Journal: Resuscitation

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Abstract

Complement activation is associated with poor outcome after out-of-hospital cardiac arrest.

Chaban V, Nakstad ER, Stær-Jensen H, Schjalm C, ... Andersen GØ, Pischke SE
Background
Cardiopulmonary resuscitation after cardiac arrest initiates a whole-body ischemia-reperfusion injury, which may activate the innate immune system, including the complement system. We hypothesized that complement activation and subsequent release of soluble endothelial activation markers were associated with cerebral outcome including death.
Methods
Outcome was assessed at six months and defined by cerebral performance category scale (1-2; good outcome, 3-5; poor outcome including death) in 232 resuscitated out-of-hospital cardiac arrest patients. Plasma samples obtained at admission and day three were analysed for complement activation products C3bc, the soluble terminal complement complex (sC5b-9), and soluble CD14. Endothelial cell activation was measured by soluble markers syndecan-1, sE-selectin, thrombomodulin, and vascular cell adhesion molecule.
Results
Forty-nine percent of the patients had good outcome. C3bc and sC5b-9 were significantly higher at admission compared to day three (p < 0.001 for both) and in patients with poor compared to good outcome (p = 0.03 and p < 0.001, respectively). Unadjusted, higher sC5b-9 at admission was associated with poor outcome (odds ratio 1.08 (95% CI 1.01-1.14), p = 0.024). Adjusted, sC5b-9 was still associated with outcome, but the association became non-significant when time to return-of-spontaneous-circulation above 25 min was included as a covariate. Endothelial cell activation markers increased from admission to day three, but only sE-selectin and thrombomodulin were significantly higher in patients with poor versus good outcome (p = 0.004 and p = 0.03, respectively) and correlated to sCD14 and sC5b-9/C3bc, respectively.
Conclusion
Complement system activation, reflected by sC5b-9 at admission, leading to subsequent endothelial cell activation, was associated with poor outcome in out-of-hospital cardiac arrest patients.

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

Resuscitation: 10 Jun 2021; epub ahead of print
Chaban V, Nakstad ER, Stær-Jensen H, Schjalm C, ... Andersen GØ, Pischke SE
Resuscitation: 10 Jun 2021; epub ahead of print | PMID: 34126135
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Abstract

Pulseless electrical activity vs. asystole in adult in-hospital cardiac arrest: Predictors and outcomes.

Høybye M, Stankovic N, Lauridsen KG, Holmberg MJ, Andersen LW, Granfeldt A
Aim
This observational cohort study aimed to identify factors associated with pulseless electrical activity (PEA) and asystole in in-hospital cardiac arrest (IHCA) patients and to determine whether differences in outcome based on the initial rhythm were explained by patient- and cardiac arrest characteristics.
Methods
Adults with IHCA from 2017 to 2018 were included from the Danish IHCA Registry (DANARREST). Additional data came from population-based registries. Unadjusted (RRs) and adjusted risk ratios (aRRs) were estimated for predictors of initial rhythm, return of spontaneous circulation (ROSC), and survival.
Results
We included 1495 PEA and 1285 asystole patients. The patients did not differ substantially in patient characteristics. Female sex, age >90 years, pulmonary disease, and obesity were associated with initial asystole. Ischemic heart disease and witnessed and monitored cardiac arrest were associated with initial PEA. In unadjusted and adjusted analyses, PEA was associated with increased ROSC (aRR = 1.21, 95% confidence interval [CI] 1.10; 1.33). PEA was also associated with increased 30-day and 1-year survival in the unadjusted analysis, while there was no clear association between the initial rhythm and 30-day (aRR = 0.88, 95% CI 0.71; 1.11) and 1-year (aRR = 0.85, 95% CI 0.69; 1.04) survival when patient- and cardiac arrest characteristics were adjusted for.
Conclusion
In patients with IHCA presenting with PEA or asystole, there were no major differences in patient demographics and comorbidities. The patients differed substantially in cardiac arrest characteristics. Initial PEA was associated with higher risk of ROSC, but there was no difference in 30-day and 1-year survival.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 10 Jun 2021; epub ahead of print
Høybye M, Stankovic N, Lauridsen KG, Holmberg MJ, Andersen LW, Granfeldt A
Resuscitation: 10 Jun 2021; epub ahead of print | PMID: 34126134
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Abstract

Cost-effectiveness of the i-gel Supraglottic Airway Device compared to Tracheal Intubation During Out-of-Hospital Cardiac Arrest: Findings from the AIRWAYS-2 Randomised Controlled Trial.

Stokes EA, Lazaroo MJ, Clout M, Brett SJ, ... Benger JR, Wordsworth S
Aim
Optimal airway management during out-of-hospital cardiac arrest (OHCA) is uncertain. Complications from tracheal intubation (TI) may be avoided with supraglottic airway (SGA) devices. The AIRWAYS-2 cluster randomised controlled trial (ISRCTN08256118) compared the i-gel SGA with TI as the initial advanced airway management (AAM) strategy by paramedics treating adults with non-traumatic OHCA. This paper reports the trial cost-effectiveness analysis.
Methods
A within-trial cost-effectiveness analysis of the i-gel compared with TI was conducted, with a 6-month time horizon, from the perspective of the UK National Health Service (NHS) and personal social services. The primary outcome measure was quality-adjusted life years (QALYs), estimated using the EQ-5D-5L questionnaire. Multilevel linear regression modelling was used to account for clustering by paramedic when combining costs and outcomes.
Results
9,296 eligible patients were attended by 1,382 trial paramedics and enrolled in the AIRWAYS-2 trial (4410 TI, 4886 i-gel). Mean QALYs to 6 months were 0.03 in both groups (i-gel minus TI difference -0.0015, 95% CI -0.0059 to 0.0028). Total costs per participant up to 6 months post-OHCA were £3,570 and £3,413 in the i-gel and TI groups respectively (mean difference £157, 95% CI -£270 to £583). Based on mean difference point estimates, TI was more effective and less costly than i-gel; however differences were small and there was great uncertainty around these results.
Conclusion
The small differences between groups in QALYs and costs shows no difference in the cost-effectiveness of the i-gel and TI when used as the initial AAM strategy in adults with non-traumatic OHCA.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 10 Jun 2021; epub ahead of print
Stokes EA, Lazaroo MJ, Clout M, Brett SJ, ... Benger JR, Wordsworth S
Resuscitation: 10 Jun 2021; epub ahead of print | PMID: 34126133
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Abstract

Spatiotemporal analysis of out-of-hospital cardiac arrest in the City of Los Angeles, 2011-2019.

Fleming D, Owens A, Eckstein M, Sanko S
Objective
The goal of this analysis is to spatiotemporally identify and categorize areas in a large urban city according to Out-of-Hospital Cardiac Arrest (OHCA) rates and No Bystander CPR (NBCPR) risk levels.
Study area and participants
The study comprised all cardiac arrests within the administrative geographic boundary of the City of Los Angeles. The final sample included 15,904 cases that were geolocated within 985 census tracts.
Main outcomes and measures
The primary outcome was stratification of census tracts into risk levels of OHCA and NBCPR by observed spatiotemporal patterns.
Results
Of 985 census tracts in the analytical sample, 206 census tracts (20.9%) were identified as having higher risk of OHCA and NBCPR. This assessment resulted in 131 census tracts in Tier 3 (moderate risk), 55 in Tier 2 (moderate-high risk), and 20 in Tier 1 (highest risk). Census tracts in Tiers 2 and 3 had higher amounts incident OHCA, while those in tier 1 had more OHCA events with NBCPR. These areas were largely contiguous and located in the central and South Los Angeles.
Conclusions
Using a novel three-tiered neighborhood risk classification tool, specific neighborhoods have been identified in the second largest city in the U.S. with consistently high or accelerating rates of OHCA and low bystander CPR. Further study of bystander response and community-based public health campaigns are needed in these communities.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 09 Jun 2021; epub ahead of print
Fleming D, Owens A, Eckstein M, Sanko S
Resuscitation: 09 Jun 2021; epub ahead of print | PMID: 34119555
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Abstract

Application of a standardized EEG pattern classification in the assessment of neurological prognosis after cardiac arrest - a retrospective analysis.

Lilja L, Joelsson S, Nilsson J, Lindgren S, Rylander C
Introduction
Electroencephalogram (EEG) is used in the neurological prognostication after cardiac arrest. \"Highly malignant\" EEG patterns classified according to Westhall have a high specificity for poor neurological outcome when applied within protocols of recent studies. However, their predictive performance when applied in everyday clinical practice has not been investigated. We studied the prognostic accuracy and the interrater agreement when standardized EEG patterns were analysed and compared to neurological outcome in a patient cohort at a tertiary centre not involved in the original study of the standardized EEG pattern classification.
Methods
Comatose patients treated for out-of-hospital cardiac arrest were included. Poor outcome was defined as Cerebral Performance Category 3-5. Two senior consultants and one resident in clinical neurophysiology, blinded to clinical data and outcome, independently reviewed their EEG registrations and categorised the pattern as \"highly malignant\", \"malignant\" or \"benign\". These categories were compared to neurological outcome at hospital discharge. Interrater agreement was assessed using Cohen\'s Kappa.
Results
In total, 62 patients were included. The median (IQR) time to EEG was 59 (42-91) h after return of spontaneous circulation. Poor outcome was found in 52 (84%) patients. In 21 patients at least one of the raters considered the EEG to contain a \"highly malignant\" pattern, all with poor outcome (42% sensitivity, 100% specificity). The interrater agreement varied from kappa 0.62 to 0.29.
Conclusion
\"Highly malignant\" patterns predict poor neurological outcome with a high specificity in everyday practice. However, interrater agreement may vary substantially even between experienced EEG interpreters.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 09 Jun 2021; epub ahead of print
Lilja L, Joelsson S, Nilsson J, Lindgren S, Rylander C
Resuscitation: 09 Jun 2021; epub ahead of print | PMID: 34119554
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Abstract

Early recovery of frontal EEG slow wave activity during propofol sedation predicts outcome after cardiac arrest.

Kortelainen J, Ala-Kokko T, Tiainen M, Strbian D, ... Skrifvars MB, Hästbacka J
Aim of the study
EEG slow wave activity (SWA) has shown prognostic potential in post-resuscitation care. In this prospective study, we investigated the accuracy of continuously measured early SWA for prediction of the outcome in comatose cardiac arrest (CA) survivors.
Methods
We recorded EEG with a disposable self-adhesive frontal electrode and wireless device continuously starting from ICU admission until 48 hours from return of spontaneous circulation (ROSC) in comatose CA survivors sedated with propofol. We determined SWA by offline calculation of C-Trend® Index describing SWA as a score ranging from 0 to 100. The functional outcome was defined based on Cerebral Performance Category (CPC) at 6 months after the CA to either good (CPC 1-2) or poor (CPC 3-5).
Results
Outcome at six months was good in 67 of the 93 patients. During the first 12 hours after ROSC, the median C-Trend Index value was 38.8 (interquartile range 28.0-56.1) in patients with good outcome and 6.49 (3.01-18.2) in those with poor outcome showing significant difference (p < 0.001) at every hour between the groups. The index values of the first 12 h predicted poor outcome with an area under curve of 0.86 (95% CI 0.61-0.99). With a cutoff value of 20, the sensitivity was 83.3% (69.6%-92.3%) and specificity 94.7% (83.4%-99.7%) for categorization of outcome.
Conclusion
EEG SWA measured with C-Trend Index during propofol sedation offers a promising practical approach for early bedside evaluation of recovery of brain function and prediction of outcome after CA.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 06 Jun 2021; epub ahead of print
Kortelainen J, Ala-Kokko T, Tiainen M, Strbian D, ... Skrifvars MB, Hästbacka J
Resuscitation: 06 Jun 2021; epub ahead of print | PMID: 34111496
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Abstract

Survival probability in avalanche victims with long burial (≥60 min): a retrospective study.

Eidenbenz D, Techel F, Kottmann A, Rousson V, ... Albrecht R, Pasquier M
Background
The survival of completely buried victims in an avalanche mainly depends on burial duration. Knowledge is limited about survival probability after 60 min of complete burial.
Aim
We aimed to study the survival probability and prehospital characteristics of avalanche victims with long burial durations.
Methods
We retrospectively included all completely buried avalanche victims with a burial duration of ≥60 min between 1997 and 2018 in Switzerland. Data were extracted from the registry of the Swiss Institute for Snow and Avalanche Research and the prehospital medical records of the physician-staffed helicopter emergency medical services. Avalanche victims buried for ≥24 h or with an unknown survival status were excluded. Survival probability was estimated by using the non-parametric Ayer-Turnbull method and logistic regression. The primary outcome was survival probability.
Results
We identified 140 avalanche victims with a burial duration of ≥60 min, of whom 27 (19%) survived. Survival probability shows a slight decrease with increasing burial duration (23% after 60 min, to <6% after 1400 min, p = 0.13). Burial depth was deeper for those who died (100 cm vs 70 cm, p = 0.008). None of the survivors sustained CA during the prehospital phase.
Conclusions
The overall survival rate of 19% for completely buried avalanche victims with a long burial duration illustrates the importance of continuing rescue efforts. Avalanche victims in CA after long burial duration without obstructed airway, frozen body or obvious lethal trauma should be considered to be in hypothermic CA, with initiation of cardiopulmonary resuscitation and an evaluation for rewarming with extracorporeal life support.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 05 Jun 2021; epub ahead of print
Eidenbenz D, Techel F, Kottmann A, Rousson V, ... Albrecht R, Pasquier M
Resuscitation: 05 Jun 2021; epub ahead of print | PMID: 34107337
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Abstract

The effective group size for teaching cardiopulmonary resuscitation skills - a randomized controlled simulation trial.

Nabecker S, Huwendiek S, Theiler L, Huber M, Petrowski K, Greif R
Aim of the study
The ideal group size for effective teaching of cardiopulmonary resuscitation is currently under debate. The upper limit is reached when instructors are unable to correct participants\' errors during skills practice. This simulation study aimed to define this limit during cardiopulmonary resuscitation teaching.
Methods
Medical students acting as simulated Basic Life Support course participants were instructed to make three different pre-defined Basic Life Support quality errors (e.g., chest compression too fast) in 7 minutes. Basic Life Support instructors were randomized to groups of 3-10 participants. Instructors were asked to observe the Basic Life Support skills and to correct performance errors. Primary outcome was the maximum group size at which the percentage of correctly identified participants\' errors drops below 80%.
Results
Sixty-four instructors participated, eight for each group size. Their average age was 41 ± 9 years and 33% were female, with a median [25th percentile; 75th percentile] teaching experience of 6 [2;11] years. Instructors had taught 3 [1;5] cardiopulmonary resuscitation courses in the year before the study. A logistic binominal regression model showed that the predicted mean percentage of correctly identified participants\' errors dropped below 80% for group sizes larger than six.
Conclusion
This randomized controlled simulation trial reveals decreased ability of instructors to detect Basic Life Support performance errors with increased group size. The maximum group size enabling Basic Life Support instructors to correct more than 80% of errors is six. We therefore recommend a maximum instructor-to-participant ratio of 1:6 for cardiopulmonary resuscitation courses.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 05 Jun 2021; epub ahead of print
Nabecker S, Huwendiek S, Theiler L, Huber M, Petrowski K, Greif R
Resuscitation: 05 Jun 2021; epub ahead of print | PMID: 34107336
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Abstract

In-hospital family-witnessed resuscitation with a focus on the prevalence, processes, and outcomes of resuscitation: a retrospective observational cohort study.

Waldemar A, Bremer A, Holm A, Strömberg A, Thylén I
Aim
International and national guidelines support in-hospital, family-witnessed resuscitation, provided that patients are not negatively affected. Empirical evidence regarding whether family presence interferes with resuscitation procedures is still scarce. The aim was to describe the prevalence and processes of family-witnessed resuscitation in hospitalised adult patients, and to investigate associations between family-witnessed resuscitation and the outcomes of resuscitation.
Methods
Nationwide observational cohort study based on data from the Swedish Registry of Cardiopulmonary Resuscitation.
Results
In all, 3,257 patients with sudden, in-hospital cardiac arrests were included. Of those, 395 had family on site (12%), of whom 186 (6%) remained at the scene. It was more common to offer family the option to stay during resuscitation if the cardiac arrest occurred in emergency departments, intensive-care units or cardiac-care units, compared to hospital wards (44% vs. 26%, p < 0.001). It was also more common for a staff member to be assigned to take care of family in acute settings (68% vs. 56%, p = 0.017). Mean time from cardiac arrest to termination of resuscitation was longer in the presence of family (20.67 min vs. 17.49 min, p = 0.020), also when controlling for different patient and contextual covariates in a regression model (Stand(β) 0.039, p = 0.027). No differences were found between family-witnessed and non-family-witnessed resuscitation in survival immediately after resuscitation (57% vs. 53%, p = 0.291) or after 30 days (35% vs. 29%, p = 0.086).
Conclusions
In-hospital, family-witnessed resuscitation is uncommon, but the processes and outcomes do not seem to be negatively affected, suggesting that staff should routinely invite family to witness resuscitation.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 05 Jun 2021; epub ahead of print
Waldemar A, Bremer A, Holm A, Strömberg A, Thylén I
Resuscitation: 05 Jun 2021; epub ahead of print | PMID: 34107335
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Abstract

Epidemiology and Outcomes of Infants after Cardiopulmonary Resuscitation in the Neonatal or Pediatric Intensive Care Unit from a National Registry.

Handley SC, Passarella M, Raymond TT, Lorch SA, Ades A, Foglia EE
Aim
Cardiopulmonary resuscitation (CPR) in hospitalized infants is a relatively uncommon but high-risk event associated with mortality. The study objective was to identify factors associated with mortality and survival among infants who receive CPR in the neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU).
Methods
Retrospective observational study of infants with an index CPR event in the NICU or PICU between 1/1/06 and 12/31/18 in the American Heart Association\'s Get With The Guidelines-Resuscitation registry. Associations between patient, event, unit, and hospital factors and the primary outcome, mortality prior to discharge, were examined using multivariable logistic regression.
Results
Among 3,521 infants who received CPR, 2,080 (59%) died before discharge, with 25% mortality during CPR and 40% within 24 hours. Mortality prior to discharge occurred in 65% and 47% of cases in the NICU and PICU, respectively. Factors most strongly independently associated with pre-discharge mortality were vasoactive agent before CPR (adjusted odds ratio (aOR): 2.77, 95% confidence interval (CI) 2.15-3.58), initial pulseless condition (aOR: 2.38, 95% CI 1.46-3.86) or development of pulselessness (aOR: 2.36, 95% CI 1.78-3.12), and NICU location compared with PICU (aOR: 3.85, 95% CI 2.86-5.19). Endotracheal intubation during CPR was associated with decreased odds of pre-discharge mortality (aOR: 0.40, 95% CI 0.33-0.49).
Conclusion
Infants who receive CPR in the intensive care unit experience high mortality rates; identifiable patient, event, and unit factors increase the odds of mortality. Further investigation should explore the association between unit type, resuscitation processes, and mortality.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 05 Jun 2021; epub ahead of print
Handley SC, Passarella M, Raymond TT, Lorch SA, Ades A, Foglia EE
Resuscitation: 05 Jun 2021; epub ahead of print | PMID: 34107334
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Impact:
Abstract

Impact of video-recording on patient outcome and data collection in out-of-hospital cardiac arrests.

Dewolf P, Rutten B, Wauters L, Van den Bempt S, ... Clarebout G, Verelst S
Background
Most research on out-of-hospital resuscitation relies on data collection from medical records. However, the data in medical records are often inaccurate.
Objective
To compare the data registration of the medical record with the data from the video recorded resuscitation and study the impact of video recording during resuscitation on the outcome.
Methods
Out-of-hospital cardiopulmonary resuscitation (CPR) was video recorded using a body-mounted camera. Video recordings were independently reviewed and compared with the data of the medical record. The presence of bystander CPR and witnessed arrest, the initial rhythm, total number of defibrillations, adrenaline dosage and the total duration of CPR were studied. Using the medical records, CPR outcomes were compared for the periods prior to, during and after video recording.
Results
In total, 129 resuscitations were analysed. Of the six parameters, only the number of defibrillations was not significantly different in the medical record compared to the video recordings. The total duration of CPR (69.0%) and the total dose of adrenaline administered (63.6%) were the most incorrectly recorded, followed by the number of defibrillations (34.0%), witnessed arrest (31.0%), bystander CPR (24.0%) and initial rhythm (7%). No statistically significant difference was found comparing the outcomes (ROSC, 24 h and 1 month survival) of the periods before, during and after video recording.
Conclusion
We detected a high number of discrepancies between the medical record and the data from the video recorded resuscitation. No significant effect of video-recording on patient outcome was found.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 05 Jun 2021; epub ahead of print
Dewolf P, Rutten B, Wauters L, Van den Bempt S, ... Clarebout G, Verelst S
Resuscitation: 05 Jun 2021; epub ahead of print | PMID: 34107333
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Abstract

Impact of Benzodiazepines on Time to Awakening in Post Cardiac Arrest Patients.

