2017 cohort, with a corresponding decrease in humerus (factor of 0.29). Proximal tibia remained unchanged. Dislodgement rates and total infusion (ml) remained unchanged.
Conclusions
The distal femur IO was feasible and associated with similar measured performance parameters as other IO sites in adult OHCA for both advanced and basic life support personnel.

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

Resuscitation: 04 Nov 2021; 170:11-16
Rayas EG, Winckler C, Bolleter S, Stringfellow M, ... Lewis A, Wampler D
Resuscitation: 04 Nov 2021; 170:11-16 | PMID: 34748766
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Impact:
Abstract

Bystander cardiopulmonary resuscitation for paediatric out-of-hospital cardiac arrest in England: An observational registry cohort study.

Albargi H, Mallett S, Berhane S, Booth S, ... Foster T, Scholefield B
Introduction
Bystander cardiopulmonary resuscitation (BCPR) is strongly advocated by resuscitation councils for paediatric out-of-hospital cardiac arrests (OHCAs). However, there are limited reports on rates of BCPR in children and its relationship with return of spontaneous circulation (ROSC) or survival outcomes.
Objective
We describe the rate of BCPR and its association with any ROSC and survival- to- hospital-discharge.
Methods
We conducted retrospective analysis of prospectively collected paediatric (<18 years of age) OHCA cases in England; we included specialist registry patients treated by emergency medical services (EMS) with known BCPR status and outcome between January 2014 and November 2018. Data included patient demographics, aetiology, witness status, initial rhythm, EMS, season, time of day and bystander status. Associations between BCPR, and any ROSC and survival-to-hospital-discharge outcomes were explored using multivariable logistic regression.
Results
There were 2363 paediatric OHCAs treated across 11 EMS regions. BCPR was performed in 69.6% (1646/2363) of the cases overall (range 57.7% (206/367) to 83.7% (139/166) across EMS regions). Only 34.9% (550/1572) of BCPR cases were witnessed. Overall, any ROSC was achieved in 22.8% (523/2289) and survival to hospital discharge in 10.8% (225/2066). Adjusted odds ratio (aOR) for any ROSC was significantly improved following BCPR compared to no BCPR (aOR 1.37, 95% CI 1.03-1.81), but adjusted odds ratio for survival-to-hospital-discharge were similar (aOR 1.01, 95% CI 0.66-1.55).
Conclusions
BCPR was associated with improved rates of any ROSC but not survival-to-hospital-discharge. Variations in EMS BCPR rates may indicate opportunities for regional targeted increase in public BCPR education.

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

Resuscitation: 04 Nov 2021; 170:17-25
Albargi H, Mallett S, Berhane S, Booth S, ... Foster T, Scholefield B
Resuscitation: 04 Nov 2021; 170:17-25 | PMID: 34748765
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Impact:
Abstract

2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces.

COVID-19 Working Group, Wyckoff MH, Singletary EM, Soar J, ... Nolan JP, Berg KM
The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 04 Nov 2021; epub ahead of print
COVID-19 Working Group, Wyckoff MH, Singletary EM, Soar J, ... Nolan JP, Berg KM
Resuscitation: 04 Nov 2021; epub ahead of print | PMID: 34774963
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Impact:
Abstract

Are there disparities in the location of automated external defibrillators in England?

Brown TP, Perkins GD, Smith CM, Deakin CD, Fothergill R
Background
Early defibrillation is an essential element of the chain of survival for out-of-hospital cardiac arrest (OHCA). Public access defibrillation (PAD) programmes aim to place automated external defibrillators (AED) in areas with high OHCA incidence, but there is sometimes a mismatch between AED density and OHCA incidence.
Objectives
This study aimed to assess whether there were any disparities in the characteristics of areas that have an AED and those that do not in England.
Methods
Details of the location of AEDs registered with English Ambulance Services were obtained from individual services or internet sources. Neighbourhood characteristics of lower layer super output areas (LSOA) were obtained from the Office for National Statistics. Comparisons were made between LSOAs with and without a registered AED.
Results
AEDs were statistically more likely to be in LSOAs with a lower residential but higher workplace population density, with people predominantly from a white ethnic background and working in higher socio-economically classified occupations (p < 0.05). There was a significant correlation between AED coverage and the LSOA Index of Multiple Deprivation (IMD) (r = 0.79, p = 0.007), with only 27.4% in the lowest IMD decile compared to about 45% in highest. AED density varied significantly across the country from 0.82/km2 in the north east to 2.97/km2 in London.
Conclusions
In England, AEDs were disproportionately placed in more affluent areas, with a lower residential population density. This contrasts with locations where OHCAs have previously occurred. Future PAD programmes should give preference to areas of higher deprivation and be tailored to the local community.