Levito MN, McGinnis CB, Groetzinger LM, Durkin JB, Elmer J
Aim
Although guidelines recommend use of short acting sedation after cardiac arrest, there is significant practice variation. We examined whether benzodiazepine use is associated with delayed awakening in this population.
Methods
We performed a retrospective single center study including comatose patients treated after in- or out-of-hospital cardiac arrest from January 2010 to September 2019. We excluded patients who awakened within 6 hours of arrest, those who arrested due to trauma or neurological event, those with nonsurvivable primary brain injury and those with refractory shock. Our primary exposure of interest was high-dose benzodiazepine (>10 mg of midazolam equivalents per day) administration in the first 72 -hs post arrest. Our primary outcome was time to awakening. We used Cox regression to test for an independent association between exposure and outcome after controlling for biologically plausible covariates.
Results
Overall, 2,778 patients presented during the study period, 621 met inclusion criteria and 209 (34%) awakened after a median of 4 [IQR 3 - 7] days. Patients who received high-dose benzodiazepines awakened later than those who did not (5 [IQR 3 to 11] vs. 3 [IQR 3 to 6] days, P = 0.004). In adjusted regression, high-dose benzodiazepine exposure was independently associated with delayed awakening (adjusted hazard ratio 0.63 (95% CI 0.43 - 0.92)). Length of stay, awakening to discharge, and duration of mechanical ventilation were similar across groups.
Conclusion
High-dose benzodiazepine exposure is independently associated with delayed awakening in comatose survivors of cardiac arrest.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 04 Jun 2021; epub ahead of print
Levito MN, McGinnis CB, Groetzinger LM, Durkin JB, Elmer J
Resuscitation: 04 Jun 2021; epub ahead of print | PMID: 34102268
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Abstract

Age and sex differences in outcomes after in-hospital cardiac arrest.

Stankovic N, Holmberg MJ, Høybye M, Granfeldt A, Andersen LW
Introduction
While specific factors have been associated with outcomes after in-hospital cardiac arrest, the association between sex and outcomes remains debated. Moreover, age-specific sex differences in outcomes have not been fully characterized in this population.
Methods
Adult patients (≥18 years) with an index in-hospital cardiac arrest were included from the Danish In-Hospital Cardiac Arrest Registry (DANARREST) from January 1st, 2017 to December 31st, 2018. Population-based registries were used to obtain data on patient characteristics, cardiac arrest characteristics, and outcomes. Unadjusted and adjusted estimates for return of spontaneous circulation (ROSC), survival to 30 days, survival to one year, duration of resuscitation, and post-cardiac arrest time-to-death were computed.
Results
A total of 3266 patients were included, of which 2041 (62%) patients were male with a median age of 73 years (quartiles: 64, 80). Among 1225 (38%) female patients, the median age was 76 years (quartiles: 67, 83). Younger age was associated with higher odds of ROSC and survival. Sex was not associated with ROSC and survival in the unadjusted analyses. In the adjusted analyses, women had 1.32 (95%CI: 1.12, 1.54) times the odds of survival to 30 days and 1.26 (95%CI: 1.02, 1.57) times the odds of survival to one year compared to men. The overall association between sex and survival did not vary substantially across age categories, although female sex was associated with a higher survival within certain age categories. Among patients who did not achieve ROSC, female sex was associated with a shorter duration of resuscitation, which was more pronounced in younger age categories.
Conclusions
In this study of patients with in-hospital cardiac arrest, female sex was associated with a shorter duration of resuscitation among patients without ROSC but a higher survival to 30 days and one year. While the overall association between sex and outcomes did not vary substantially across age categories, female sex was associated with a higher survival within certain age categories.

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

Resuscitation: 03 Jun 2021; epub ahead of print
Stankovic N, Holmberg MJ, Høybye M, Granfeldt A, Andersen LW
Resuscitation: 03 Jun 2021; epub ahead of print | PMID: 34098034
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Abstract

CPR compression strategy 30:2 is difficult to adhere to, but has better survival than continuous chest compressions when done correctly.

Schmicker RH, Nichol G, Kudenchuk P, Christenson J, ... Idris AH, Daya MR
Background
A large, randomized trial showed no significant difference in survival to discharge between cardiopulmonary resuscitation (CPR) strategies of 30 compressions with pause for 2 ventilations per cycle (30:2) and continuous chest compression with asynchronous ventilations (CCC). Data from the same trial suggested that adherence to the intended CPR strategy was associated with significantly greater survival. We sought to determine the adherence rate with intended strategy and then explore the association of adherence with survival to discharge in the Resuscitation Outcomes Consortium (ROC).
Methods
This secondary analysis of data from the ROC included three interventional trials and a prospective registry. We modified an automated software algorithm that classified care as 30:2 or CCC before intubation based on compression segment length (defined as the elapsed time from start of compressions to subsequent pause of ≥2 seconds), number of pauses per minute ≥2 seconds in length and chest compression fraction. Intended CPR strategy for individual agencies was based on study randomization (during trial phase) or local standard of care (during registry phase). We defined CPR delivered as adherent when its classification matched the intended strategy. We characterized adherence with intended strategy across trial and registry periods. We examined its association with survival to hospital discharge using multivariate logistic regression after adjustment for Utstein and other potential confounders. Effect modification with intended strategy was assessed through a multiplicative interaction term.
Results
Included were 26,810 adults with out of hospital cardiac arrest, of which 10,942 had an intended strategy of 30:2 and 15,868 an intended strategy of CCC. The automated algorithm classified 12,276 cases as CCC, 7,037 as 30:2 and left 7,497 as unclassified. Adherence to intended strategy was 54.4%; this differed by intended strategy (58.6% for CCC vs 48.3% for 30:2). Overall adherence was less during the registry phase as compared to during the trial phase(s). The association between adherence and survival was modified by treatment arm (CCC OR: 0.72, 95% CI: 0.64-0.81 vs 30:2 OR: 1.05, 95% CI: 0.90-1.22; interaction p-value<0.01) after adjustment for known confounders.
Conclusion
For intended strategy CCC, survival was significantly lower, OR (95%CI) = 0.72 (0.64, 0.81), when adhered to while for intended strategy 30:2, survival was higher, OR (95%CI) = 1.05 (0.90, 1.22), when adhered to. Intended strategy of 30:2 had lower adherence rates than CCC possibly a result of being a more difficult strategy to administer.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 03 Jun 2021; epub ahead of print
Schmicker RH, Nichol G, Kudenchuk P, Christenson J, ... Idris AH, Daya MR
Resuscitation: 03 Jun 2021; epub ahead of print | PMID: 34098033
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Impact:
Abstract

Shock decision algorithm for use during load distributing band cardiopulmonary resuscitation.

Isasi I, Irusta U, Aramendi E, Olsen JA, Wik L
Aim
Chest compressions delivered by a load distributing band (LDB) induce artefacts in the electrocardiogram. These artefacts alter shock decisions in defibrillators. The aim of this study was to demonstrate the first reliable shock decision algorithm during LDB compressions.
Methods
The study dataset comprised 5813 electrocardiogram segments from 896 cardiac arrest patients during LDB compressions. Electrocardiogram segments were annotated by consensus as shockable (1154, 303 patients) or nonshockable (4659, 841 patients). Segments during asystole were used to characterize the LDB artefact and to compare its characteristics to those of manual artefacts from other datasets. LDB artefacts were removed using adaptive filters. A machine learning algorithm was designed for the shock decision after filtering, and its performance was compared to that of a commercial defibrillator\'s algorithm.
Results
Median (90% confidence interval) compression frequencies were lower and more stable for the LDB than for the manual artefact, 80min-1(79.9-82.9) vs 104.4min-1(48.5-114.0). The amplitude and waveform regularity (Pearson\'s correlation coefficient) were larger for the LDB artefact, with 5.5mV(0.8-23.4) vs 0.5mV(0.1-2.2) (p<0.001) and 0.99(0.78-1.0) vs 0.88 (0.55-0.98)(p<0.001). The shock decision accuracy was significantly higher for the machine learning algorithm than for the defibrillator algorithm, with sensitivity/specificity pairs of 92.1/96.8% (machine learning) vs 91.4/87.1% (defibrillator) (p<0.001).
Conclusion
Compared to other cardiopulmonary resuscitation artefacts, removing the LDB artefact was challenging due to larger amplitudes and lower compression frequencies. The machine learning algorithm achieved clinically reliable shock decisions during LDB compressions.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 03 Jun 2021; epub ahead of print
Isasi I, Irusta U, Aramendi E, Olsen JA, Wik L
Resuscitation: 03 Jun 2021; epub ahead of print | PMID: 34098032
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Impact:
Abstract

Expired Carbon Dioxide during Newborn Resuscitation as Predictor of Outcome.

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

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 03 Jun 2021; epub ahead of print
Holte K, Ersdal H, Klingenberg C, Eilevstjønn J, ... Kidanto H, Størdal K
Resuscitation: 03 Jun 2021; epub ahead of print | PMID: 34098031
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Abstract

Resuscitative endovascular occlusion of the aorta (REBOA) for refractory out of hospital cardiac arrest. An Utstein-based case series.

Gamberini L, Coniglio C, Lupi C, Tartaglione M, ... Gordini G, collaborators
Aims
Out of hospital cardiac arrest (OHCA) is still a leading cause of mortality worldwide. In recent years, resuscitative endovascular balloon occlusion of the aorta (REBOA) has been progressively studied as an adjunct to standard advanced life support (ALS) in both traumatic and non-traumatic refractory OHCA. Since January 2019, the REBOA procedure has been applied to all the patients experiencing both traumatic and non-traumatic refractory OHCA (≥15 minutes of cardiopulmonary resuscitation) not eligible for ECPR for clinical or logistic reasons. We aimed at describing the feasibility and effects of REBOA performed both in the Emergency Department and in the pre-hospital environment served by the local HEMS for refractory OHCA.
Methods
Twenty consecutive patients experiencing refractory OHCA and in whom REBOA was attempted in 2019 and 2020 were included in the study, Utstein data and REBOA specific variables were recorded.
Results
Successful catheter placement was achieved in 18 out of 20 patients, 11 of these were non-traumatic OHCAs while 7 were traumatic OHCAs, the 2 failures were related to repeated arterial puncture failure. Median time between the EMS dispatch and REBOA catheter placing attempt was 46 minutes. An increase in etCO2 over 10 mmHg was observed after balloon inflation in 12 out of 18 patients (8/11 non-traumatic and 4/7 traumatic OHCAs), a sustained ROSC was observed in 5 patients (1 traumatic and 4 non-traumatic OHCA) that were subsequently admitted to the ICU. Four out of the 5 patients reached the criteria for brain death in the subsequent 24 hours while one patient experienced another episode of refractory cardiac arrest in ICU and subsequently died.
Conclusion
Our data confirm the feasibility of REBOA technique as an adjunct to ALS in both the ED and prehospital phase and most of the treated patients experienced a transient ROSC after balloon inflation while 5 out of 18 experienced a sustained ROSC. However, while in the trauma setting increasing evidence suggests an improved survival when REBOA is applied to refractory OHCA, in non-traumatic OHCA this has yet to be demonstrated and large studies are needed.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 01 Jun 2021; epub ahead of print
Gamberini L, Coniglio C, Lupi C, Tartaglione M, ... Gordini G, collaborators
Resuscitation: 01 Jun 2021; epub ahead of print | PMID: 34089774
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Impact:
Abstract

Quantitative characterization of left ventricular function during pulseless electrical activity using echocardiography during out-of-hospital cardiac arrest.

Teran F, Paradis NA, Dean AJ, Delgado MK, ... Peberdy MA, Abella BS
Background
Several prospective studies have demonstrated that the echocardiographic detection of any myocardial activity during PEA is strongly associated with higher rates of return of spontaneous circulation (ROSC). We hypothesized that PEA represents a spectrum of disease in which not only the presence of myocardial activity, but more specifically that the degree of left ventricular (LV) function would be a predictor of outcomes. The purpose of this study was to retrospectively assess the association between LV function and outcomes in patients with OHCA.
Materials and methods
Using prospectively obtained data from an observational cohort of patients receiving focused echocardiography during cardiopulmonary resuscitation (CPR) in the Emergency Department (ED) setting, we analyzed 312 consecutive subjects with available echocardiography images with initial rhythm of PEA. We used left ventricular systolic fractional shortening (LVFS), a unidimensional echocardiographic parameter to perform the quantification of LV function during PEA. Regression analyses were performed independently to evaluate for relationships between LVFS and a primary outcome of ROSC and secondary outcome of survival to hospital admission. We analyzed LVFS both as a continuous variable and as a categorial variable using the quartiles and the median to perform multiple different comparisons and to illustrate the relationship of LVFS and outcomes of interest. We performed survival analysis using Cox proportional hazards model to evaluate the hazard corresponding to length of resuscitation.
Results
We found a positive association between LVFS and the primary outcome of ROSC (OR 1.04, 95%CI 1.01-1.08), but not with the secondary outcome of survival to hospital admission (OR 1.02, 95%CI 0.96-1.08). Given that the relationship was not linear and that we observed a threshold effect in the relationship between LVFS and outcomes, we performed an analysis using quartiles of LVFS. The predicted probability of ROSC was 75% for LVFS between 23.4-96% (fourth quartile) compared to 47% for LVFS between 0-4.7% (first quartile). The hazard of not achieving ROSC was significantly greater for subjects with LVFS below the median (13.1%) compared to the subgroup with LVFS greater than 13.1% (p < 0.05), with the separation of the survival curves occurring at approximately 40 min of resuscitation duration.
Conclusions
Left ventricular function measured by LVFS is positively correlated with higher probability of ROSC and may be associated with higher chances of survival in patients with PEA arrest.

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

Resuscitation: 31 May 2021; epub ahead of print
Teran F, Paradis NA, Dean AJ, Delgado MK, ... Peberdy MA, Abella BS
Resuscitation: 31 May 2021; epub ahead of print | PMID: 34087419
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Abstract

Glycopyrrolate does not ameliorate hypothermia associated bradycardia in healthy individuals: A randomized crossover trial.

Rittenberger JC, Weissman A, Flickinger KL, Guyette FX, ... Sawyer KN, Callaway CW
Background
Hypothermia improves outcomes following ischemia-reperfusion injury. Shivering is common and can be mediated by agents such as dexmedetomidine. The combination of dexmedetomidine and hypothermia results in bradycardia. We hypothesized that glycopyrrolate would prevent bradycardia during dexmedetomidine-mediated hypothermia.
Methods
We randomly assigned eight healthy subjects to premedication with a single 0.4 mg glycopyrrolate intravenous (IV) bolus, titrated glycopyrrolate (0.01 mg IV every 3 min as needed for heart rate <50), or no glycopyrrolate during three separate sessions of 3 h cooling. Following 1 mg/kg IV dexmedetomidine bolus, subjects received 20 ml/kg IV 4 °C saline and surface cooling (EM COOLS, Weinerdorf, Austria). We titrated dexmedetomidine infusion to suppress shivering but permit arousal to verbal stimuli. After 3 h of cooling, we allowed subjects to passively rewarm. We compared heart rate, core temperature, mean arterial blood pressure, perceived comfort and thermal sensation between groups using Kruskal-Wallis test and ANOVA.
Results
Mean age was 27 (SD 6) years and most (N = 6, 75%) were male. Neither heart rate nor core temperature differed between the groups during maintenance of hypothermia (p > 0.05). Mean arterial blood pressure was higher in the glycopyrrolate bolus condition (p < 0.048). Thermal sensation was higher in the control condition than the glycopyrrolate bolus condition (p = 0.01). Bolus glycopyrrolate resulted in less discomfort than titrated glycopyrrolate (p = 0.04).
Conclusions
Glycopyrrolate did not prevent the bradycardic response to hypothermia and dexmedetomidine. Mean arterial blood pressure was higher in subjects receiving a bolus of glycopyrrolate before induction of hypothermia. Bolus glycopyrrolate was associated with less intense thermal sensation and less discomfort during cooling.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 31 May 2021; 164:79-83
Rittenberger JC, Weissman A, Flickinger KL, Guyette FX, ... Sawyer KN, Callaway CW
Resuscitation: 31 May 2021; 164:79-83 | PMID: 34087418
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Impact:
Abstract

Trend analysis of disability-adjusted life years following adult out-of-hospital cardiac arrest in the United States: A study from the CARES Surveillance Group.

Coute RA, Nathanson BH, Mader TJ, McNally B, Kurz MC
Aim
To estimate and trend disability-adjusted life years (DALY) following adult out-of-hospital cardiac arrest (OHCA) over time, and to compare OHCA DALY to other leading causes of death and disability in the U.S.
Methods
DALY were calculated as the sum of years of life lost (YLL) and years lived with disability (YLD). Adult non-traumatic emergency medical services-treated OHCA from the Cardiac Arrest Registry to Enhance Survival (CARES) database for 2013-2018 were used to estimate YLL. Cerebral performance category score disability weights were used to estimate YLD. The calculated DALY for the study population was extrapolated to a national level to estimate total U.S. DALY. Data were reported as DALY total and rate. Data were compared to the top 10 causes of DALY in the U.S.
Results
337,991 OHCA met study inclusion criteria. Total U.S. OHCA DALY increased from 3,005,308 in 2013 to 4,326,745 in 2018. The DALY rate increased from 950.9 per 100,000 individuals to 1322.4 per 100,000 individuals. OHCA DALY ranked fifth in the U.S. behind ischemic heart disease (2470), drug use disorders (1703), chronic obstructive pulmonary disease (1449), and back pain (1336). OHCA represented the largest percent increase in DALY rate (40.3%) over the study period.
Conclusion
Adult non-traumatic OHCA is a leading cause of DALY in the U.S. and the burden of disease due to OHCA has increased rapidly over time. These findings are likely due to more precise national OHCA surveillance, and suggest that the public health impact of OHCA is larger than previously described.

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

Resuscitation: 30 May 2021; 163:124-129
Coute RA, Nathanson BH, Mader TJ, McNally B, Kurz MC
Resuscitation: 30 May 2021; 163:124-129 | PMID: 33359108
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Impact:
Abstract

Impact of prehospital airway interventions on outcome in cardiac arrest following drowning: A study from the CARES Surveillance Group.

Ryan KM, Bui MD, Dugas JN, Zvonar I, Tobin JM
Introduction
Drowning results in more than 360,000 deaths annually, making it the 3rd leading cause of unintentional injury death worldwide. Prior studies have examined airway interventions affecting patient outcomes in cardiac arrest, but less is known about drowning patients in arrest. This study evaluated the outcomes of drowning patients in the Cardiac Arrest Registry to Enhance Survival (CARES) who received advanced airway management.
Methods
A retrospective analysis of the CARES database identified cases of drowning etiology between 2013 and 2018. Patients were stratified by airway intervention performed by EMS personnel. Demographics, sustained return of spontaneous circulation [ROSC], survival to hospital admission, survival to hospital discharge, and neurological outcomes were compared between airway groups using chi-squared tests and logistic regression.
Results
Among 2388 drowning patients, 70.4% were male, 41.8% white, and 13.1% survived to hospital discharge. Patients that received supraglottic airways [SGA] had statistically significantly lower odds of survival to hospital admission compared to endotracheal tube [ETT] use (adjusted odds ratio [aOR] = 0.56, 95% confidence interval [CI] 0.42-0.76) as well as lower odds of survival to discharge compared to bag valve mask [BVM] use (aOR = 0.40, 95% CI 0.19-0.86) when accounting for relative ROSC timing.
Conclusion
In this national cohort of drowning patients in cardiac arrest, SGA use was associated with significantly lower odds of survival to hospital admission and discharge. However, survival to discharge with favorable neurological outcome did not differ significantly between airway management techniques. Further studies will need to examine if airway intervention order or time to intervention affects outcomes.

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

Resuscitation: 30 May 2021; 163:130-135
Ryan KM, Bui MD, Dugas JN, Zvonar I, Tobin JM
Resuscitation: 30 May 2021; 163:130-135 | PMID: 33482267
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Impact:
Abstract

National coverage of out-of-hospital cardiac arrests using automated external defibrillator-equipped drones - A geographical information system analysis.

Schierbeck S, Nord A, Svensson L, Rawshani A, ... Hilding F, Claesson A
Background
Early defibrillation is essential for increasing the chance of survival in out-of-hospital-cardiac-arrest (OHCA). Automated external defibrillator (AED)-equipped drones have a substantial potential to shorten times to defibrillation in OHCA patients. However, optimal locations for drone deployment are unknown. Our aims were to find areas of high incidence of OHCA on a national level for placement of AED-drones, and to quantify the number of drones needed to reach 50, 80, 90 and 100% of the target population within eight minutes.
Methods
This is a retrospective observational study of OHCAs reported to the Swedish Registry for Cardiopulmonary Resuscitation between 2010-2018. Spatial analyses of optimal drone placement were performed using geographical information system (GIS)-analyses covering high-incidence areas (>100 OHCAs in 2010-2018) and response times.
Results
39,246 OHCAs were included. To reach all OHCAs in high-incidence areas with AEDs delivered by drone or ambulance within eight minutes, 61 drone systems would be needed, resulting in overall OHCA coverage of 58.2%, and median timesaving of 05:01 (min:sec) [IQR 03:22-06:19]. To reach 50% of the historically reported OHCAs in <8 min, 21 drone systems would be needed; for 80%, 366; for 90%, 784, and for 100%, 2408.
Conclusions
At a national level, GIS-analyses can identify high incidence areas of OHCA and serve as tools to quantify the need of AED-equipped drones. Use of only a small number of drone systems can increase national coverage of OHCA substantially. Prospective real-life studies are needed to evaluate theoretically optimized suggestions for drone placement.

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

Resuscitation: 30 May 2021; 163:136-145
Schierbeck S, Nord A, Svensson L, Rawshani A, ... Hilding F, Claesson A
Resuscitation: 30 May 2021; 163:136-145 | PMID: 33675868
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Abstract

SSEP amplitudes add information for prognostication in postanoxic coma.

van Soest TM, van Rootselaar AF, Admiraal MM, Potters WV, Koelman JHMT, Horn J
Objective
To investigate whether somatosensory evoked potential (SSEP) amplitude adds information for prediction of poor outcome in postanoxic coma.
Methods
In this retrospective cohort study we included adult patients admitted after cardiac arrest between January 2010 and June 2018 who remained in coma and had SSEP recorded for prognostication. Outcome was dichotomized in poor (Cerebral Performance Category (CPC) 4-5) and good (CPC 1-3) at ICU discharge. Sensitivity of bilaterally absent N20 potential was calculated. In case the N20 potential was not bilaterally absent, the amplitude contralateral to stimulation side (baseline-N20, N20-P25, and maximum) was determined. At a specificity of 100%, SEPP amplitude sensitivities were determined for poor outcome.
Results
SSEP recordings were performed in 197 patients of whom 57 had bilaterally absent N20 potentials. From 140 patients, 16 (11%) had a good outcome. The sensitivity for poor outcome of bilaterally absent N20 was 31%. At a specificity of 100%, contralateral amplitude thresholds were 0.34 μV (baseline-N20), 0.99 μV (N20-P25) and 1.0 μV (maximum), corresponding to a sensitivity for poor outcome of 38%, 44% and 40%. Combination of bilaterally absent N20 and a N20-P25 threshold below 0.99 μV yielded a sensitivity of 62%.
Conclusions
Our results confirm that very low cortical SSEP amplitudes are highly predictive of poor outcome in patients with postanoxic coma. Adding \'N20-P25 threshold amplitude\' to the \'bilaterally absent N20\' criterion, increased sensitivity substantially.

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

Resuscitation: 30 May 2021; 163:172-175
van Soest TM, van Rootselaar AF, Admiraal MM, Potters WV, Koelman JHMT, Horn J
Resuscitation: 30 May 2021; 163:172-175 | PMID: 33848583
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Impact:
Abstract

Trends of the incidence and clinical outcomes of suicide-related out-of-hospital cardiac arrest in Korea: A 10-year nationwide observational study.

Lee SY, Ro YS, Park JH, Jeong J, Song KJ, Shin SD
Background
The purpose of this study was to evaluate the characteristics and temporal trends of the incidence and survival outcomes of suicide-related out-of-hospital cardiac arrest (OHCA) according to the suicide attempt method during the past decade.
Methods
A population-based observational study between 2009 and 2018 was conducted. EMS-treated suicide-related OHCAs were classified according to the suicide method into hanging, jumping, poisoning, asphyxia and drowning, and other trauma. The study outcomes were survival to discharge and good neurological outcome. The temporal trends of crude and age- and sex-standardized incidence per 100,000 person-years and standardized rates for outcomes were calculated using direct standardization methods. Predictors of survival to discharge were investigated using multivariable logistic regression.
Results
From 2009 to 2018, the age- and sex-standardized incidence rate of suicide-related OHCA increased from 3.5 to 4.0 cases per 100,000 person-years. Of 21,720 eligible OHCAs, hanging (59.2%) was the most common suicide method, followed by jumping (21.3%), poisoning (14.9%), and asphyxia and drowning (3.5%). Although the standardized rates of survival to hospital discharge improved from 2.9% to 5.1% during the study period, good neurological outcome was not improved (from 0.7% to 1.0%). By suicide method, survival to discharge for the hanging group was increased, and good neurological outcome for the poisoning group showed improvement (both p-for-trend <0.05). Compared with hanging, other suicide methods were negatively associated with survival outcome.
Conclusion
The incidence of suicide-related OHCA has increased over the past decade in Korea, and survival outcomes are still very low. New interventions are needed to decrease the incidence and burden of suicide-related OHCAs.

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

Resuscitation: 30 May 2021; 163:146-154
Lee SY, Ro YS, Park JH, Jeong J, Song KJ, Shin SD
Resuscitation: 30 May 2021; 163:146-154 | PMID: 33766665
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Impact:
Abstract

Rapid dispatch for out-of-hospital cardiac arrest is associated with improved survival.

Gnesin F, Møller AL, Mills EHA, Zylyftari N, ... Folke F, Torp-Pedersen C
Aim
As proxy for initiation of the first link in the Chain of Survival by the dispatcher, we aimed to investigate the effect of time to first dispatch on 30-day survival among patients with OHCA ultimately receiving the highest-level emergency medical response.
Methods
We linked data on all OHCA unwitnessed by emergency medical services (EMS) treated by Copenhagen EMS from 2016 through 2018 to corresponding emergency call records. Among patients receiving highest priority emergency response, we calculated time to dispatch as time from start of call to time of first dispatch.
Results
We included 3548 patients with OHCA. Of these, 94.1% received the highest priority response (median time to dispatch 0.84 min, 25th-75th percentile 0.58-1.24 min). Patients with time to dispatch within one minute compared to three or more minutes were more likely to receive bystander cardiopulmonary resuscitation (77.3 vs 54.2%), bystander defibrillation (11.5 vs 6.5%) and defibrillation by emergency medical services (24.1 vs 7.5%) and were 2.6-fold more likely to survive 30 days after the OHCA (P = 0.004). Results from multivariate logistic regression were similar: odds ratio (OR) of survival 0.83 per minute increase (95% confidence interval 0.70-1.00, P = 0.04). However, survival was similar between those who received highest priority response and those who did not: OR of survival 0.88 (95% confidence interval 0.53-1.46, P = 0.61).
Conclusion
Rapid time to dispatch among patients with highest priority response was significantly associated with a higher probability of 30-day survival following OHCA.

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

Resuscitation: 30 May 2021; 163:176-183
Gnesin F, Møller AL, Mills EHA, Zylyftari N, ... Folke F, Torp-Pedersen C
Resuscitation: 30 May 2021; 163:176-183 | PMID: 33775800
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Impact:
Abstract

SSEP amplitude accurately predicts both good and poor neurological outcome early after cardiac arrest; a post-hoc analysis of the ProNeCA multicentre study.

Scarpino M, Lolli F, Lanzo G, Carrai R, ... Sandroni C, ProNeCA study group
Aim
To assess if, in comatose resuscitated patients, the amplitude of the N20 wave (N20amp) of somatosensory evoked potentials (SSEP) can predict 6-months neurological outcome.
Setting
Multicentre study in 13 Italian intensive care units.
Methods
The N20amp in microvolts (μV) was measured at 12 h, 24 h, and 72 h from cardiac arrest, along with pupillary reflex (PLR) and a 30-min EEG classified according to the ACNS terminology. Sensitivity and false positive rate (FPR) of N20amp alone or in combination were calculated.
Results
403 patients (age 69[58-68] years) were included. At 12 h, an N20amp >3 μV predicted good neurological outcome (Cerebral Performance Categories [CPC] 1-2) with 61[50-72]% sensitivity and 11[6-18]% FPR. Combining it with a benign (continuous or nearly continuous) EEG increased sensitivity to 91[82-96]%. For poor outcome (CPC 3-5), an N20Amp ≤0.38 μV, ≤0.73 μV and ≤1.01 μV at 12 h, 24 h, and 72 h, respectively, had 0% FPR with sensitivity ranging from 61[51-69]% and 82[76-88]%. Sensitivity was higher than that of a bilaterally absent N20 at all time points. At 12 h and 24 h, a highly malignant (suppression or burst-suppression) EEG and bilaterally absent PLR achieved 0% FPR only when combined with SSEP. A combination of all three predictors yielded a 0[0-4]% FPR, with maximum sensitivity of 44[36-53]%.
Conclusion
At 12 h from arrest, a high N20Amp predicts good outcome with high sensitivity, especially when combined with benign EEG. At 12 h and 24 h from arrest a low-voltage N20amp has a high sensitivity and is more specific than EEG or PLR for predicting poor outcome.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 30 May 2021; 163:162-171
Scarpino M, Lolli F, Lanzo G, Carrai R, ... Sandroni C, ProNeCA study group
Resuscitation: 30 May 2021; 163:162-171 | PMID: 33819501
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Impact:
Abstract

Does experience in prehospital post-resuscitation critical care affect outcomes? A retrospective cohort study.

Saviluoto A, Jäntti H, Holm A, Nurmi JO
Aims:
of the study
Helicopter Emergency Medical Services (HEMS) often provide post-resuscitation care. Our aims were to investigate whether physicians\' frequent exposure to prehospital post-resuscitation care is associated with differences in (1) medical management, (2) achieving treatment targets recommended by resuscitation guidelines, (3) survival.
Methods
We conducted a retrospective cohort study using data from a national HEMS quality register. We included patients between January 1st, 2012 and September 9th, 2019 who received post-resuscitation care by a HEMS physician. We excluded patients <16 years old. For each patient we determined the number of post-resuscitation cases the physician had attended in the previous 12 months. Patients were divided in to three groups: low (0-5), intermediate (6-11) and high exposure (≥12 cases). Medical management and proportions within treatment targets were compared. Survival at 30-days and 1-year was analysed by multivariate logistic regression analysis, controlling for known prognostic factors.
Results
2272 patients were analysed. Patients in the high exposure group had mechanical ventilation and vasoactive medications initiated more often (P < 0.001 and P = 0.008, respectively) and on-scene times were longer (P < 0.001). The target for blood pressure was achieved more often in this group (P = 0.026), but targets for oxygenation and ventilation were not. We did not see an association between survival and physicians\' exposure to post-resuscitation care (odds ratio 0.96, 95% confidence interval 0.70-1.33 for low and 0.78, 0.56-1.08 for intermediate, compared to high exposure).
Conclusions
Physicians with more, frequent exposure take a more active approach to post-resuscitation care, but this does not seem to improve survival.

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

Resuscitation: 30 May 2021; 163:155-161
Saviluoto A, Jäntti H, Holm A, Nurmi JO
Resuscitation: 30 May 2021; 163:155-161 | PMID: 33811958
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Impact:
Abstract

Sex differences in outcomes for out-of-hospital cardiac arrest in the United States.

Kotini-Shah P, Del Rios M, Khosla S, Pugach O, ... Vanden Hoek T, Chan PS
Background
Approximately 1000 out-of-hospital cardiac arrest (OHCA) occur each day in the United States. Although sex differences exist for other cardiovascular conditions such as stroke and acute myocardial infarction, they are less well understood for OHCA. Specifically, the extent to which neurological and survival outcomes after OHCA differ between men and women remains poorly characterized in the U.S.
Methods and results
Within the national Cardiac Arrest Registry to Enhance Survival (CARES) registry, we identified 326,138 adults with an OHCA from 2013 to 2019. Using multivariable logistic regression, we evaluated for sex differences in rates of survival to hospital admission, survival to hospital discharge, and favorable neurological survival (i.e., without severe neurological disability), adjusted for demographics, cardiac arrest characteristics and bystander interventions. Overall, 117,281 (36%) patients were women. Median age was 62 and 65 years for men and women, respectively. An initial shockable rhythm (25.1% vs 14.7%, standardized difference of 0.26) and an arrest in a public location (22.2% vs. 11.3%; standardized difference of 0.30) were more common in men, but there were no meaningful sex differences in rates of witnessed arrests, bystander cardiopulmonary resuscitation, intra-venous access, or use of mechanical devices for delivering cardiopulmonary resuscitation. Overall, the unadjusted rates of all survival outcomes were similar between men and women: survival to hospital admission (27.0% for men vs. 27.9% for women, standardized difference of -0.02), survival to hospital discharge (10.5% for men vs. 8.6% for women, standardized difference of 0.07), and favorable neurological survival (9.0% for men vs. 6.6% for women, standardized difference of 0.09). After multivariable adjustment, however, men were less likely to survive to hospital admission (adjusted OR = 0.75, 95% CI: 0.73, 0.77), survive to hospital discharge (adjusted OR = 0.83, 95% CI: 0.80, 0.85), or have favorable neurological survival (adjusted OR = 0.88, 95% CI: 0.85, 0.91).
Conclusions
Compared to women, men with OHCA have more favorable cardiac arrest characteristics but were less likely to survive to hospital admission, survive to discharge, nor have favorable neurological survival.

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

Resuscitation: 30 May 2021; 163:6-13
Kotini-Shah P, Del Rios M, Khosla S, Pugach O, ... Vanden Hoek T, Chan PS
Resuscitation: 30 May 2021; 163:6-13 | PMID: 33798627
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Impact:
Abstract

Plasma proenkephalin A 119-159 and dipeptidyl peptidase 3 on admission after cardiac arrest help predict long-term neurological outcome.

Thorgeirsdóttir B, Levin H, Spångfors M, Annborn M, ... Friberg H, Frigyesi A
Background
A large proportion of adult survivors of cardiac arrest have a poor neurological outcome. Guidelines recommend multimodal neuro-prognostication no earlier than 72-96 h after cardiac arrest. There is great interest in earlier prognostic markers, including very early markers at admission. The novel blood biomarkers proenkephalin A 119-159 (penKid), bioactive adrenomedullin (bio-ADM) and circulating dipeptidyl peptidase 3 (cDPP3) have not been previously investigated for the early prognosis of cardiac arrest survivors.
Methods
This multicentre observational study included adult survivors of cardiac arrest admitted to intensive care at four Swedish intensive care units (ICUs) during 2016. Blood samples were collected at ICU admission and batch analysed. The association between admission plasma penKid, bio-ADM and cDPP3 and poor long-term neurological outcome, according to the Cerebral Performance Category (CPC) scale, was assessed by binary logistic regression. Their prognostic performance was assessed using the area under the receiver operating characteristic curve (AUC).
Results
A total of 190 patients were included, of which 136 patients had suffered out-of-hospital and 54 patients in-hospital cardiac arrest. Poor long-term neurological outcome was associated with elevated admission plasma concentrations of penKid and cDPP3, but not with bio-ADM. The association for penKid, but not for cDPP3, remained after adjusting for clinical cardiac arrest variables with prognostic value (time to return of spontaneous circulation (ROSC), initial rhythm, admission Glasgow coma scale (GCS) motor score and absence of pupillary reflexes). The prognostic performance of above mentioned clinical cardiac arrest variables alone was very good with an AUC of 0.90 (95% confidence interval, CI, 0.86-0.95), but improved further with the addition of penKid resulting in an AUC of 0.93 (95% CI 0.89-0.97, p < 0.026). Plasma penKid and cDPP3 alone provided moderate long-term prognostic information with AUCs of 0.70 and 0.71, respectively.
Conclusion
After cardiac arrest, admission plasma levels of penKid and cDPP3, but not bio-ADM, predicted long-term neurological outcome. When added to clinical cardiac arrest variables, penKid further improved prognostic performance.

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

Resuscitation: 30 May 2021; 163:108-115
Thorgeirsdóttir B, Levin H, Spångfors M, Annborn M, ... Friberg H, Frigyesi A
Resuscitation: 30 May 2021; 163:108-115 | PMID: 33930500
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Impact:
Abstract

Acting on the potentially reversible causes of traumatic cardiac arrest: possible but not sufficient.

Savary D, Douillet D, Morin F, Drouet A, ... Fadel M, Descatha A
Introduction
Traumatic cardiac arrest (TCA) guidelines emphasize specific actions that aim to treat the potential reversible causes of the arrest. The aim of this study was to measure the impact of these recommendations on specific rescue measures carried out in the field, and their influence on short-term outcomes in the resuscitation of TCA patients.
Methods
We conducted a retrospective study of all TCA patients treated in two emergency medical units, which are part of the Northern Alps Emergency Network, from January 2004 to December 2017. We categorised cases into three periods: pre-guidelines (from January 2004 to December 2007), during guidelines (from January 2008 to December 2011), and post-guidelines (from January 2012 to December 2017). Local guidelines, a physician education programme, and specific training were set up during the post-guidelines period to increase adherence to recommendations. Utstein variables, and specific rescue measures were collected: advanced airway management, fluid administration, pelvic stabilisation or tourniquet application, bilateral thoracostomy, and thoracotomy procedures. The primary endpoint was survival rate at day 30 with good neurological status (cerebral performance category scores 1 & 2) in each period, considering the pre-guidelines period as the reference.
Results
There were 287 resuscitation attempts in the TCA cases included, and 279 specific interventions were identified with a significant increase in the number of fluid expansions (+16%), bilateral thoracostomies (+75%), and pelvic stabilisations (+25%) from the pre- to post-guidelines periods. However, no improvement in survival over time was found.
Conclusion
Reversible measures were applied but to a varying degree, and may not adequately capture pre-hospital performance on overall TCA survival.

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

Resuscitation: 30 May 2021; epub ahead of print
Savary D, Douillet D, Morin F, Drouet A, ... Fadel M, Descatha A
Resuscitation: 30 May 2021; epub ahead of print | PMID: 34082034
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Abstract

Association between shockable rhythms and long-term outcome after pediatric out-of-hospital cardiac arrest in Rotterdam, the Netherlands: an 18-year observational study.

Albrecht M, de Jonge RCJ, Nadkarni VM, de Hoog M, ... van Zellem L, Buysse CMP
Introduction
Shockable rhythm following pediatric out-of-hospital cardiac arrest (pOHCA) is consistently associated with hospital and short-term survival. Little is known about the relationship between shockable rhythm and long-term outcomes (>1 year) after pOHCA. The aim was to investigate the association between first documented rhythm and long-term outcomes in a pOHCA cohort over 18 years.
Methods
All children aged 1 day-18 years who experienced non-traumatic pOHCA between 2002-2019 and were subsequently admitted to the emergency department (ED) or pediatric intensive care unit (PICU) of Erasmus MC-Sophia Children\'s Hospital were included. Data was abstracted retrospectively from patient files, (ground) ambulance and Helicopter Emergency Medical Service (HEMS) records, and follow-up clinics. Long-term outcome was determined using a Pediatric Cerebral Performance Category (PCPC) score at the longest available follow-up interval through august 2020. The primary outcome measure was survival with favorable neurologic outcome, defined as PCPC 1-2 or no difference between pre- and post-arrest PCPC. The association between first documented rhythm and the primary outcome was calculated in a multivariable regression model.
Results
369 children were admitted, nine children were lost to follow-up. Median age at arrest was age 3.4 (IQR 0.8-9.9) years, 63% were male and 14% had a shockable rhythm (66% non-shockable, 20% unknown or return of spontaneous circulation (ROSC) before emergency medical service (EMS) arrival). In adolescents (aged 12-18 years), 39% had shockable rhythm. 142 (39%) of children survived to hospital discharge. On median follow-up interval of 25 months (IQR 5.1-49.6), 115/142 (81%) of hospital survivors had favorable neurologic outcome. In multivariable analysis, shockable rhythm was associated with survival with favorable long-term neurologic outcome (OR 8.9 [95%CI 3.1-25.9]).
Conclusion
In children with pOHCA admitted to ED or PICU shockable rhythm had significantly higher odds of survival with long-term favorable neurologic outcome compared to non-shockable rhythm. Survival to hospital discharge after pOHCA was 39% over the 18-year study period. Of survivors to discharge, 81% had favorable long-term (median 25 months, IQR 5.1-49.6) neurologic outcome. Efforts for improving outcome of pOHCA should focus on early recognition and treatment of shockable pOHCA at scene.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 30 May 2021; epub ahead of print
Albrecht M, de Jonge RCJ, Nadkarni VM, de Hoog M, ... van Zellem L, Buysse CMP
Resuscitation: 30 May 2021; epub ahead of print | PMID: 34082030
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Abstract

Impact of bradycardia and hypoxemia on oxygenation in preterm infants requiring respiratory support at birth.