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

Resuscitation: 28 Oct 2021; 170:28-35
Brown TP, Perkins GD, Smith CM, Deakin CD, Fothergill R
Resuscitation: 28 Oct 2021; 170:28-35 | PMID: 34757059
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Impact:
Abstract

Delivery room CPAP in improving outcomes of preterm neonates in low-and middle-income countries: A systematic review and network meta-analysis.

Ramaswamy VV, Abiramalatha T, Bandyopadhyay T, Shaik NB, ... Roehr CC, Trevisanuto D
Aim
To study the impact of delivery room continuous positive airway pressure (DRCPAP) on outcomes of preterm neonates in low- and middle- income countries (LMICs) by comparing with interventions: oxygen supplementation, late DRCPAP, DRCPAP with sustained inflation, DRCPAP with surfactant and invasive mechanical ventilation (IMV).
Methods
Medline, Embase, CENTRAL, WOS and CINAHL searched. Observational studies and randomized controlled trials (RCTs) were included. Pair-wise meta-analysis and Bayesian network meta-analysis (NMA) were utilized. Primary outcome was receipt of IMV.
Results
Data from 11 of the 18 included studies (4 observational studies, 7 RCTs) enrolling 4210 preterm infants was synthesized. Moderate certainty of evidence (CoE) from NMA of RCTs comparing DRCPAP with surfactant administration versus DRCPAP alone suggested no decrease in subsequent receipt of IMV [Risk ratio (RR); 95% Credible Interval (CrI): 0.73; (0.34, 1.40)]. Very low CoE from observational studies comparing use of DRCPAP versus oxygen supplementation indicated a trend towards decreased IMV [RR; 95% Confidence Interval (CI): 0.75; (0.56-1.00)]. Although moderate CoE from NMA evaluating DRCPAP versus oxygen supplementation showed a trend towards decreased receipt of surfactant, it did not reach statistical significance [RR; 95% CrI: 0.69; (0.44, 1.06)]. Moderate CoE from NMA indicated that none of the interventions, when compared with use of supplemental oxygen alone or with each other decreased mortality or bronchopulmonary dysplasia.
Limitations
CoE was very low for primary outcome.
Conclusions
Present evidence is not sufficient for use of DRCPAP, but also did not show harm. Since it seems unlikely that there are marked variations in patient physiology to explain the difference in efficacy between high income countries and LMICs, we suggest future research evaluating other barriers in improving the effectiveness of DRCPAP in LMICs.

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

Resuscitation: 28 Oct 2021; epub ahead of print
Ramaswamy VV, Abiramalatha T, Bandyopadhyay T, Shaik NB, ... Roehr CC, Trevisanuto D
Resuscitation: 28 Oct 2021; epub ahead of print | PMID: 34757058
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Impact:
Abstract

Association of end-tidal carbon dioxide levels during cardiopulmonary resuscitation with survival in a large paediatric cohort.

Sorcher JL, Hunt EA, Shaffner DH, O\'Brien CE, ... Newton H, Duval-Arnould J
Aim
To examine the associations between ETCO2, ROSC, and chest compression quality markers in paediatric patients during active resuscitation.
Methods
This was a single-centre cohort study of data collected as part of an institutional prospective quality initiative improvement program that included all paediatric patients who received chest compressions of any duration from January 1, 2013, through July 10, 2018, in the Johns Hopkins Children\'s Center. Data was collected from Zoll R Series® defibrillators. Events were included if Zoll data files contained both chest compression and ETCO2 data. 2,746 minutes corresponding to 143 events were included in the analyses.
Results
The median event ETCO2 for all 143 events was 16.8 [9.3-26.3] mmHg. There was a significant difference in median event ETCO2 between events that achieved ROSC and those that did not (ROSC: 19.3 [14.4-26.6] vs. NO ROSC: 13.9 [6.6-25.5] mmHg; p < 0.05). When the events were based on patient age, this relationship held in adolescents (ROSC: 18.8 [15.5-22.3] vs. NO ROSC: 9.6 [4.4-15.9] mmHg; p < 0.05), but not in children or infants. Median event ETCO2 was significantly associated with chest compression rate less than 140 (p < 0.0001) and chest compression fraction 90-100 (p < 0.0001).
Conclusions
This represents the largest collection of ETCO2 and chest compression data in paediatric patients to date and unadjusted analyses suggests an association between ETCO2 and ROSC in some paediatric patients.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 26 Oct 2021; epub ahead of print
Sorcher JL, Hunt EA, Shaffner DH, O'Brien CE, ... Newton H, Duval-Arnould J
Resuscitation: 26 Oct 2021; epub ahead of print | PMID: 34718083
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Abstract

Impact of availability of catheter laboratory facilities on management and outcomes of acute myocardial infarction presenting with out of hospital cardiac arrest.