Bresesti I, Avian A, Bruckner M, Binder-Heschl C, ... Pichler G, Urlesberger B
Aim of the study
Analysis of the impact of bradycardia and hypoxemia on the course of cerebral and peripheral oxygenation parameters in preterm infants in need for respiratory support during foetal-to-neonatal transition.
Methods
The first 15 min after birth of 150 preterm neonates in need for respiratory support born at the Division of Neonatology, Graz (Austria) were analyzed. Infants were divided into different groups according to duration of bradycardia exposure (no Bradycardia, brief bradycardia <2 min, and prolonged bradycardia ≥2 min) and to systemic oxygen saturation (SpO2) value at 5 min of life (<80% or ≥80%). Analysis was performed considering the degree of bradycardia alone (step 1) and in association with the presence of hypoxemia (step 2).
Results
In step 1, courses of SpO2 differed significantly between bradycardia groups (p = 0.002), while courses of cerebral regional oxygen saturation (crStO2) and cerebral fractional tissue oxygen extraction (cFTOE) were not influenced (p = 0.382 and p = 0.878). In step 2, the additional presence of hypoxemia had a significant impact on the courses of SpO2 (p < 0.001), crStO2 (p < 0.001) and cFTOE (p = 0.045).
Conclusion
Our study shows that the degree of bradycardia has a significant impact on the course of SpO2 only, but when associated with the additional presence of hypoxemia a significant impact on cerebral oxygenation parameters was seen (crStO2, cFTOE). Furthermore, the additional presence of hypoxemia has a significant impact on FiO2 delivered. Our study emphasizes the importance of HR and SpO2 during neonatal resuscitation, underlining the relevance of hypoxemia during the early transitional phase.

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

Resuscitation: 24 May 2021; 164:62-69
Bresesti I, Avian A, Bruckner M, Binder-Heschl C, ... Pichler G, Urlesberger B
Resuscitation: 24 May 2021; 164:62-69 | PMID: 34048860
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Impact:
Abstract

Barriers and facilitators for in-hospital resuscitation: A prospective clinical study.

Lauridsen KG, Krogh K, Müller SD, Schmidt AS, ... Kirkegaard H, Løfgren B
Introduction
Guideline deviations with impact on patient outcomes frequently occur during in-hospital cardiopulmonary resuscitation (CPR). However, barriers and facilitators for preventing these guideline deviations are understudied. We aimed to characterize challenges occurring during IHCA and identify barriers and facilitators perceived by actual team members immediately following IHCA events.
Methods
This was a prospective multicenter clinical study. Following each resuscitation attempt in 6 hospitals over a 4-year period, we immediately sent web-based structured questionnaires to all responding team members, reporting their perceived resuscitation quality, teamwork, and communication and what they perceived as barriers or facilitators. Comments were analyzed using qualitative inductive thematic analysis methodology.
Results
We identified 924 resuscitation attempts and 3,698 survey responses were collected including 2,095 qualitative comments (response rate: 65%). Most frequent challenges were overcrowding (27%) and poor ergonomics/choreography of people in the room (17%). Narrative comments aligned into 24 unique barrier and facilitator themes in 4 domains: 6 related to treatment (most prevalent: CPR, rhythm check, equipment), 7 for teamwork (most prevalent: role allocation, crowd control, collaboration with ward staff), 6 for leadership (most prevalent: visible and distinct leader, multiple leaders, leader experience), and 5 for communication (most prevalent: closed loops, atmosphere in room, speaking loud/clear).
Conclusion
Using novel, immediate after-event survey methodology of individual cardiac arrest team members, we characterized challenges and identified 24 themes within 4 domains that were barriers and facilitators for in-hospital resuscitation teams. We believe this level of detail is necessary to contextualize guidelines and training to facilitate high-quality resuscitation.

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

Resuscitation: 23 May 2021; 164:70-78
Lauridsen KG, Krogh K, Müller SD, Schmidt AS, ... Kirkegaard H, Løfgren B
Resuscitation: 23 May 2021; 164:70-78 | PMID: 34033863
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Impact:
Abstract

To transport or to terminate resuscitation on-site. What factors influence EMS decisions in patients without ROSC? A mixed-methods study.

de Graaf C, de Kruif AJTCM, Beesems SG, Koster RW
Background
If a patient in out-of-hospital cardiac arrest (OHCA) does not achieve return of spontaneous circulation (ROSC) despite advanced life support, emergency medical services can decide to either transport the patient with ongoing CPR or terminate resuscitation on scene.
Purpose
To determine differences between patients without ROSC to be transported vs. terminated on scene and explore medical and nonmedical factors that contribute to the decision-making of paramedics on scene.
Methods
Mixed-methods approach combining quantitative and qualitative data. Quantitative data on all-cause OHCA patients without ROSC on scene, between January 1, 2012, and December 31, 2016, in the Amsterdam Resuscitation Study database, were analyzed to find factors associated with decision to transport. Qualitative data was collected by performing 16 semi-structured interviews with paramedics from the study region, transcribed and coded to identify themes regarding OHCA decision-making on the scene.
Results
In the quantitative Utstein dataset, of 5870 OHCA patients, 3190 (54%) patients did not achieve ROSC on scene. In a multivariable model, age (OR 0.98), public location (OR 2.70), bystander witnessed (OR 1.65), EMS witnessed (OR 9.03), and first rhythm VF/VT (OR 11.22) or PEA (OR 2.34), were independently associated with transport with ongoing CPR. The proportion of variance explained by the model was only 0.36. With the qualitative method, four main themes were identified: patient-related factors, local circumstances, paramedic-related factors, and the structure of the organization.
Conclusion
In patients without ROSC on scene, besides known resuscitation characteristics, the decision to transport a patient is largely determined by non-protocollized factors.

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

Resuscitation: 20 May 2021; 164:84-92
de Graaf C, de Kruif AJTCM, Beesems SG, Koster RW
Resuscitation: 20 May 2021; 164:84-92 | PMID: 34023427
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Impact:
Abstract

Coronary angiography findings in patients with shock-resistant ventricular fibrillation cardiac arrest.

Nas J, Thannhauser J, van Dijk EGJA, Verkroost C, ... Ten Cate T, Brouwer MA
Introduction
Shock-resistant ventricular fibrillation (VF) poses a therapeutic challenge during out-of-hospital cardiac arrest (OHCA). For these patients, new treatment strategies are under active investigation, yet underlying trigger(s) and substrate(s) have been poorly characterised, and evidence on coronary angiography (CAG) data is often limited to studies without a control group.
Methods
In our OHCA-registry, we studied CAG-findings in OHCA-patients with VF who underwent CAG after hospital arrival. We compared baseline demographics, arrest characteristics, CAG-findings and outcomes between patients with VF that was shock-resistant (defined as >3 shocks) or not shock-resistant (≤3 shocks).
Results
Baseline demographics, arrest location, bystander resuscitation and AED-use did not differ between 105 patients with and 196 patients without shock-resistant VF. Shock-resistant VF-patients required more shocks, with higher proportions endotracheal intubation, mechanical CPR, amiodaron and epinephrine. In both groups, significant coronary artery disease (≥1 stenosis >70%) was highly prevalent (78% vs. 77%, p = 0.76). Acute coronary occlusions (ACOs) were more prevalent in shock-resistant VF-patients (41% vs. 26%, p = 0.006). Chronic total occlusions did not differ between groups (29% vs. 33%, p = 0.47). There was an association between increasing numbers of shocks and a higher likelihood of ACO. Shock-resistant VF-patients had lower proportions 24-h survival (75% vs. 93%, p < 0.001) and survival to discharge (61% vs. 78%, p = 0.002).
Conclusion
In this cohort of OHCA-patients with VF and CAG after transport, acute coronary occlusions were more prevalent in patients with shock-resistant VF compared to VF that was not shock-resistant, and their clinical outcome was worse. Confirmative studies are warranted for this potentially reversible therapeutic target.

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

Resuscitation: 20 May 2021; 164:54-61
Nas J, Thannhauser J, van Dijk EGJA, Verkroost C, ... Ten Cate T, Brouwer MA
Resuscitation: 20 May 2021; 164:54-61 | PMID: 34023425
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Impact:
Abstract

The interplay between bystander cardiopulmonary resuscitation and ambient temperature on neurological outcome after cardiac arrest: A nationwide observational cohort study.

Hayashida K, Takegawa R, Nishikimi M, Aoki T, ... Matsui S, Becker LB
Background
At lower ambient temperature, patients with out-of-hospital cardiac arrest (OHCA) easily experience hypothermia. Hypothermia has shown to improve the rate of successful return of spontaneous circulation (ROSC) in animal models. We hypothesized that lower temperature affects the impact of bystander cardiopulmonary resuscitation (CPR) on the increased odds of a favorable neurological outcome post-OHCA.
Methods
This study used information collected by the prospective, nationwide, Utstein registry to examine data from 352,689 adult patients who experienced OHCA from 2012 to 2016 in Japan. The primary outcome was a 1-month favorable neurological outcomes. Multivariable logistic regression analyses were conducted to test the impact of bystander CPR according to the temperature on the favorable outcome.
Results
A total of 201,111 patients with OHCA were included in the complete case analysis. The lower temperature group had lower proportions of receiving bystander CPR (46.5 vs. 47.9%) and having favorable outcome (2.1 vs 2.8%) than those in the higher group. Multivariable analysis revealed that bystander CPR at lower temperatures was significantly associated with favorable outcomes (adjusted odds ratio, 1.22; 95% CI, 1.09-1.37), whereas bystander CPR at higher temperatures was not associated with favorable outcomes (1.02; 0.92-1.13). The nonlinear relationship using a spline curve in the multivariable model revealed that odds ratio of favorable neurological outcomes associated with bystander CPR increased as the temperature decreased.
Conclusion
Bystander CPR was associated with favorable neurological outcomes at lower temperatures. The odds of a favorable outcome associated with bystander CPR increased as the temperature decreased.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 19 May 2021; 164:46-53
Hayashida K, Takegawa R, Nishikimi M, Aoki T, ... Matsui S, Becker LB
Resuscitation: 19 May 2021; 164:46-53 | PMID: 34023426
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Impact:
Abstract

Association between functional status at hospital discharge and long-term survival after out-of-hospital-cardiac-arrest.

Chocron R, Fahrenbruch C, Yin L, Guan S, ... Kudenchuk PJ, Rea T
Background
Out-of-hospital cardiac arrest (OHCA) causes brain injury. Functional status of survivors at hospital discharge is a core resuscitation measure, frequently using the Cerebral Performance Category (CPC) or modified Rankin Scale (mRS). Which scale better predicts long-term survival following OHCA is not known.
Methods
We evaluated long-term survival after hospital discharge in a retrospective cohort of persons resuscitated from OHCA in King County, WA from 2007 to 2015. Patients were independently assessed at discharge using both scales, leveraging the regional quality improvement registry, which records the 5-level CPC, and concurrent research studies involving the Resuscitation Outcomes Consortium, which used the 7-level mRS, taken from information in the hospital record. The risk of mortality associated with CPC and mRS categories was estimated using Kaplan-Meier survival analysis and Cox proportional hazards regression.
Results
Among 878 eligible patients discharged alive, there were 358 deaths during 9118.5 person-years of follow-up. Overall 1, 5 and 10-year survival was 84.4%, 68.5%, and 53.7% and varied according to CPC and mRS (p < 0.01 per Kaplan-Meier). Compared to CPC-1, hazard ratio (HR) increased incrementally for CPC-2 = 1.33 (1.03-1.73), CPC-3 = 1.90 (1.37-2.65), and CPC-4 = 8.25 (5.63-12.10). Compared to mRS = 0, HR for mRS-1 = 1.02 (0.66-1.58), mRS-2 = 1.52 (1.00-2.32), mRS-3 = 1.41 (0.92-2.14), mRS-4 = 2.00 (1.37-2.97), and mRS-5 = 4.90 (3.23-7.44).
Conclusion
In OHCA survivors, CPC and mRS scales both predicted long-term survival. However mRS 0-1 and 2-3 groups did not have distinct prognoses, suggesting that a consolidated mRS score may simplify capture of relevant prognostic information for survival predictions.

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

Resuscitation: 18 May 2021; 164:30-37
Chocron R, Fahrenbruch C, Yin L, Guan S, ... Kudenchuk PJ, Rea T
Resuscitation: 18 May 2021; 164:30-37 | PMID: 33965475
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Impact:
Abstract

Factors associated with non-survival from in-hospital maternal cardiac arrest: An analysis of Get With The Guidelines® (GWTG) data.

Zelop CM, Shaw RE, Edelson DP, Lipman SS, ... Einav S, American Heart Association’s Get With The Guidelines®-Resuscitation Investigators
Introduction
Maternal mortality has risen in the United States during the 21st century. Factors influencing outcome of maternal cardiac arrest (MCA) remain largely unexplored.
Objective
We sought to further elucidate the factors affecting maternal death from in-hospital (IH) MCA.
Methods
Our query of the American Heart Association\'s GWTG®-Resuscitation voluntary registry from 2000-2017 revealed 561 index cases of IH MCA with complete outcome data. Logistic regression was performed using hospital death as the primary outcome and included variables with a p value = 0.1 or less based upon univariate analysis. Age, race, year of arrest, pre-existing conditions, first documented pulseless rhythm and location of arrest were used in the model. Sensitivity analyses and assessment of variable interaction were also performed to test model stability. Institutional review deemed this research exempt from ethical approval.
Results
Among 561 cases of MCA, 57.2% (321/561) did not survive to hospital discharge. IH death was not associated with maternal age, race and year of event. In the final model, IH death was significantly associated with pre-arrest hypotension/hypoperfusion (OR = 1.80 (95% CI, 1.16-2.79); p = 0.009). The occurrence of MCA outside of the delivery suite (referent group) or operating room was associated with a significantly higher risk of death: ICU/Post-Anesthesia Care Unit (PACU) (OR = 3.32 (95% CI, 2.00-5.52); p < 0.001) and ER/other (OR = 1.89 (95% CI, 1.15-3.11); p = 0.012). While MCA cases with a shockable vs. non-shockable first documented pulseless rhythm had similar outcomes, those with an indeterminate rhythm were less likely to die, (OR = 0.41(95% CI, 0.20-0.84); p = 0.014). In a sensitivity analysis, removal of the indeterminate group did not alter outcomes regarding first documented pulseless rhythm or arrest location. Area under the curve for the final model was 0.715 (95% CI 0.673-0.757).
Conclusions
Our study identified several novel factors associated with IH death of our MCA cohort. More research is required to further understand the pathophysiologic dynamics affecting outcomes of IH MCA in this unique population.

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

Resuscitation: 14 May 2021; 164:40-45
Zelop CM, Shaw RE, Edelson DP, Lipman SS, ... Einav S, American Heart Association’s Get With The Guidelines®-Resuscitation Investigators
Resuscitation: 14 May 2021; 164:40-45 | PMID: 34004263
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Impact:
Abstract

Outcomes associated with delayed enteral feeding after cardiac arrest treated with veno-arterial extracorporeal membrane oxygenation and targeted temperature management.

Gutierrez A, Carlson C, Kalra R, Elliott AM, Yannopoulos D, Bartos JA
Introduction
While early enteral nutrition is generally preferred in critically ill patients, the optimal timing of feeding among refractory cardiac arrest patients is unknown. We examined the association between timing of enteral nutrition and patient survival and safety outcomes in patients with refractory out-of-hospital cardiac arrest (OHCA) who were treated with extracorporeal cardiopulmonary resuscitation (ECPR).
Methods
We performed a retrospective analysis of 142 consecutive patients presenting with OHCA due to ventricular fibrillation or ventricular tachycardia treated with ECPR and targeted temperature management (TTM). Neurologically favorable survival and clinical outcomes were compared between patients who received early enteral nutrition (<48 h after admission to the intensive care unit) and patients receiving delayed enteral nutrition (initiated >48 h after admission).
Results
Enteral nutrition was initiated in 90/142 (63%) patients. Early enteral nutrition was provided in 34/90 (38%) while delayed nutrition occurred in 56/90 (62%). In adjusted analysis including patients who received nutrition, delayed enteral feeding was associated with increased odds of neurologically favorable survival (29 vs 54%, CI 1.04-7.25, p = 0.04). There were no significant differences in the incidence of pneumonia (18 vs 27%, p = 0.16), gastrointestinal bleeding (5.9 vs 3.6%, p = 0.42), intestinal ischemia (5.9 vs 5.4%, p = 0.90), ileus (12 vs 11%, p = 0.98), or need for tracheostomy (15 vs 20%, p = 0.81) between early and late feeding groups.
Conclusion
In patients with refractory OHCA treated with ECPR and TTM, delayed enteral nutrition was associated with improved neurologically favorable survival. Adverse events related to enteral feeding were not associated with timing of feeding initiation.

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

Resuscitation: 13 May 2021; 164:20-26
Gutierrez A, Carlson C, Kalra R, Elliott AM, Yannopoulos D, Bartos JA
Resuscitation: 13 May 2021; 164:20-26 | PMID: 33965476
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Impact:
Abstract

Cognitive dysfunction after out-of-hospital cardiac arrest: Rate of impairment and clinical predictors.

Byron-Alhassan A, Collins B, Bedard M, Quinlan B, ... Smith AM, Tulloch HE
Background
The purpose of this study was to evaluate the rate and domains of cognitive impairment in out-of-hospital cardiac arrest (OHCA) survivors, as compared to patients who experienced a myocardial infarction (MI), and to explore mechanisms and predictors of this impairment.
Methods and results
OHCA survivors with \"good\" neurological recovery (i.e., Cerebral Performance Categories Scale ≤ 2) (n = 79), as well as a control group of MI patients (n = 69), underwent a comprehensive neuropsychological assessment. Forty-three percent of OHCA survivors were cognitively impaired (in the lowest decile on a global measure of cognitive functioning). Rates of impairment were approximately six times higher in the OHCA group than the MI group. Attention, memory, language and executive function were affected. Downtime was a significant predictor of cognitive impairment; the interaction between downtime and immediate intervention was significant such that, at short downtimes, receiving cardiopulmonary resuscitation (CPR) or defibrillation within 1 min of collapse predicted less cognitive impairment.
Conclusions
OHCA survivors - even those with seemingly good neurological recovery - are at risk for cognitive impairment. Cognitive rehabilitation may be an important consideration post-OHCA.

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

Resuscitation: 11 May 2021; epub ahead of print
Byron-Alhassan A, Collins B, Bedard M, Quinlan B, ... Smith AM, Tulloch HE
Resuscitation: 11 May 2021; epub ahead of print | PMID: 33991604
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Impact:
Abstract

Effectiveness of public-access automated external defibrillators at Tokyo railroad stations.

Shibahashi K, Sakurai S, Kobayashi M, Ishida T, Hamabe Y
Aim
To investigate the effectiveness of public-access automated external defibrillators (AEDs) at Tokyo railroad stations.
Methods
We analysed data from a population-based registry of out-of-hospital cardiac arrests in Tokyo, Japan (2014-2018). We identified patients aged ≥18 years who experienced bystander-witnessed cardiac arrest due to ventricular fibrillation of presumed cardiac origin at railroad stations. The primary outcome was survival at 1 month after cardiac arrest with favourable neurological outcomes (cerebral performance category 1-2).
Results
Among 280 eligible patients who had bystander-witnessed cardiac arrest and received defibrillation at railroad stations, 245 patients (87.5%) received defibrillation using public-access AEDs and 35 patients (12.5%) received defibrillation administered by emergency medical services (EMS). Favourable neurological outcomes at 1 month after cardiac arrest were significantly more common in the group that received defibrillation using public-access AEDs (50.2% vs. 8.6%; adjusted odds ratio: 11.2, 95% confidence interval: 1.43-88.4) than in the group that received defibrillation by EMS. Over a 5-year period, favourable neurological outcomes at 1 month after cardiac arrest of 101.9 cases (95% confidence interval: 74.5-129.4) were calculated to be solely attributable to public-access AED use. The incremental cost-effectiveness ratio to gain one favourable neurological outcome obtained from public-access AEDs at railroad stations was lower than that obtained from nationwide deployment (48.5 vs. 2133.4 AED units).
Conclusion
Deploying public-access AEDs at Tokyo railroad stations presented significant benefits and cost-effectiveness. Thus, it may be prudent to prioritise metropolitan railroad stations in public-access defibrillation programs.

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

Resuscitation: 05 May 2021; 164:4-11
Shibahashi K, Sakurai S, Kobayashi M, Ishida T, Hamabe Y
Resuscitation: 05 May 2021; 164:4-11 | PMID: 33964334
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Impact:
Abstract

Prognostic value of brainstem auditory and visual evoked potentials in cardiac arrest patients with targeted temperature management.

Lim JY, Oh SH, Park KN, Choi SP, ... Kim HJ, Song H
Purpose
We analysed the prognostic value of somatosensory, brainstem auditory and visual evoked potentials (SSEPs, BAEPs and VEPs, respectively) for outcome prediction in cardiac arrest patients with targeted temperature management (TTM) and assessed whether BAEP and VEP measurements conferred added value to SSEP measurements.
Methods
Cases with SSEPs and VEPs or BAEPs were reviewed in a TTM registry. We focused on whether the following responses were clearly discernible: N20 for SSEPs, V for BAEPs, and P100 for VEPs. Each type of evoked potential was classified as absent, present or indeterminable. Neurological outcomes after 6 months were dichotomized as good (Cerebral Performance Category [CPC] 1-2) or poor (CPC 3-5).
Results
From 185 patients, 185 SSEPs, 172 BAEPs and 178 VEPs were included. None of the patients with a good outcome had absent SSEP, BAEP or VEP responses. Absent SSEP, BAEP and VEP responses yielded sensitivities of 42.3% (95% confidence interval [CI], 33.7-51.3%), 9.4% (95% CI, 4.6-16.7%) and 54.4% (95% CI, 46.0-62.5%) for poor outcomes, respectively. For the overall cohort, the addition of VEP measurements improved the sensitivities of single SSEP measurements (65.8% [95% CI, 57.7-73.3%] versus 36.2% [95% CI, 28.6-44.4%] and multimodal prognostication using SSEPs, brainstem reflex and brain computed tomography (75.7% [95% CI, 68.0-82.3%] versus 60.5% [95% CI, 52.3-68.4%]).
Conclusions
The prognostic value of VEPs was comparable to that of SSEPs, but the use of BAEPs was limited due to their low sensitivity. Additional VEP measurements can reduce prognostic uncertainty.

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

Resuscitation: 04 May 2021; 164:12-19
Lim JY, Oh SH, Park KN, Choi SP, ... Kim HJ, Song H
Resuscitation: 04 May 2021; 164:12-19 | PMID: 33964333
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Impact:
Abstract

Mortality after in-hospital cardiac arrest in patients with COVID-19: A systematic review and meta-analysis.

Ippolito M, Catalisano G, Marino C, Fucà R, ... Einav S, Cortegiani A
Aim
To estimate the mortality rate, the rate of return of spontaneous circulation (ROSC) and survival with favorable neurological outcome in patients with COVID-19 after in-hospital cardiac arrest (IHCA) and attempted cardiopulmonary resuscitation (CPR).
Methods
PubMed, EMBASE, Web of Science, bioRxiv and medRxiv were surveyed up to 8th February 2021 for studies reporting data on mortality of patients with COVID-19 after IHCA. The primary outcome sought was mortality (in-hospital or at 30 days) after IHCA with attempted CPR. Additional outcomes were the overall rate of IHCA, the rate of non-shockable presenting rhythms, the rate of ROSC and the rate of survival with favorable neurological status.
Results
Ten articles were included in the systematic review and meta-analysis, for a total of 1179 COVID-19 patients after IHCA with attempted CPR. The estimated overall mortality rate (in-hospital or at 30 days) was 89.9% (95% Predicted Interval [P.I.] 83.1%-94.2%; 1060/1179 patients; I2 = 82%). The estimated rate of non-shockable presenting rhythms was 89% (95% P.I. 82.8%-93.1%; 1022/1205 patients; I2 = 85%), and the estimated rate of ROSC was 32.9% (95% P.I. 26%-40.6%; 365/1205 patients; I2 = 82%). The estimated overall rate of survival with favorable neurological status at 30 days was 6.3% (95% P.I. 4%-9.7%; 50/851 patients; I2 = 48%). Sensitivity analysis showed that COVID-19 patients had higher risk of death after IHCA than non COVID-19 patients (OR 2.34; 95% C.I. 1.37-3.99; number of studies = 3; 1215 patients).
Conclusions
Although one of three COVID-19 patients undergoing IHCA may achieve ROSC, almost 90% may not survive at 30 days or to hospital discharge.

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

Resuscitation: 04 May 2021; epub ahead of print
Ippolito M, Catalisano G, Marino C, Fucà R, ... Einav S, Cortegiani A
Resuscitation: 04 May 2021; epub ahead of print | PMID: 33964332
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Impact:
Abstract

Do not attempt cardiopulmonary resuscitation (DNACPR) decisions in people admitted with suspected COVID-19: Secondary analysis of the PRIEST observational cohort study.

Sutton L, Goodacre S, Thomas B, Connelly S
Aims
We aimed to describe the characteristics and outcomes of adults admitted to hospital with suspected COVID-19 according to their DNACPR decisions, and identify factors associated with DNACPR decisions.
Methods
We undertook a secondary analysis of 13,977 adults admitted to hospital with suspected COVID-19 and included in the Pandemic Respiratory Infection Emergency System Triage (PRIEST) study. We recorded presenting characteristics and outcomes (death or organ support) up to 30 days. We categorised patients as early DNACPR (before or on the day of admission) or late/no DNACPR (no DNACPR or occurring after the day of admission). We undertook descriptive analysis comparing these groups and multivariable analysis to identify independent predictors of early DNACPR.
Results
We excluded 1249 with missing DNACPR data, and identified 3929/12748 (31%) with an early DNACPR decision. They had higher mortality (40.7% v 13.1%) and lower use of any organ support (11.6% v 15.7%), but received a range of organ support interventions, with some being used at rates comparable to those with late or no DNACPR (e.g. non-invasive ventilation 4.4% v 3.5%). On multivariable analysis, older age (p < 0.001), active malignancy (p < 0.001), chronic lung disease (p < 0.001), limited performance status (p < 0.001), and abnormal physiological variables were associated with increased recording of early DNACPR. Asian ethnicity was associated with reduced recording of early DNACPR (p = 0.001).
Conclusions
Early DNACPR decisions were associated with recognised predictors of adverse outcome, and were inversely associated with Asian ethnicity. Most people with an early DNACPR decision survived to 30 days and many received potentially life-saving interventions.
Registration
ISRCTN registry, ISRCTN28342533, http://www.isrctn.com/ISRCTN28342533.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 03 May 2021; epub ahead of print
Sutton L, Goodacre S, Thomas B, Connelly S
Resuscitation: 03 May 2021; epub ahead of print | PMID: 33961960
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Impact:
Abstract

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

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

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

Resuscitation: 29 Apr 2021; 162:314-319
Kusztos AE, Coppler PJ, Salcido DD, Callaway CW, Elmer J
Resuscitation: 29 Apr 2021; 162:314-319 | PMID: 33127440
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Impact:
Abstract

Analyzing the heart rhythm during chest compressions: Performance and clinical value of a new AED algorithm.

de Graaf C, Beesems SG, Oud S, Stickney RE, ... Chapman FW, Koster RW
Purpose
Automated external defibrillators (AED) prompt the rescuer to stop chest compressions (CC) for ECG analysis during out-of-hospital cardiac arrest (OHCA). We assessed the diagnostic accuracy and clinical benefit of a new AED algorithm (cprINSIGHT), which analyzes ECG and impedance signals during CC, allowing rhythm analysis with ongoing chest compressions.
Methods
Amsterdam Police and Fire Fighters used a conventional AED in 2016-2017 (control) and an AED with cprINSIGHT in 2018-2019 (intervention). In the intervention AED, cprINSIGHT was activated after the first (conventional) analysis. This algorithm classified the rhythm as \"shockable\" (S) and \"non-shockable\" (NS), or \"pause needed\". Sensitivity for S, specificity for NS with 90% lower confidence limit (LCL), chest compression fractions (CCF) and pre-shock pause were compared between control and intervention cases accounting for multiple observations per patient.
Results
Data from 465 control and 425 intervention cases were analyzed. cprINSIGHT reached a decision during CC in 70% of analyses. Sensitivity of the intervention AED was 96%, (LCL 93%) and specificity was 98% (LCL 97%), both not significantly different from control. Intervention cases had a shorter median pre-shock pause compared to control cases (8 s vs 22 s, p < 0.001) and higher median CCF (86% vs 80%, P < 0.001).
Conclusion
AEDs with cprINSIGHT analyzed the ECG during chest compressions in 70% of analyses with 96% sensitivity and 98% specificity when it made a S or a NS decision. Compared to conventional AEDs, cprINSIGHT leads to a significantly shorter pre-shock pause and a significant increase in CCF.

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

Resuscitation: 29 Apr 2021; 162:320-328
de Graaf C, Beesems SG, Oud S, Stickney RE, ... Chapman FW, Koster RW
Resuscitation: 29 Apr 2021; 162:320-328 | PMID: 33460749
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Impact:
Abstract

Why, when and how do secondary-care clinicians have emergency care and treatment planning conversations? Qualitative findings from the ReSPECT Evaluation study.

Eli K, Hawkes CA, Ochieng C, Huxley CJ, ... Slowther AM, Griffiths F
Background
The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is an emergency care and treatment planning (ECTP) process, developed to offer a patient-centred approach to deciding about and recording treatment recommendations. Conversations between clinicians and patients or their representatives are central to the ReSPECT process. This study aims to understand why, when, and how ReSPECT conversations unfold in practice.
Methods
ReSPECT conversations were observed in hospitals within six acute National Health Service (NHS) trusts in England; the clinicians who conducted these conversations were interviewed. Following observation-based thematic analysis, five ReSPECT conversation types were identified: resuscitation and escalation; confirmation of decision; bad news; palliative care; and clinical decision. Interview-based thematic analysis examined the reasons and prompts for each conversation type, and the level of detail and patient engagement in these different conversations.
Results
Whereas resuscitation and escalation conversations concerned possible futures, palliative care and bad news conversations responded to present-tense changes. Conversations were timed to respond to organisational, clinical, and patient/relative prompts. While bad news and palliative care conversations included detailed discussions of treatment options beyond CPR, this varied in other conversation types. ReSPECT conversations varied in doctors\' engagement with patient/relative preferences, with only palliative care conversations consistently including an open-ended approach.
Conclusions
While ReSPECT supports holistic, person-centred, anticipatory decision-making in some situations, a gap remains between the ReSPECT\'s aims and their implementation in practice. Promoting an understanding and valuing of the aims of ReSPECT among clinicians, supported by appropriate training and structural support, will enhance ReSPECT conversations.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 29 Apr 2021; 162:343-350
Eli K, Hawkes CA, Ochieng C, Huxley CJ, ... Slowther AM, Griffiths F
Resuscitation: 29 Apr 2021; 162:343-350 | PMID: 33482270
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Impact:
Abstract

Neurological and clinical status from early time point to long-term follow-up after in-hospital cardiac arrest.

Jeon SB, Lee H, Park B, Choi SH, ... Hong SB, Kim YH
Aim
We aimed to evaluate neurological profiles of patients with in-hospital cardiac arrest (IHCA) from early time points to long-term follow-up periods.
Methods
For this prospective cohort study, we established a neurological rapid response team, and serially evaluated the neurological status of patients with IHCA from the initial resuscitation to 12 months after the onset of IHCA. The primary outcome was good neurological status defined as a Clinical Performance Category score of 1-2 at 12 months after IHCA. The secondary outcomes included the awakening and neurological recovery during the first week, the survival and neurological status at hospital discharge, and the survival at 12 months.
Results
A total of 291 adult patients with IHCA were included. On the first day and during the first week after IHCA, the awakening was achieved in 61 (21.0 %) and 119 patients (40.9 %), respectively; and neurological recovery in 12 (4.1 %) and 46 patients (15.8 %), respectively. Epileptic seizures developed in 9.7 % following restoration of spontaneous circulation. At hospital discharge, 106 patients (36.4 %) had survived; among them, 63.2 % showed good neurological status. At 12 months, 63 (21.6 %) patients survived; among them, 81.7 % showed good neurological status (17.0 % among all patients with IHCA). Of patients without awakening during the first 3 and 7 days, 2.7 % and 1.2 % showed good neurological status at 12 months, respectively.
Conclusions
Among patients with IHCA, awakening and neurological recovery were remarkable throughout the first week. Survival and good neurological status were substantial at 12 months after IHCA.

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

Resuscitation: 29 Apr 2021; 162:334-342
Jeon SB, Lee H, Park B, Choi SH, ... Hong SB, Kim YH
Resuscitation: 29 Apr 2021; 162:334-342 | PMID: 33485879
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Impact:
Abstract

Lung ultrasound during newborn resuscitation predicts the need for surfactant therapy in very- and extremely preterm infants.

Badurdeen S, Kamlin COF, Rogerson SR, Kane SC, ... Davis PG, Blank DA
Introduction
Early identification of infants requiring surfactant therapy improves outcomes. We evaluated the accuracy of delivery room lung ultrasound (LUS) to predict surfactant therapy in very- and extremely preterm infants.
Methods
Infants born at <320/7 weeks were prospectively enrolled at 2 centres. LUS videos of both sides of the chest were obtained 5-10 min, 11-20 min, and 1-3 h after birth. Clinicians were masked to the results of the LUS assessment and surfactant therapy was provided according to local guidelines. LUS videos were graded blinded to clinical data. Presence of unilateral type 1 (\'whiteout\') LUS or worse was considered test positive. Receiver Operating Characteristic (ROC) analysis compared the accuracy of LUS and an FiO2 threshold of 0.3 to predict subsequent surfactant therapy.
Results
Fifty-two infants with a median age of 276/7 weeks (IQR 260/7-286/7) were studied. Thirty infants (58%) received surfactant. Area under the ROC curve (AUC) for LUS at 5-10 min, 11-20 min and 1-3 h was 0.78 (95% CI, 0.66-0.90), 0.76 (95% CI, 0.65-0.88) and 0.86 (95% CI, 0.75-0.97) respectively, outperforming FiO2 at the 5-10 min timepoint (AUC 0.45, 95% CI 0.29-0.62, p = 0.001). At 11-20 min, LUS had a specificity of 95% (95% CI 77-100%) and sensitivity of 59% (95% CI, 39-77%) to predict surfactant therapy. All infants born at 23-276/7 weeks with LUS test positive received surfactant. Twenty-six infants (50%) had worsening of LUS grades on serial assessment.
Conclusions
LUS in the delivery room and accurately predicts surfactant therapy in infants <320/7 weeks.

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

Resuscitation: 29 Apr 2021; 162:227-235
Badurdeen S, Kamlin COF, Rogerson SR, Kane SC, ... Davis PG, Blank DA
Resuscitation: 29 Apr 2021; 162:227-235 | PMID: 33548362
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Impact:
Abstract

P-COSCA (Pediatric Core Outcome Set for Cardiac Arrest) in Children: An Advisory Statement From the International Liaison Committee on Resuscitation.

Topjian AA, Scholefield BR, Pinto NP, Fink EL, ... Hazinski MF, Slomine BS
Studies of pediatric cardiac arrest use inconsistent outcomes, including return of spontaneous circulation and short-term survival, and basic assessments of functional and neurological status. In 2018, the International Liaison Committee on Resuscitation sponsored the COSCA initiative (Core Outcome Set After Cardiac Arrest) to improve consistency in reported outcomes of clinical trials of adult cardiac arrest survivors and supported this P-COSCA initiative (Pediatric COSCA). The P-COSCA Steering Committee generated a list of potential survival, life impact, and economic impact outcomes and assessment time points that were prioritized by a multidisciplinary group of healthcare providers, researchers, and parents/caregivers of children who survived cardiac arrest. Then expert panel discussions achieved consensus on the core outcomes, the methods to measure those core outcomes, and the timing of the measurements. The P-COSCA includes assessment of survival, brain function, cognitive function, physical function, and basic daily life skills. Survival and brain function are assessed at discharge or 30 days (or both if possible) and between 6 and 12 months after arrest. Cognitive function, physical function, and basic daily life skills are assessed between 6 and 12 months after cardiac arrest. Because many children have prearrest comorbidities, the P-COSCA also includes documentation of baseline (ie, prearrest) brain function and calculation of changes after cardiac arrest. Supplementary outcomes of survival, brain function, cognitive function, physical function, and basic daily life skills are assessed at 3 months and beyond 1 year after cardiac arrest if resources are available.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 29 Apr 2021; 162:351-364
Topjian AA, Scholefield BR, Pinto NP, Fink EL, ... Hazinski MF, Slomine BS
Resuscitation: 29 Apr 2021; 162:351-364 | PMID: 33515637
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Impact:
Abstract

Health-related quality of life after out-of-hospital cardiac arrest - a five-year follow-up studyJūratė Šaltytė Benth.

Wimmer H, Lundqvist C, Šaltytė Benth J, Stavem K, ... Sunde K, Nakstad ER
Background
Health-related quality of life (HRQoL) is affected after out-of-hospital cardiac arrest (OHCA), but data several years after the arrest are lacking. We assessed long-term HRQoL in OHCA survivors and how known outcome predictors impact HRQoL.
Methods
In adult OHCA survivors, HRQoL was assessed five years post arrest using Short-form 36 (SF-36), EQ-5D-3 L (EQ-5D) and Hospital Anxiety and Depression Scale (HADS) among others. Results were compared to the next of kins\' estimates and to a Norwegian reference population.
Results
Altogether 96 survivors were included mean 5.3 (range 3.6-7.2) years after OHCA. HRQoL compared well to the reference population, except for lower score for general health with 67.2 (95%CI (62.1; 72.3) vs. 72.9 (71.9; 74.0)), p = 0.03. Younger (≤58 years) vs. older survivors scored lower for general health with mean (SD) of 62.1 (27.5) vs. 73.0 (19.5), p = 0.03, vitality (55.2 (20.5) vs. 64.6 (17.3), p = 0.02, social functioning (75.3 (28.7) vs. 94.1 (13.5), p < 0.001 and mental component summary (49.0 (9.9) vs. 55.8 (6.7), p < 0.001. They scored higher for HADS-anxiety (4.8 (3.6 vs. 2.7 (2.5), p = 0.001, and had lower EQ-5D index (0.72 (0.34) vs. 0.84 (0.19), p = 0.04. Early vs. late awakeners had higher EQ-5D index (0.82 (0.23) vs. 0.71 (0.35), p = 0.04 and lower HADS-depression scores (2.5 (2.9) vs. 3.8 (2.3), p = 0.04. Next of kin estimated HRQoL similar to the survivors\' own estimates.
Conclusions
HRQoL five years after OHCA was good and mainly comparable to a matched reference population. Stratified analyses revealed impaired HRQoL among younger survivors and those awakening late, mainly for mental domains.

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

Resuscitation: 29 Apr 2021; 162:372-380
Wimmer H, Lundqvist C, Šaltytė Benth J, Stavem K, ... Sunde K, Nakstad ER
Resuscitation: 29 Apr 2021; 162:372-380 | PMID: 33571604
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Impact:
Abstract

Impact of therapeutic hypothermia during cardiopulmonary resuscitation on neurologic outcome: A systematic review and meta-analysis.

Annoni F, Peluso L, Fiore M, Nordberg P, ... Creteur J, Taccone FS
Background
Therapeutic cooling initiated during cardiopulmonary resuscitation (intra arrest therapeutic hypothermia, IATH) provided diverging effect on neurological outcome of out-of-hospital cardiac arrest (OHCA) patients depending on the initial cardiac rhythm and the cooling methods used.
Methods
We performed a systematic search of PubMed, EMBASE and the CENTRAL databases using established Medical Subject Headings (MeSH) terms for IATH and OHCA. Only studies comparing IATH to standard in-hospital targeted temperature management (TTM) were selected. We used the revised Cochrane RoB-2 and the Newcastle-Ottawa scale tool to assess risk of bias of each study. Primary outcome was favorable neurological outcome (FO); secondary outcomes included return of spontaneous circulation (ROSC) rate and survival to hospital discharge.
Results
Out of 20,950 studies, 8 studies (n = 3493 patients, including 4 randomized trials, RCTs) were included in the final analysis. Compared to controls, the use of IATH was not associated with improved FO (OR 0.96 [95% CIs 0.68-1.37]; p = 0.84), increased ROSC rate (OR 1.11 [95% CIs 0.83-1.49]; p = 0.46) or survival (OR 0.91 [95% CIs 0.73-1.14]; p = 0.43). Significant heterogeneity among studies was observed for the analysis of ROSC rate (I2 = 69%). Trans-nasal evaporative cooling and cold fluids were explored in two RCTs each and no differences were observed on FO, event when only patients with an initial shockable rhythm were analyzed (OR 1.62 [95% CI 1.00-2.64]; p = 0.05].
Conclusions
In this meta-analysis, IATH was not associated with improved neurological outcome when compared to standard in-hospital TTM, based on very low certainty of evidence.
Clinical trial registration
PROSPERO (CRD42019130322).

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

Resuscitation: 29 Apr 2021; 162:365-371
Annoni F, Peluso L, Fiore M, Nordberg P, ... Creteur J, Taccone FS
Resuscitation: 29 Apr 2021; 162:365-371 | PMID: 33545107
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Impact:
Abstract

Resuscitation and emergency care in drowning: A scoping review.