Dafaalla M, Rashid M, Sun L, Quinn T, ... Curzen N, Mamas MA
Objectives
We aimed to identify whether the availability of catheter laboratory affects clinical outcomes of out-of-hospital cardiac arrest (OHCA) complicating myocardial infarction (AMI).
Methods
Patients admitted with a diagnosis of AMI and OHCA from the Myocardial Ischaemia National Audit Project (MINAP) between 2010 to 2017 were stratified into three groups based on initial hospital\'s catheter laboratory status: hospitals without a catheter laboratory (No-catheter lab hospitals), hospitals with diagnostic catheter laboratory (Diagnostic hospitals), and hospitals with PCI facilities (PCI hospitals). We used multivariable logistic regression to evaluate factors associated with clinical outcomes.
Results
We included 12,303 patients of which 9,798 were admitted to PCI hospitals, 1,595 to no-catheter lab hospitals, and 910 to diagnostic hospitals. Patients admitted to PCI hospitals were more frequently reviewed by a cardiologist (96%, p < 0.001) than no-catheter lab hospitals (80%) and diagnostic hospitals (74%), and more likely to receive coronary angiography (PCI hospitals (87%), diagnostic hospitals (31%), no-catheter lab hospitals (54%), p < 0.001). They also were more likely to undergo PCI (PCI hospitals (42%), diagnostic hospitals (17%), no-catheter lab hospitals (17%), p < 0.001). After adjustment, there was no significant difference in the in-hospital mortality (OR 0.76, 95% CI 0.55-1.06) or re-infarction (OR 1.28, 95% CI 0.72-2.26) in patients admitted to PCI hospitals nor in patients admitted to diagnostic hospitals (mortality (OR 1.28, 95% CI 0.72-2.26), re-infarction (OR 1.38, 95% CI 0.68-2.82)).
Conclusion
There is variation in coronary angiography use between hospitals without a catheter laboratory and PCI centres, which was not associated with better in-hospital survival.

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

Resuscitation: 26 Oct 2021; epub ahead of print
Dafaalla M, Rashid M, Sun L, Quinn T, ... Curzen N, Mamas MA
Resuscitation: 26 Oct 2021; epub ahead of print | PMID: 34718080
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Impact:
Abstract

Mechanical active compression-decompression versus standard mechanical cardiopulmonary resuscitation: A randomised haemodynamic out-of-hospital cardiac arrest study.

Berve PO, Hardig BM, Skålhegg T, Kongsgaard H, Kramer-Johansen J, Wik L
Background
Active compression-decompression cardiopulmonary resuscitation (ACD-CPR) utilises a suction cup to lift the chest-wall actively during the decompression phase (AD). We hypothesised that mechanical ACD-CPR (Intervention), with AD up to 30 mm above the sternal resting position, would generate better haemodynamic results than standard mechanical CPR (Control).
Methods
This out-of-hospital adult non-traumatic cardiac arrest trial was prospective, block-randomised and non-blinded. We included intubated patients with capnography recorded during mechanical CPR. Exclusion criteria were pregnancy, prisoners, and prior chest surgery. The primary endpoint was maximum tidal carbon dioxide partial pressure (pMTCO2) and secondary endpoints were oxygen saturation of cerebral tissue (SctO2), invasive arterial blood pressures and CPR-related injuries. Intervention device lifting force performance was categorised as Complete AD (≥30 Newtons) or Incomplete AD (≤10 Newtons). Haemodynamic data, analysed as one measurement for each parameter per ventilation (Observation Unit, OU) with non-linear regression statistics are reported as mean (standard deviation). A two-sided p-value < 0.05 was considered as statistically significant.
Results
Of 221 enrolled patients, 210 were deemed eligible (Control 109, Intervention 101). The Control vs. Intervention results showed no significant differences for pMTCO2: 29(17) vs 29(18) mmHg (p = 0.86), blood pressures during compressions: 111(45) vs. 101(68) mmHg (p = 0.93) and decompressions: 21(20) vs. 18(18) mmHg (p = 0.93) or for SctO2%: 55(36) vs. 57(9) (p = 0.42). The 48 patients who received Complete AD in > 50% of their OUs had higher SctO2 than Control patients: 58(11) vs. 55(36)% (p < 0.001).
Conclusions
Mechanical ACD-CPR provided similar haemodynamic results to standard mechanical CPR. The Intervention device did not consistently provide Complete AD.
Clinical trial registration
ClinicalTrials.gov identifier (NCT number): NCT02479152. The Haemodynamic Effects of Mechanical Standard and Active Chest Compression-decompression During Out-of-hospital CPR.

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

Resuscitation: 24 Oct 2021; 170:1-10
Berve PO, Hardig BM, Skålhegg T, Kongsgaard H, Kramer-Johansen J, Wik L
Resuscitation: 24 Oct 2021; 170:1-10 | PMID: 34710550
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Impact:

This program is still in alpha version.