Bierens J, Abelairas-Gomez C, Barcala Furelos R, Beerman S, ... Morley PT, Perkins GD
Background
The ILCOR Basic Life Support Task Force and the international drowning research community considered it timely to undertake a scoping review of the literature to identify evidence relating to the initial resuscitation, hospital-based interventions and criteria for safe discharge related to drowning.
Methods
Medline, PreMedline, Embase, Cochrane Reviews and Cochrane CENTRAL were searched from 2000 to June 2020 to identify relevant literature. Titles and abstracts and if necessary full text were reviewed in duplicate. Studies were eligible for inclusion if they reported on the population (adults and children who are submerged in water), interventions (resuscitation in water/boats, airway management, oxygen administration, AED use, bystander CPR, ventilation strategies, ECMO, protocols for hospital discharge (I), comparator (standard care) and outcomes (O) survival, survival with a favourable neurological outcome, CPR quality, physiological end-points).
Results
The database search yielded 3242 references (Medline 1104, Pre-Medline 202, Embase 1722, Cochrane reviews 12, Cochrane CENTRAL 202). After removal of duplicates 2377 papers were left for screening titles and abstracts. In total 65 unique papers were included. The evidence identified was from predominantly high-income countries and lacked consistency in the populations, interventions and outcomes reported. Clinical studies were exclusively observational in nature.
Conclusion
This scoping review found that there is very limited evidence from observational studies to inform evidence based clinical practice guidelines for drowning. The review highlights an urgent need for high quality research in drowning.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 29 Apr 2021; 162:205-217
Bierens J, Abelairas-Gomez C, Barcala Furelos R, Beerman S, ... Morley PT, Perkins GD
Resuscitation: 29 Apr 2021; 162:205-217 | PMID: 33549689
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Impact:
Abstract

Incidence and characteristics of drowning in Sweden during a 15-year period.

Claesson A, Krig A, Jonsson M, Ringh M, ... Nilsson L, Hollenberg J
Aim
Drowning is a global health problem and deeper knowledge about the extent and causes is of utmost importance for implementing preventative actions. The aim of this study was to describe the incidence and characteristics of drowning in Sweden over time, including both non-fatal and fatal cases.
Methods
All cases identified as drowning (ICD-10 coding) at a national level in Sweden between 2003-2017 were collected. Three sources of data from the Swedish National Board of Health and Welfare were extracted via the Cause of Death Register and the National Patient Register.
Results
Over 15 years, a total of 6609 cases occurred, resulting in an annual incidence of 4.66 per 100 000. The median age was 49 years (IQR 23-67) and 67% were males. Non-fatal drownings represented 51% (n = 3363), with an overall non-fatal to fatal ratio of 1:1, this being 8:1 for children (0-17 years of age). Non-fatal cases were more often female (36% vs. 30%; p < 0.001), younger 30 (IQR 10-56) vs. 60 (IQR: 45-72) (p < 0.001) and of unintentional nature (81% vs. 55%; p < 0.001). The overall incidence decreased over time from 5.6 to 4.1 per 100 000 (p < 0.001). The highest rate of 30-day survival was found in females 0-17 years (94%, 95% CI 91.1-95.5) and the lowest in males >66 years (28.7%, 95% CI 26.2-31.2). Although the incidence in children 0-4 years increased from 7.4 to 8.1 per 100 000 (p < 0.001), they demonstrated the highest non-fatal to fatal ratio (13:1).
Conclusion
Drowning is declining but remains a consistent and underestimated public-health problem. Non-fatal drowning cases represent about half of the burden and characteristics differ from fatal drowning cases, being younger, more often female and of unintentional nature.

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

Resuscitation: 29 Apr 2021; 162:11-19
Claesson A, Krig A, Jonsson M, Ringh M, ... Nilsson L, Hollenberg J
Resuscitation: 29 Apr 2021; 162:11-19 | PMID: 33549688
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Impact:
Abstract

Peri-intubation cardiac arrest in the Emergency Department: A National Emergency Airway Registry (NEAR) study.

April MD, Arana A, Reynolds JC, Carlson JN, ... Brown CA, NEAR Investigators
Aim
To determine the incidence of peri-intubation cardiac arrest through analysis of a multi-center Emergency Department (ED) airway registry and to report associated clinical characteristics.
Methods
This is a secondary analysis of prospectively collected data (National Emergency Airway Registry) comprising ED endotracheal intubations (ETIs) of subjects >14 years old from 2016 to 2018. We excluded those with cardiac arrest prior to intubation. The primary outcome was peri-intubation cardiac arrest. Multivariable logistic regression generated adjusted odds ratios (aOR) of variables associated with this outcome, controlling for clinical features, difficult airway characteristics, and ETI modality.
Results
Of 15,776 subjects who met selection criteria, 157 (1.0%, 95% CI 0.9-1.2%) experienced peri-intubation cardiac arrest. Pre-intubation systolic blood pressure <100 mm Hg (aOR 6.2, 95% CI 2.5-8.5), pre-intubation oxygen saturation <90% (aOR 3.1, 95% CI 2.0-4.8), and clinician-reported need for immediate intubation without time for full preparation (aOR 1.8, 95% CI, 1.2-2.7) were associated with higher likelihood of peri-intubation cardiac arrest. The association between pre-intubation shock and cardiac arrest persisted in additional modeling stratified by ETI indication, induction agent, and oxygenation status.
Conclusions
Peri-intubation cardiac arrest for patients undergoing ETI in the ED is rare. Higher likelihood of arrest occurs in patients with pre-intubation shock or hypoxemia. Prospective trials are necessary to determine whether a protocol to optimize pre-intubation haemodynamics and oxygenation mitigates the risk of peri-intubation cardiac arrest.

Published by Elsevier B.V.

Resuscitation: 29 Apr 2021; 162:403-411
April MD, Arana A, Reynolds JC, Carlson JN, ... Brown CA, NEAR Investigators
Resuscitation: 29 Apr 2021; 162:403-411 | PMID: 33684505
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Impact:
Abstract

Arterial carbon dioxide tension has a non-linear association with survival after out-of-hospital cardiac arrest: A multicentre observational study.

Mckenzie N, Finn J, Dobb G, Bailey P, ... Bray J, Ho KM
Purpose
International guidelines recommend targeting normocapnia in mechanically ventilated out-of-hospital cardiac arrest (OHCA) survivors, but the optimal arterial carbon dioxide (PaCO2) target remains controversial. We hypothesised that the relationship between PaCO2 and survival is non-linear, and targeting an intermediate level of PaCO2 compared to a low or high PaCO2 in the first 24-h of ICU admission is associated with an improved survival to hospital discharge (STHD) and at 12-months.
Methods
We conducted a retrospective multi-centre cohort study of adults with non-traumatic OHCA requiring admission to one of four tertiary hospital intensive care units for mechanical ventilation. A four-knot restricted cubic spline function was used to allow non-linearity between the mean PaCO2 within the first 24 h of ICU admission after OHCA and survival, and optimal PaCO2 cut-points were identified from the spline curve to generate corresponding odds ratios.
Results
We analysed 3769 PaCO2 results within the first 24-h of ICU admission, from 493 patients. PaCO2 and survival had an inverted U-shape association; normocapnia was associated with significantly improved STHD compared to either hypocapnia (<35 mmHg) (adjusted odds ratio [aOR] 0.45, 95% confidence interval [CI] 0.24-0.83) or hypercapnia (>45 mmHg) (aOR 0.45, 95% CI 0.24-0.84). Of the twelve predictors assessed, PaCO2 was the third most important predictor, and explained >11% of the variability in survival. The survival benefits of normocapnia extended to 12-months.
Conclusions
Normocapnia within the first 24-h of intensive care admission after OHCA was associated with an improved survival compared to patients with hypocapnia or hypercapnia.

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

Resuscitation: 29 Apr 2021; 162:82-90
Mckenzie N, Finn J, Dobb G, Bailey P, ... Bray J, Ho KM
Resuscitation: 29 Apr 2021; 162:82-90 | PMID: 33571603
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Impact:
Abstract

Family presence during resuscitation in paediatric and neonatal cardiac arrest: A systematic review.

Dainty KN, Atkins DL, Breckwoldt J, Maconochie I, ... Education, Implementation and Teams Task Force
Context
Parent/family presence at pediatric resuscitations has been slow to become consistent practice in hospital settings and has not been universally implemented. A systematic review of the literature on family presence during pediatric and neonatal resuscitation has not been previously conducted.
Objective
To conduct a systematic review of the published evidence related to family presence during pediatric and neonatal resuscitation.
Data sources
Six major bibliographic databases was undertaken with defined search terms and including literature up to June 14, 2020.
Study selection
3200 titles were retrieved in the initial search; 36 ultimately included for review.
Data extraction
Data was double extracted independently by two reviewers and confirmed with the review team. All eligible studies were either survey or interview-based and as such we turned to narrative systematic review methodology.
Results
The authors identified two key sets of findings: first, parents/family members want to be offered the option to be present for their child\'s resuscitation. Secondly, health care provider attitudes varied widely (ranging from 15% to >85%), however, support for family presence increased with previous experience and level of seniority.
Limitations
English language only; lack of randomized control trials; quality of the publications.
Conclusions
Parents wish to be offered the opportunity to be present but opinions and perspectives on the family presence vary greatly among health care providers. This topic urgently needs high quality, comparative research to measure the actual impact of family presence on patient, family and staff outcomes.
Prospero registration number
CRD42020140363.

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

Resuscitation: 29 Apr 2021; 162:20-34
Dainty KN, Atkins DL, Breckwoldt J, Maconochie I, ... Education, Implementation and Teams Task Force
Resuscitation: 29 Apr 2021; 162:20-34 | PMID: 33577966
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Impact:
Abstract

Bystander interventions and survival following out-of-hospital cardiac arrest at Copenhagen International Airport.

Gantzel Nielsen C, Andelius LC, Hansen CM, Blomberg SNF, ... Ringgren KB, Folke F
Aim
To examine incidence and outcome following out-of-hospital cardiac (OHCA) arrest in a high-risk area characterised by high density of potential bystanders and easy access to nearby automated external defibrillators (AEDs).
Methods
This retrospective observational study investigated pre-hospital and in-hospital treatment, as well as survival amongst persons with OHCA at Copenhagen International Airport between May 25, 2015 and May 25, 2019. OHCA data from pre- and in-hospital medical records were obtained and compared with public bystander witnessed OHCAs in Denmark.
Results
Of the 23 identified non-traumatic OHCAs, 91.3% were witnessed by bystanders, 73.9% received bystander cardiopulmonary resuscitation (CPR), and 43.5% were defibrillated by a bystander. Survival to hospital discharge was 56.5%, with 100% survival among persons with an initial shockable heart rhythm. Compared with nationwide bystander witnessed OHCAs, persons with OHCA at the airport were less likely to receive bystander CPR (73.9% vs. 89.4%, OR 0.33; 95% CI, 0.13-0.86), more likely to receive bystander defibrillation (43.5% vs. 24.8%, OR 2.32; 95% CI, 1.01-5.31), to achieve return of spontaneous circulation (78.2% vs. 50.6%, OR 3.51; 95% CI, 1.30-9.49), and survive to hospital discharge (56.5% vs. 45.2%, OR 1.58; 95% CI, 0.69-3.62).
Conclusion
We found a high proportion of bystander defibrillation indicating that bystanders will quickly apply an AED, when accessible. Importantly, 56% of all persons, and all persons with a shockable heart rhythm survived. These findings suggest increased potential for survival following OHCA and support current guidelines to strategically deploy accessible AEDs in high-risk OHCA areas.

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

Resuscitation: 29 Apr 2021; 162:381-387
Gantzel Nielsen C, Andelius LC, Hansen CM, Blomberg SNF, ... Ringgren KB, Folke F
Resuscitation: 29 Apr 2021; 162:381-387 | PMID: 33577965
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Impact:
Abstract

Ubiquinol (reduced coenzyme Q10) as a metabolic resuscitator in post-cardiac arrest: A randomized, double-blind, placebo-controlled trial.

Holmberg MJ, Andersen LW, Moskowitz A, Berg KM, ... Kirkegaard H, Donnino MW
Introduction
Ubiquinol (reduced coenzyme Q10) is essential for adequate aerobic metabolism. The objective of this trial was to determine whether ubiquinol administration in patients resuscitated from cardiac arrest could increase physiological coenzyme Q10 levels, improve oxygen consumption, and reduce neurological biomarkers of injury.
Materials and methods
This was a randomized, double-blind, placebo-controlled trial in patients successfully resuscitated from cardiac arrest. Patients were randomized to receive enteral ubiquinol (300 mg) or placebo every 12 h for up to 7 days. The primary endpoint was total coenzyme Q10 plasma levels at 24 h after enrollment. Secondary endpoints included neuron specific enolase, S100B, lactate, cellular and global oxygen consumption, neurological status, and in-hospital mortality.
Results
Forty-three patients were included in the modified intention-to-treat analysis. Median coenzyme Q10 levels were significantly higher in the ubiquinol group as compared to the placebo group at 24 h (441 [IQR, 215-510] ηg/mL vs. 113 [IQR, 94-208] ηg/mL, P < 0.001). Similar results were observed at 48 and 72 h. There were no differences between the two groups in any of the secondary endpoints. Median neuron specific enolase levels were not different between the two groups at 24 h (16.8 [IQR, 9.5-19.8] ηg/mL vs. 8.2 [IQR, 4.3-19.1] ηg/mL, P = 0.61).
Conclusions
Administration of enteral ubiquinol increased plasma coenzyme Q10 levels in post-cardiac arrest patients as compared to placebo. There were no differences in neurological biomarkers and oxygen consumption between the two groups.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 29 Apr 2021; 162:388-395
Holmberg MJ, Andersen LW, Moskowitz A, Berg KM, ... Kirkegaard H, Donnino MW
Resuscitation: 29 Apr 2021; 162:388-395 | PMID: 33577964
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Impact:
Abstract

Resuscitation highlights in 2020.

Nolan JP, Ornato JP, Parr MJA, Perkins GD, Soar J
Background
This review is the latest in a series of regular annual reviews undertaken by the editors and aims to highlight some of the key papers published in Resuscitation during 2020. The number of papers submitted to the Journal in 2020 increased by 25% on the previous year.MethodsHand-searching by the editors of all papers published in Resuscitation during 2020. Papers were selected based on then general interest and novelty and were categorised into general themes.ResultsA total of 103 papers were selected for brief mention in this review.ConclusionsResuscitation science continues to evolve rapidly and incorporate all links in the chain of survival.

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

Resuscitation: 29 Apr 2021; 162:1-10
Nolan JP, Ornato JP, Parr MJA, Perkins GD, Soar J
Resuscitation: 29 Apr 2021; 162:1-10 | PMID: 33577963
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Impact:
Abstract

Use and coverage of automated external defibrillators according to location in out-of-hospital cardiac arrest.

Sarkisian L, Mickley H, Schakow H, Gerke O, ... Jørgensen G, Henriksen FL
Aims
To evaluate 1) the relative use of automated external defibrillators (AEDs) at different types of AED locations 2) the percentage of AEDs crossing location types during OHCA before use 3) the AED coverage distance at different types of AED locations, and 4) the 30-day-survival in different subgroups.
Methods
From 2014-2018, AEDs used by bystanders during out-of-hospital cardiac arrest (OHCA) in the Region of Southern Denmark were collected. Data regarding registered AEDs was retrieved from the national AED-network. The OHCA site and AED placement was categorized into; 1) Residential; 2) Public; 3) Nursing home, 4) Company/workplace; 5) Institution; 6) Health clinic and 7) Sports facility/recreational. To evaluate 30-day-survival, groups 4-7 were pooled into one Mixed group.
Results
In total 509 OHCAs were included. There was high relative usage of AEDs from public places, nursing homes, health clinics and sports facilities, and low relative usage from companies/workplaces, residential areas and institutions. Of AEDs used during residential OHCAs 39% were collected from public places. AEDs placed in residential areas and public places had a coverage of 575 m (IQR 130-1300) and 270 m (IQR5-550), respectively. Thirty-day- survival in public, residential and mixed groups were 49%, 14% and 67%, respectively.
Conclusion
The relative use of AEDs from public places, nursing homes, sports facilities and health clinics was high, and AEDs used during OHCA in residential areas were most frequently collected from public places. AEDs placed in both residential areas and public places may have a wider coverage area than proposed in current literature.

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

Resuscitation: 29 Apr 2021; 162:112-119
Sarkisian L, Mickley H, Schakow H, Gerke O, ... Jørgensen G, Henriksen FL
Resuscitation: 29 Apr 2021; 162:112-119 | PMID: 33581227
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Impact:
Abstract

Outcome in refractory out-of-hospital cardiac arrest before and after implementation of an ECPR protocol.

Alm-Kruse K, Sørensen G, Osbakk SA, Sunde K, ... Hagen OA, Kramer-Johansen J
Aim
To compare the outcomes in patients with refractory out-of-hospital cardiac arrest (OHCA) fulfilling the criteria for extracorporeal cardiopulmonary resuscitation (ECPR) before and after implementation of an ECPR protocol, whether the patient received ECPR or not.
Methods
We compared cardiac arrest registry data before (2014-2015) and after (2016-2019) implementation of the ECPR protocol. The ECPR criteria were presumed cardiac origin, witnessed arrest with ventricular fibrillation, bystander CPR, age 18-65, advanced life support (ALS) within 15 min and ALS > 10 min without return of spontaneous circulation (ROSC). The primary outcome was 30-day survival; the secondary outcomes were sustained ROSC, neurological outcome and the proportion of patients transported with ongoing ALS.
Results
There were 1086 and 3135 patients in the pre- and post-implementation sample; 48 (4%) and 100 (3%) met the ECPR criteria, respectively. Of these, 21 (44%) vs. 37 (37%) were alive after 30 days, p = 0.4, and 30 (63%) vs. 50 (50%) achieved sustained ROSC, p = 0.2. All survivors in the pre-implementation sample had cerebral performance category 1-2 vs. 30 (81%) in the post-implementation sample, p = 0.03. Of the patients fulfilling the ECPR criteria, 7 (15%) and 26 (26%), p = 0.1, were transported with ongoing ALS in the pre- and post-implementation sample, respectively.
Conclusions
There were no differences in 30-day survival or prehospital ROSC in patients with refractory OHCA before and after initiation of an ECPR protocol.

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

Resuscitation: 29 Apr 2021; 162:35-42
Alm-Kruse K, Sørensen G, Osbakk SA, Sunde K, ... Hagen OA, Kramer-Johansen J
Resuscitation: 29 Apr 2021; 162:35-42 | PMID: 33581226
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Impact:
Abstract

Targeted temperature management after cardiac arrest. A systematic review and meta-analysis of animal studies.

Arrich J, Herkner H, Müllner D, Behringer W
Aim
Animal studies are an important knowledge base when information from clinical trials is missing or conflicting. The goal of this systematic review and meta-analysis was to investigate the effect of conventional targeted temperature management (TTM) between 32-36 °C in animal cardiac arrest models, and to estimate the influence of effect modifiers on the pooled effect of TTM.
Data sources
We searched Medline and Scopus from inception to May 2020 for randomised controlled animal trials assessing the effect of conventional TTM versus normothermia on neurologic outcome after cardiac arrest. We extracted data on study characteristics, study quality data, neurologic outcome, mortality, and potential effect modifiers.
Results
We retrieved 1635 studies, 45 studies comprising data of 981 animals met the inclusion criteria. Risk of bias was high in 17 studies and moderate in 28 studies. We undertook random-effects meta-analyses and meta-regression analyses to calculate the pooled effect and the influence of effect modifiers. There was a strong beneficial effect of TTM as compared to normothermia on neurologic outcome (standardised mean difference of 1.4 [95% CI -1.7 to -1.1; I2 = 75%]). Faster cooling rates, lower target temperature of TTM within the range of 32-36 °C, and shorter duration of cooling were independently associated with an increasing effect size of TTM.
Conclusions
This systematic review of animal cardiac arrest studies showed a consistent favourable effect of postresuscitation TTM as compared to normothermia on neurologic outcome that increased with lower target temperatures.

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

Resuscitation: 29 Apr 2021; 162:47-55
Arrich J, Herkner H, Müllner D, Behringer W
Resuscitation: 29 Apr 2021; 162:47-55 | PMID: 33582259
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Impact:
Abstract

Airway strategy and chest compression quality in the Pragmatic Airway Resuscitation Trial.

Wang HE, Jaureguibeitia X, Aramendi E, Jarvis JL, ... Suchting R, Idris AH
Background
Chest compression (CC) quality is associated with improved out-of-hospital cardiopulmonary arrest (OHCA) outcomes. Airway management efforts may adversely influence CC quality. We sought to compare the effects of initial laryngeal tube (LT) and initial endotracheal intubation (ETI) airway management strategies upon chest compression fraction (CCF), rate and interruptions in the Pragmatic Airway Resuscitation Trial (PART).
Methods
We analyzed CPR process files collected from adult OHCA enrolled in PART. We used automated signal processing techniques and a graphical user interface to calculate CC quality measures and defined interruptions as pauses in chest compressions longer than 3 s. We determined CC fraction, rate and interruptions (number and total duration) for the entire resuscitation and compared differences between LT and ETI using t-tests. We repeated the analysis stratified by time before, during and after airway insertion as well as by successive 3-min time segments. We also compared CC quality between single vs. multiple airway insertion attempts, as well as between bag-valve-mask (BVM-only) vs. ETI or LT.
Results
Of 3004 patients enrolled in PART, CPR process data were available for 1996 (1001 LT, 995 ETI). Mean CPR analysis duration were: LT 22.6 ± 10.8 min vs. ETI 25.3 ± 11.3 min (p < 0.001). Mean CC fraction (LT 88% vs. ETI 87%, p = 0.05) and rate (LT 114 vs. ETI 114 compressions per minute (cpm), p = 0.59) were similar between LT and ETI. Median number of CC interruptions were: LT 11 vs. ETI 12 (p = 0.001). Total CC interruption duration was lower for LT than ETI (LT 160 vs. ETI 181 s, p = 0.002); this difference was larger before airway insertion (LT 56 vs. ETI 78 s, p < 0.001). There were no differences in CC quality when stratified by 3-min time epochs.
Conclusion
In the PART trial, compared with ETI, LT was associated with shorter total CC interruption duration but not other CC quality measures. CC quality may be associated with OHCA airway management.

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

Resuscitation: 29 Apr 2021; 162:93-98
Wang HE, Jaureguibeitia X, Aramendi E, Jarvis JL, ... Suchting R, Idris AH
Resuscitation: 29 Apr 2021; 162:93-98 | PMID: 33582258
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Impact:
Abstract

The effect of alternative methods of cardiopulmonary resuscitation - Cough CPR, percussion pacing or precordial thump - on outcomes following cardiac arrest. A systematic review.

Dee R, Smith M, Rajendran K, Perkins GD, ... Vaillancourt C, International Liaison Committee on Resuscitation Basic Life Support Task Force Collaborators
Background
Cardiopulmonary resuscitation (CPR) improves cardiac arrest survival. Cough CPR, percussion pacing and precordial thump have been reported as alternative CPR techniques. We aimed to summarise in a systematic review the effectiveness of these alternative CPR techniques.
Methods
We searched Ovid MEDLINE, EMBASE and the Cochrane Library on 24/08/2020. We included randomised controlled trials, observational studies and case series with five or more patients. Two reviewers independently reviewed title and abstracts to identify studies for full-text review, and reviewed bibliographies and \'related articles\' (using PubMed) of full-texts for further eligible studies. We extracted data and performed risk-of-bias assessments on studies included in the systematic review. We summarised data in a narrative synthesis, and used GRADE to assess evidence certainty.
Results
We included 23 studies (cough CPR n = 4, percussion pacing n = 4, precordial thump n = 16; one study studied two interventions). Only two (both precordial thump) had a comparator group (\'standard\' CPR). For all techniques evidence certainty was very low. Available evidence suggests that precordial thump does not improve survival to hospital discharge in out-of-hospital cardiac arrest. The review did not find evidence that cough CPR or percussion pacing improve clinical outcomes following cardiac arrest.
Conclusion
Cough CPR, percussion pacing and precordial thump should not be routinely used in established cardiac arrest. In specific inpatient, monitored settings cough CPR (in conscious patients) or percussion pacing may be attempted at the onset of a potential lethal arrhythmia. These must not delay standard CPR efforts in those who lose cardiac output.
Prospero registration number
CRD42019152925.

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

Resuscitation: 29 Apr 2021; 162:73-81
Dee R, Smith M, Rajendran K, Perkins GD, ... Vaillancourt C, International Liaison Committee on Resuscitation Basic Life Support Task Force Collaborators
Resuscitation: 29 Apr 2021; 162:73-81 | PMID: 33582257
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Impact:
Abstract

Thermoregulation in post-cardiac arrest patients treated with targeted temperature management.

Hoeyer-Nielsen AK, Holmberg MJ, Christensen EF, Cocchi MN, Donnino MW, Grossestreuer AV
Objective
Evaluate the relationship between heat generation during rewarming in post-cardiac arrest patients receiving targeted temperature management (TTM) as a surrogate of thermoregulatory ability and clinical outcomes.
Methods
This is a prospective observational single-centre study conducted at an urban tertiary-care hospital. We included post-cardiac arrest adults who received TTM via surface cooling device between April 2018 and June 2019.
Results
Patient heat generation was calculated by multiplying the inverse of the average machine water temperature with time to rewarm to 37 °C and standardized in two ways to account for target temperature variation: (1) divided by number of degrees between target temperature and 37 °C, and (2) limited to when patient was rewarmed from 36 °C to 37 °C. The primary outcome was poor neurologic status, defined as Cerebral Performance Category (CPC) score 3-5, and the secondary outcome was 30-day survival. Sixty-six patients were included: 45 (68%) had a CPC-score of 3-5 and 23 (35%) were alive at 30 days. Besides initial rhythm and arrest downtime, baseline characteristics were similar between outcomes. Heat generation was not associated with poor neurological outcome (CPC 3-5: 6.6 [IQR: 6.1, 7.4] versus CPC 1-2: 6.6 [IQR: 5.7, 7.6], p = 0.89) or survival at 30 days (non-survivors: 6.6 [IQR: 6.6, 7.4] vs. survivors: 6.6 [IQR: 5.7, 8.0, p = 0.78]).
Conclusion
Heat generation during rewarming was not associated with neurologic outcomes. However, there was a relationship between poor neurological outcome and higher median water temperatures. Time to rewarm was prolonged in patients with poor neurological outcome.

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

Resuscitation: 29 Apr 2021; 162:63-69
Hoeyer-Nielsen AK, Holmberg MJ, Christensen EF, Cocchi MN, Donnino MW, Grossestreuer AV
Resuscitation: 29 Apr 2021; 162:63-69 | PMID: 33582256
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Impact:
Abstract

Comparison of femoral and carotid arteries in terms of pulse check in cardiopulmonary resuscitation: A prospective observational study.

Yılmaz G, Bol O
Background
There is no gold standard pulse localisation for pulse check in cardiopulmonary resuscitation.
Aim
To compare the femoral and carotid arteries in terms of pulse check in cardiopulmonary resuscitation and recommend the most appropriate pulse localisation in advanced life support guidelines and cardiopulmonary resuscitation training programmes.
Materials and methods
We prospectively conducted the study with patients who developed non-traumatic cardiopulmonary arrest between September 2018 and March 2019. The pulse check team was established and divided into two groups, A and B. Both carotid and femoral arteries were checked simultaneously for pulse by members of groups A and B, with the groups alternating between sites to avoid bias. We used some criteria to make pulse detection more effective. These were ETCO2, rhythm and cardiac ultrasonography.
Results
We evaluated 1289 pulse checks in 102 patients. As a result of the statistical analysis with manual palpations and pulses criteria, which we used to detected the presence of a pulse in CPR, we found that the sensitivity of the carotid artery was significantly higher than that of the femoral artery (p = 0.017), with almost identical specificities.
Conclusion
The carotid artery should be recommended as the gold standard localisation for pulse checks in cardiopulmonary resuscitation in CPR training programmes and ACLS guidelines.

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

Resuscitation: 29 Apr 2021; 162:56-62
Yılmaz G, Bol O
Resuscitation: 29 Apr 2021; 162:56-62 | PMID: 33582255
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Impact:
Abstract

Age-related cognitive bias in in-hospital cardiac arrest.

Holmberg MJ, Granfeldt A, Moskowitz A, Andersen LW, American Heart Association\'s Get With The Guidelines-Resuscitation Investigators
Aims
Cognitive bias has been recognized as a potential source of medical error as it may affect clinical decision making. In this study, we explored how cognitive bias, specifically left-digit bias, may affect patient outcomes in in-hospital cardiac arrest.
Methods
Using the Get With The Guidelines® - Resuscitation registry, we included adult patients with an in-hospital cardiac arrest from 2011 to 2019. The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation, favorable neurological outcome, and duration of resuscitation. Using a regression discontinuity design, we explored whether there was a sudden change in survival at the age threshold of 80 years which would indicate left-digit bias. Additional analyses were performed at age thresholds of 60, 70, and 90 years.
Results
A total of 26,784 patients were included for the primary analysis. The overall survival was 22% in this cohort. There was no discontinuity of survival below and above the age of 80 years (risk difference, 0.47%; 95%CI, -1.61% to 2.56%). Similar results were estimated for the secondary outcomes and for the age thresholds of 60, 70, and 90 years. The results were consistent in sensitivity analyses.
Conclusions
There was no indication that cognitive bias based on age affected outcomes in in-hospital cardiac arrest in these data.

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

Resuscitation: 29 Apr 2021; 162:43-46
Holmberg MJ, Granfeldt A, Moskowitz A, Andersen LW, American Heart Association's Get With The Guidelines-Resuscitation Investigators
Resuscitation: 29 Apr 2021; 162:43-46 | PMID: 33582254
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Impact:
Abstract

Prognostic value of signs of life throughout cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest.

Debaty G, Lamhaut L, Aubert R, Nicol M, ... Chouihed T, Labarère J
Purpose
Prognostication of refractory out-of-hospital cardiac arrest (OHCA) is essential for selecting the population that may benefit from extracorporeal cardiopulmonary resuscitation (ECPR). We aimed to examine the prognostic value of signs of life before or throughout conventional CPR for individuals undergoing ECPR for refractory OHCA.
Methods
Pooling the original data from three cohort studies, we estimated the prevalence of signs of life, for individuals with refractory OHCA resuscitated with ECPR. We performed multivariable logistic regression to examine the independent associations between the occurrence of signs of life and 30-day survival with a CPC score ≤ 2.
Results
The analytical sample consisted of 434 ECPR recipients. The prevalence of any sign of life was 61%, including pupillary light reaction (48%), gasping (32%), or increased level of consciousness (13%). Thirty-day survival with favorable neurological outcome was 15% (63/434). In multivariable analysis, the adjusted odds ratios of 30-day survival with favorable neurological outcome were 7.35 (95% confidence interval [CI], 2.71-19.97), 5.86 (95% CI, 2.28-15.06), 4.79 (95% CI, 2.16-10.63), and 1.75 (95% CI, 0.95-3.21) for any sign of life, pupillary light reaction, increased level of consciousness, and gasping, respectively.
Conclusion
The assessment of signs of life before or throughout CPR substantially improves the accuracy of a multivariable prognostic model in predicting 30-day survival with favorable neurological outcome. The lack of any sign of life might obviate the provision of ECPR for patients without shockable cardiac rhythm.

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

Resuscitation: 29 Apr 2021; 162:163-170
Debaty G, Lamhaut L, Aubert R, Nicol M, ... Chouihed T, Labarère J
Resuscitation: 29 Apr 2021; 162:163-170 | PMID: 33609608
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Impact:
Abstract

Video laryngoscopy for out of hospital cardiac arrest.

Huebinger RM, Stilgenbauer H, Jarvis JL, Ostermayer DG, Schulz K, Wang HE
Introduction
Endotracheal intubation is an import component of out-of-hospital cardiac arrest (OHCA) resuscitation. In this analysis, we evaluate the association of video laryngoscopy (VL) with first pass success and return of spontaneous circulation (ROSC) using a national OHCA cohort.
Methods
We analyzed 2018 data from ESO Inc. (Austin, TX), a national prehospital electronic health record. We included all adult, non-traumatic cardiac arrests undergoing endotracheal intubation. We defined VL and direct laryngoscopy (DL) based on paramedic recorded intubation device. The primary outcomes were first pass success, ROSC, and sustained ROSC. Using multivariable, mixed models, we determined the association between VL and first pass success rate, ROSC, and sustained ROSC (survival to ED or ROSC in the field for greater than 20 min), fitting agency as a random intercept and adjusting for confounders.
Results
We included 22,132 patients cared for by 914 EMS agencies, including 5702 (25.7%) VL and 16,430 (74.2%) DL. Compared to DL, VL had a lower rate of bystander CPR, but other characteristics were similar between the groups. VL exhibited higher first pass success than DL (75.1% v 69.5%, p < .001). On mixed model analysis, VL was associated with a higher first pass success (OR 1.5, CI 1.3-1.6) but not ROSC (OR 1.1, CI 0.97-1.2) or sustained ROSC (OR 1.1, CI 0.9-1.2).
Conclusion
While associated with higher FPS, VL was not associated with increased rate of ROSC. The role of VL in OHCA remains unclear.

Published by Elsevier B.V.

Resuscitation: 29 Apr 2021; 162:143-148
Huebinger RM, Stilgenbauer H, Jarvis JL, Ostermayer DG, Schulz K, Wang HE
Resuscitation: 29 Apr 2021; 162:143-148 | PMID: 33640431
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Impact:
Abstract

Machine learning-based dispatch of drone-delivered defibrillators for out-of-hospital cardiac arrest.

Chu J, Leung KHB, Snobelen P, Nevils G, ... Cheskes S, Chan TCY
Background
Drone-delivered defibrillators have the potential to significantly reduce response time for out-of-hospital cardiac arrest (OHCA). However, optimal policies for the dispatch of such drones are not yet known. We sought to develop dispatch rules for a network of defibrillator-carrying drones.
Methods
We identified all suspected OHCAs in Peel Region, Ontario, Canada from Jan. 2015 to Dec. 2019. We developed drone dispatch rules based on the difference between a predicted ambulance response time to a calculated drone response time for each OHCA. Ambulance response times were predicted using linear regression and neural network models, while drone response times were calculated using drone specifications from recent pilot studies and the literature. We evaluated the dispatch rules based on response time performance and dispatch decisions, comparing them to two baseline policies of never dispatching and always dispatching drones.
Results
A total of 3573 suspected OHCAs were included in the study with median and mean historical ambulance response times of 5.8 and 6.2 min. All machine learning-based dispatch rules significantly reduced the median response time to 3.9 min and mean response time to 4.1-4.2 min (all P < 0.001) and were non-inferior to universally dispatching drones (all P < 0.001) while reducing the number of drone flights by up to 30%. Dispatch rules with more drone flights achieved higher sensitivity but lower specificity and accuracy.
Conclusion
Machine learning-based dispatch rules for drone-delivered defibrillators can achieve similar response time reductions as universal drone dispatch while substantially reducing the number of trips.

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

Resuscitation: 29 Apr 2021; 162:120-127
Chu J, Leung KHB, Snobelen P, Nevils G, ... Cheskes S, Chan TCY
Resuscitation: 29 Apr 2021; 162:120-127 | PMID: 33631293
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Impact:
Abstract

Impact of a trauma-focused resuscitation protocol on survival outcomes after traumatic out-of-hospital cardiac arrest: An interrupted time series analysis.

Alqudah Z, Nehme Z, Williams B, Oteir A, Bernard S, Smith K
Aim
In this study, we examine the impact of a trauma-focused resuscitation protocol on survival outcomes following adult traumatic out-of-hospital cardiac arrest (OHCA).
Methods
We included adult traumatic OHCA patients aged >16 years occurring between 2008 and 2019. In December 2016, a new resuscitation protocol for traumatic OHCA was introduced prioritising the treatment of potentially reversible causes before conventional cardiopulmonary resuscitation (CPR). The effect of the new protocol on survival outcomes was assessed using adjusted interrupted time series regression.
Results
Over the study period, paramedics attempted resuscitation on 996 patients out of 3,958 attended cases. Of the treated cases, 672 (67.5%) and 324 (32.5%) occurred during pre-intervention and intervention periods, respectively. The frequency of almost all trauma interventions was significantly higher in the intervention period, including external haemorrhage control (15.7% vs 7.6; p-value <0.001), blood administration (3.8% vs 0.2%; p-value <0.001), and needle thoracostomy (75.9% vs 42.0%; p-value <0.001). There was also a significant reduction in the median time from initial patient contact to the delivery of needle thoracostomy (4.4 min vs 8.7 min; p-value <0.001) and splinting (8.7 min vs 17.5 min; p-value = 0.009). After adjustment, the trauma-focused resuscitation protocol was not associated with a change in the level of survival to hospital discharge (adjusted odds ratio [AOR] 0.98; 95% confidence interval [CI]: 0.11-8.59), event survival (AOR 0.82; 95% CI: 0.33-2.03), or prehospital return of spontaneous circulation (AOR 1.30; 95% CI: 0.61-2.76).
Conclusion
Despite an increase in trauma-based interventions and a reduction in the time to their administration, our study did not find a survival benefit from a trauma-focused resuscitation protocol over initial conventional CPR. However, survival was low with both approaches.

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

Resuscitation: 29 Apr 2021; 162:104-111
Alqudah Z, Nehme Z, Williams B, Oteir A, Bernard S, Smith K
Resuscitation: 29 Apr 2021; 162:104-111 | PMID: 33631292
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Impact:
Abstract

Biomarker prognostication of cognitive impairment may be feasible even in out-of hospital cardical arrest survivors with good neurological outcome.

Brønnick K, Evald L, Duez CHV, Grejs AM, ... Nielsen JF, Søreide E
Background
Patients surviving out-of hospital cardicac arrest, with good neurological outcome according to Cerebral Performance Category, frequently have neuropsychological impairment. We studied whether biomarker data (S-100b and neuron-specific enolase) obtained during the ICU stay predicted cognitive impairment 6 months after resuscitation.
Methods
Patients (N = 79) with a CPC-score ≤2 were recruited from two trial sites taking part in the TTH48 trial comparing targeted temperature management (TTM) for 48 h vs. 24 h at 33 ± 1 °C. We assessed patients 6 months after the OHCA. We measured biomarkers S-100b and NSE at arrival and at 24, 48 and 72 h after reaching the target temperature of 33 ± 1 °C. Four cognitive domain z-scores were calculated, and global cognitive impairment was defined as z < -1.67 on at least 3 out of 13 cognitive tests. Non-parametric correlations were used to assess the relationship between cognitive domain and biomarkers. ROC curves were used to assess prediction of cognitive impairment from the biomarkers. Logistic regression was used to investigate whether TTM duration moderated biomarker prediction of cognitive impairment.
Results
Cognitive impairment was present in 22% of the patients with memory impairment being the most common. The biomarkers correlated significantly with several cognitive domain scores and NSE at 48 h predicted cognitive impairment with 100% sensitivity and 56% specificity. The predictive properties of NSE at 48 h was unaffected by duration of TTM.
Conclusions
Early biomarker prognostication of cognitive impairment is feasible even in OHCA survivors with good neurological outcome as defined by CPC. NSE at 48 h predicted cognitive impairment.

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

Resuscitation: 29 Apr 2021; 162:396-402
Brønnick K, Evald L, Duez CHV, Grejs AM, ... Nielsen JF, Søreide E
Resuscitation: 29 Apr 2021; 162:396-402 | PMID: 33631291
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Impact:
Abstract

Long-term survival among OHCA patients who survive to 30 days: Does initial arrest rhythm remain a prognostic determinant?

Majewski D, Ball S, Bailey P, Bray J, Finn J
Objective
To determine whether initial cardiac arrest rhythm remains a prognostic determinant in longer term OHCA survival.
Methods
The St John Western Australian OHCA database was used to identify adults who survived for at least 30 days after an OHCA of presumed medical aetiology, in the Perth metropolitan area between 1998 and 2017. Associations between 8-year OHCA survival and variables of interest were analysed using a Multi-Resolution Hazard (MRH) estimator model with 1-year intervals.
Results
Of the 871 OHCA patients who survived 30 days, 718 (82%) presented with a shockable initial arrest rhythm and 153 (18%) presented with a non-shockable rhythm. Compared to patients with initial shockable arrests, patients with non-shockable arrests experienced increased mortality in the first (HR 3.33, 95% CI 2.12-5.32), second (HR 2.58, 95% CI 1.22-5.15), third (HR 2.21, 95% CI 1.02-4.42) and fourth (HR 2.21, 95% CI 1.02-4.42) year post arrest; however, in subsequent years the initial arrest rhythm ceased to be significantly associated with survival. The overall 8-year survival estimates after adjustment for peri-arrest factors (as potential confounders) were 87% (95% CI 77-93%) for shockable arrests and 73% (95% CI 55-86%) for non-shockable arrests.
Conclusions
Patients with non-shockable (as opposed to shockable) initial arrest rhythms experienced higher mortality in the first 4-years following their OHCA; however, after four years the initial arrest rhythm ceased to be associated with survival.

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

Resuscitation: 29 Apr 2021; 162:128-134
Majewski D, Ball S, Bailey P, Bray J, Finn J
Resuscitation: 29 Apr 2021; 162:128-134 | PMID: 33640430
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Impact:
Abstract

QT interval dynamics and triggers for QT prolongation immediately following cardiac arrest.

Cohen RB, Dai M, Aizer A, Barbhaiya C, ... Chinitz LA, Jankelson L
Background
The prolongation in QT interval typically observed following cardiac arrest is considered to be multifactorial and induced by external triggers such as hypothermia therapy and exposure to antiarrhythmic medications.
Objective
To evaluate the corrected QT interval (QTc) dynamics in the first 10 days following cardiac arrest with respect to the etiology of arrest, hypothermia and QT prolonging medications.
Methods
We enrolled 104 adult survivors of cardiac arrest, where daily ECG was available for at least 3 days. We followed their QT and QRS intervals for the first 10 days of hospitalization. We used both Bazett and Fridericia formulas to correct for heart rate. For patients with QRS < 120 we analyzed the QTc interval (n = 90) and for patients with QRS > 120 ms we analyzed the JTc (n = 104) vs. including only the narrow QRS samples (n = 89). We stratified patients by 3 groups: (1) presence of ischemic heart disease (IHD) (2) treatment with hypothermia protocol, and (3) treatment with QTc prolonging medications. Additionally, genetic information obtained during hospitalization was analyzed.
Results
QTc and JTc intervals were significantly prolonged in the first 6 days. Maximal QTc/JTc prolongation was observed in day 2 (QTcB = 497 ± 55). There were no differences in daily QTc/JTc and QRS intervals in the first 2 days post arrest between patients with or without hypothermia induction but such difference was found with QT prolonging medications. All subgroups demonstrated significantly prolonged QTc/JTc interval regardless of the presence of IHD, hypothermia protocol or QTc prolonging medication exposure. Our results were consistent for both Bazetts\' and Frediricia correction and for any QRS duration. Prolongation of the JTcB beyond 382 ms after day 3 predicted sustained QTc/JTc prolongation beyond day 6 with an ROC of 0.78.
Conclusions
QTc/JTc interval is significantly and independently prolonged post SCA, regardless of known QT prolonging triggers. Normalization of the QTc post cardiac arrest should be expected only after day 6 of hospitalization. Assessment of the QTc for adjudication of the etiology of arrest or for monitoring the effect of QT prolonging medications may be unreliable.

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

Resuscitation: 29 Apr 2021; 162:171-179
Cohen RB, Dai M, Aizer A, Barbhaiya C, ... Chinitz LA, Jankelson L
Resuscitation: 29 Apr 2021; 162:171-179 | PMID: 33652119
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Impact:
Abstract

Sodium bicarbonate administration during in-hospital pediatric cardiac arrest: A systematic review and meta-analysis.

Chang CY, Wu PH, Hsiao CT, Chang CP, Chen YC, Wu KH
Background
Current American Heart Association Pediatric Life Support (PLS) guidelines do not recommend the routine use of sodium bicarbonate (SB) during cardiac arrest in pediatric patients. However, SB administration during pediatric resuscitation is still common in clinical practice. The objective of this study was to assess the impact of SB on mortality and neurological outcomes in pediatric patients with in-hospital cardiac arrest.
Methods
We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials from inception to January 2021. We included studies of pediatric patients that had two treatment arms (treated with SB or not treated with SB) during in-hospital cardiac arrest (IHCA). Risk of bias was assessed using the Newcastle-Ottawa Scale and the certainty of evidence was assessed using GRADE system.
Results
We included 7 observational studies with a total of 4877 pediatric in-hospital cardiac arrest patients. Meta-analysis showed that SB administration during pediatric cardiac resuscitation was associated with a significantly decreased rate of survival to hospital discharge (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.25-0.63, p value = 0.0003). There were insufficient studies for 24-h survival and neurologic outcomes analysis. The subgroup analysis showed a significantly decreased rate of survival to hospital discharge in both the \"before 2010\" subgroup (OR 0.47; 95% CI 0.30-0.73; p value = 0.006) and the \"after 2010\" subgroup (OR 0.46; 95% CI 0.25-0.87; p value = 0.02). The certainty of evidence ranged from very low to low.
Conclusions
This meta-analysis of non-randomized studies supported current PLS guideline that routine administration of SB is not recommended in pediatric cardiac arrest except in special resuscitation situations.
Trial registration
The protocol was registered with PROSPERO on 8 August 2020 (registration number: CRD42020197837).

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

Resuscitation: 29 Apr 2021; 162:188-197
Chang CY, Wu PH, Hsiao CT, Chang CP, Chen YC, Wu KH
Resuscitation: 29 Apr 2021; 162:188-197 | PMID: 33662526
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Impact:
Abstract

Recovery among post-arrest patients with mild-to-moderate cerebral edema.

Fuller ZL, Faro JW, Callaway CW, Coppler PJ, Elmer J, University of Pittsburgh Post-Cardiac Arrest Service
Background
Cerebral edema after cardiac arrest may be a modifiable cause of secondary brain injury. We aimed to identify processes of care associated with recovery in a cohort of patients with mild to moderate edema.
Methods
We conducted a retrospective cohort study of adults resuscitated from out-of-hospital arrest (OHCA) at a single center from 2010 to 2018. We included those with cerebral edema ranging from mild to moderate (gray to white matter attenuation ratio (GWR) 1.2 to 1.3 on initial brain computerized tomography (CT). We used Pittsburgh Cardiac Arrest Category (PCAC) to adjust for illness severity and considered the following values in the first 24 h of admission as additional predictors: GWR, lab values affecting serum osmolality (sodium, glucose, blood urea nitrogen (BUN)), total osmolality, change in osmolality from 0 to 24 h, cardiac etiology of arrest, targeted temperature to 33 °C (vs 36 °C), time-weighted mean arterial pressure (MAP), partial pressures of arterial oxygen and carbon dioxide and select medications. Our primary outcome was discharge with cerebral performance category 1-3. We used unadjusted and adjusted logistic regression for analysis.
Results
We included 214 patients for whom CT was performed median 3.8 [IQR 2.4-5.2] hours after collapse. Median age was 57 [IQR 48-67] years, 82 (38%) were female, and 68 (32%) arrested from ventricular tachycardia or fibrillation. In adjusted models, modifiable processes of care were not associated with outcome.
Conclusions
Illness severity, but not modifiable processes of care, were associated with recovery among post-arrest patients with mild-to-moderate cerebral edema.

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

Resuscitation: 29 Apr 2021; 162:149-153
Fuller ZL, Faro JW, Callaway CW, Coppler PJ, Elmer J, University of Pittsburgh Post-Cardiac Arrest Service
Resuscitation: 29 Apr 2021; 162:149-153 | PMID: 33662524
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Impact:
Abstract

Public health impact of daily life triggers of sudden cardiac death: A systematic review and comparative risk assessment.

Čulić V, AlTurki A, Proietti R
Background
Sudden cardiac death (SCD) may be triggered by daily circumstances and activities such as stressful psycho-emotional events, physical exertion or substance misuse. We calculated population attributable fractions (PAFs) to estimate the public health relevance of daily life triggers of SCD and to compare their population impacts.
Methods
We searched PubMed, Scopus and the Web of Science citation databases to retrieve studies of triggers of SCD and cardiac arrest that would enable a computation of PAFs. When more studies investigated the same trigger, a meta-analytical pooled risk random-effect estimate was used.
Results
Of the retrieved studies, eight provided data enabling computation of PAFs. The prevalence of exposure within population for SCD triggers in the control periods ranged from 1.06% for influenza infection to 8.73% for recent use of cannabis. Triggers ordered from the highest to the lowest risk increase were: physical exertion, recent cocaine use, episodic alcohol consumption, recent amphetamine use, episodic coffee consumption, psycho-emotional stress within the previous month, influenza infection, and recent cannabis use. The relative risk increase ranged from 1.10 to 4.98. By accounting for both the magnitude of the risk increase and the prevalence in the population, the present estimates of PAF assign 14.5% (95% confidence interval [CI] 4.9-28.5) of all SCDs to episodic alcohol consumption, 9.4% (95% CI 1.2-29.3) to physical exertion, 6.9% (95% CI 0.3-25.0) to cocaine, 6% (95% CI 1.2-14.6) to episodic coffee consumption, 3% (95% CI 0.4-6.8) to psycho-emotional stress in the previous month, 1.7% (95% CI -0.9 to 12.9) to amphetamines, 0.9% (95% CI -4.9 to 12.5) to cannabis, and 0.3% (95% CI 0.2-0.4) to influenza infections.
Conclusions
In addition to episodic alcohol consumption, a trigger with the greatest public health importance for SCD, episodic physical exertion, cocaine use and coffee consumption also show a considerable population impact.

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

Resuscitation: 29 Apr 2021; 162:154-162
Čulić V, AlTurki A, Proietti R
Resuscitation: 29 Apr 2021; 162:154-162 | PMID: 33662523
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Impact:
Abstract

Prognosis of myocardial infarction-related cardiogenic shock according to preadmission out-of-hospital cardiac arrest.

Lauridsen MD, Josiassen J, Schmidt M, Butt JH, ... Køber L, Fosbøl EL
Aims
Out-of-hospital cardiac arrest (OHCA) is highly prevalent among patients with myocardial infarction and cardiogenic shock (MI-CS). We aimed to examine the prognostic importance of OHCA in patients with MI-CS.
Methods
Using Danish nationwide registries, we identified first-time hospitalized MI-CS patients (2010-2015) by OHCA status. Cumulative incidence curves and adjusted Cox regression models were used to compare in-hospital mortality, and among hospital survivors we compared 5-year rates of heart failure hospitalization and mortality.
Results
We identified 3107 MI-CS patients of whom 979 presented with OHCA (32%). OHCA patients were younger (median age: 65 vs. 74 years) and had less comorbidity. In-hospital mortality was 57% in those with OHCA compared with 67% in those without, but after adjustment the hazard ratio (HR) was 0.99 [95% CI: 0.87-1.11]. Hospital survivors consisted of 1375 MI-CS patients including 531 OHCA patients (39%). Five-year mortality was 22% for OHCA patients and 42% for patients without OHCA (adjusted HR: 0.90 [95% CI: 0.70-0.1.17]). The HR for five-year cardiovascular mortality was 0.80 [95% CI: 0.62-0.98]. Lastly, 5-year rate of heart failure hospitalization was 17% for patients with OHCA compared with 34% in those without (HR: 0.44 [95% CI: 0.34-0.57]).
Conclusion
Among patients hospitalized with MI-CS, OHCA did not influence all-cause in-hospital or long-term mortality but was a marker for reduced long-term rates of heart failure hospitalization and cardiovascular mortality. Future randomized studies are needed to improve prognosis of MI-CS, however, the importance of OHCA must be considered.

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

Resuscitation: 29 Apr 2021; 162:135-142
Lauridsen MD, Josiassen J, Schmidt M, Butt JH, ... Køber L, Fosbøl EL
Resuscitation: 29 Apr 2021; 162:135-142 | PMID: 33662522
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Impact:
Abstract

Clinical staging of accidental hypothermia: The Revised Swiss System: Recommendation of the International Commission for Mountain Emergency Medicine (ICAR MedCom).

Musi ME, Sheets A, Zafren K, Brugger H, ... Hölzl N, Pasquier M
Clinical staging of accidental hypothermia is used to guide out-of-hospital treatment and transport decisions. Most clinical systems utilize core temperature, by measurement or estimation, to stage hypothermia, despite the challenge of obtaining accurate field measurements. Recent studies have demonstrated that field estimation of core temperature is imprecise. We propose a revision of the original Swiss Staging system. The revised system uses the risk of cardiac arrest, instead of core temperature, to determine the staging level. Our revised system simplifies assessment by using the level of responsiveness, based on the AVPU scale, and by removing shivering as a stage-defining sign.

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

Resuscitation: 29 Apr 2021; 162:182-187
Musi ME, Sheets A, Zafren K, Brugger H, ... Hölzl N, Pasquier M
Resuscitation: 29 Apr 2021; 162:182-187 | PMID: 33675869
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Impact:
Abstract

Machine learning can support dispatchers to better and faster recognize out-of-hospital cardiac arrest during emergency calls: A retrospective study.

Byrsell F, Claesson A, Ringh M, Svensson L, ... Hollenberg J, Nord A
Aim
Fast recognition of out-of-hospital cardiac arrest (OHCA) by dispatchers might increase survival. The aim of this observational study of emergency calls was to (1) examine whether a machine learning framework (ML) can increase the proportion of calls recognizing OHCA within the first minute compared with dispatchers, (2) present the performance of ML with different false positive rate (FPR) settings, (3) examine call characteristics influencing OHCA recognition.
Methods
ML can be configured with different FPR settings, i.e., more or less inclined to suspect an OHCA depending on the predefined setting. ML OHCA recognition within the first minute is evaluated with a 1.5 FPR as the primary endpoint, and other FPR settings as secondary endpoints. ML was exposed to a random sample of emergency calls from 2018. Voice logs were manually audited to evaluate dispatchers time to recognition.
Results
Of 851 OHCA calls, the ML recognized 36% (n = 305) within 1 min compared with 25% (n = 213) by dispatchers. The recognition rate at any time during the call was 86% for ML and 84% for dispatchers, with a median time to recognition of 72 versus 94 s. OHCA recognized by both ML and dispatcher showed a 28 s mean difference in favour of ML (P < 0.001). ML with higher FPR settings reduced recognition times.
Conclusion
ML recognized a higher proportion of OHCA within the first minute compared with dispatchers and has the potential to be a supportive tool during emergency calls. The optimal FPR settings need to be evaluated in a prospective study.

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

Resuscitation: 29 Apr 2021; 162:218-226
Byrsell F, Claesson A, Ringh M, Svensson L, ... Hollenberg J, Nord A
Resuscitation: 29 Apr 2021; 162:218-226 | PMID: 33689794
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Impact:
Abstract

Chest stiffness dynamics in extended continuous compressions cardiopulmonary resuscitation.

Russell JK, González-Otero DM, Leturiondo M, Ruiz de Gauna S, Ruiz JM, Daya MR
Aim of the study
To characterize the effects of extended duration continuous compressions cardiopulmonary resuscitation (CPR) on chest stiffness, and its association with adherence to CPR guidelines.
Methods
Records of force and acceleration were extracted from CPR monitors used during attempts of resuscitation from out-of-hospital cardiac arrest. Cases of patients receiving at least 1000 compressions were selected for analysis to focus on extended CPR efforts. Stiffness was normalized per patient to their initial stiffness. Force remaining at the end of compression was used to identify complete release. Non-parametric statistical methods were used throughout as underlying distributions of all types of measurements were non-Gaussian. Averages are reported as median (interquartile range).
Results
More than 1000 chest compressions were delivered in 471 of 703 cases. Rate of change in normalized stiffness (Sn) was unrelated to patient age, sex or initial ECG rhythm, and did not predict survival. Most (76%) chests became less stiff over the course of resuscitation efforts. While the remainder (24%) exhibited increased stiffness, overall Sn decreased monotonically, declining by 31% through 3500 compressions. Rate adherence did not show a consistent trend with Sn. Depth adherence and complete release improved modestly with decreasing Sn.
Conclusion
Chest compressions during extended CPR reduced the stiffness of most patients\' chests, in the aggregate by 31% after 3500 compressions. This softening was associated with modestly improved adherence to depth and release guidelines, with inconsistent relation to rate adherence to guidelines.

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

Resuscitation: 29 Apr 2021; 162:198-204
Russell JK, González-Otero DM, Leturiondo M, Ruiz de Gauna S, Ruiz JM, Daya MR
Resuscitation: 29 Apr 2021; 162:198-204 | PMID: 33705805
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Impact:
Abstract

Automatic external defibrillator provided by unmanned aerial vehicle (drone) in Greater Paris: A real world-based simulation.

Derkenne C, Jost D, Miron De L\'Espinay A, Corpet P, ... Prunet B, Paris Fire Brigade Cardiac Arrest Task Force
Aim
To reduce the delay in defibrillation of out-of-hospital cardiac arrest (OHCA) patients, recent publications have shown that drones equipped with an automatic external defibrillator (AED) appear to be effective in sparsely populated areas. To study the effectiveness of AED-drones in high-density urban areas, we developed an algorithm based on emergency dispatch parameters for the rate and detection speed of cardiac arrests and technical and meteorological parameters.
Methods
We ran a numerical simulation to compare the actual time required by the Basic Life Support team (BLSt) for OHCA patients in Greater Paris in 2017 to the time required by an AED-drone. Endpoints were the proportion of patients with \"AED-drone first\" and the defibrillation time gained. We built an open-source website (https://airborne-aed.org/) to allow modelling by modifying one or more parameters and to help other teams model their own OHCA data.
Results
Of 3014 OHCA patients, 72.2 ± 0.7% were in the \"no drone flight\" group, 25.8 ± 0.2% in the \"AED-drone first\" group, and 2.1 ± 0.2% in the \"BLSt-drone first\" group. When a drone flight was authorized, it arrived an average 190 s before BLSt in 93% of cases. The possibility of flying the drone during the aeronautical night improved the results of the \"AED-drone first\" group the most (+60%).
Conclusions
In our very high-density urban model, at most 26% of OHCA patients received an AED from an AED-drone before BLSt. The flexible parameters of our website model allows evaluation of the impact of each choice and concrete implementation of the AED-drone.

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

Resuscitation: 29 Apr 2021; 162:259-265
Derkenne C, Jost D, Miron De L'Espinay A, Corpet P, ... Prunet B, Paris Fire Brigade Cardiac Arrest Task Force
Resuscitation: 29 Apr 2021; 162:259-265 | PMID: 33766669
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Impact:
Abstract

A randomized and blinded trial of inhaled nitric oxide in a piglet model of pediatric cardiopulmonary resuscitation.

Morgan RW, Sutton RM, Himebauch AS, Roberts AL, ... Berg RA, Kilbaugh TJ
Aim
Inhaled nitric oxide (iNO) during cardiopulmonary resuscitation (CPR) improved systemic hemodynamics and outcomes in a preclinical model of adult in-hospital cardiac arrest (IHCA) and may also have a neuroprotective role following cardiac arrest. The primary objectives of this study were to determine if iNO during CPR would improve cerebral hemodynamics and mitochondrial function in a pediatric model of lipopolysaccharide-induced shock-associated IHCA.
Methods
After lipopolysaccharide infusion and ventricular fibrillation induction, 20 1-month-old piglets received hemodynamic-directed CPR and were randomized to blinded treatment with or without iNO (80 ppm) during and after CPR. Defibrillation attempts began at 10 min with a 20-min maximum CPR duration. Cerebral tissue from animals surviving 1-h post-arrest underwent high-resolution respirometry to evaluate the mitochondrial electron transport system and immunohistochemical analyses to assess neuropathology.
Results
During CPR, the iNO group had higher mean aortic pressure (41.6 ± 2.0 vs. 36.0 ± 1.4 mmHg; p = 0.005); diastolic BP (32.4 ± 2.4 vs. 27.1 ± 1.7 mmHg; p = 0.03); cerebral perfusion pressure (25.0 ± 2.6 vs. 19.1 ± 1.8 mmHg; p = 0.02); and cerebral blood flow relative to baseline (rCBF: 243.2 ± 54.1 vs. 115.5 ± 37.2%; p = 0.02). Among the 8/10 survivors in each group, the iNO group had higher mitochondrial Complex I oxidative phosphorylation in the cerebral cortex (3.60 [3.56, 3.99] vs. 3.23 [2.44, 3.46] pmol O2/s mg; p = 0.01) and hippocampus (4.79 [4.35, 5.18] vs. 3.17 [2.75, 4.58] pmol O2/s mg; p = 0.02). There were no other differences in mitochondrial respiration or brain injury between groups.
Conclusions
Treatment with iNO during CPR resulted in superior systemic hemodynamics, rCBF, and cerebral mitochondrial Complex I respiration in this pediatric cardiac arrest model.

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

Resuscitation: 29 Apr 2021; 162:274-283
Morgan RW, Sutton RM, Himebauch AS, Roberts AL, ... Berg RA, Kilbaugh TJ
Resuscitation: 29 Apr 2021; 162:274-283 | PMID: 33766668
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Impact:
Abstract

Elevated risk of venous thromboembolism in patients undergoing therapeutic hypothermia after cardiac arrest.

Sharma T, Kunkes J, O\'Sullivan D, Fernandez AB
Introduction
Targeted Temperature Management (TTM) reduces mortality and improves neurological outcomes after cardiac arrest. Cardiac arrest is considered a pro-thrombotic state. Endovascular cooling catheters may increase the risk of thrombosis. Targeted Temperature Management, however, increases fibrinolysis. The net outcome of these opposing effects remains largely unexplored. Moreover, the exact rate of venous thromboembolism (VTE) is uncertain in these patients. We sought to determine the incidence and potential predictors of VTE in patients undergoing TTM.
Methods
Single center retrospective analysis. Participants were age ≥18 years old, admitted with out-of-hospital or in-hospital cardiac arrest, underwent TTM between January 1, 2007 and April 30, 2019 with endovascular cooling catheter. A total of 562 patients who underwent TTM (Study group) were compared to 562 patients treated for ARDS (control group). This control group was based on presumed similarities in factors affecting VTE: intensive care setting, immobility, length of stay and likely presence of central venous catheters.
Results
Patients who underwent TTM had a significantly higher rate of VTE (6.6% vs 2.3%, p = 0.006) and deep vein thrombosis (DVT) (4.6% vs 1.3%, p = 0.011) when compared to control group. In multivariate analysis age, gender, race and hospital length of stay were not associated with development of VTE in the study group.
Conclusion
Patients undergoing TTM after cardiac arrest have statistically higher incidence of VTE and DVT compared to patients with ARDS. This risk is independent of age, gender, race or length of stay.

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

Resuscitation: 29 Apr 2021; 162:251-256
Sharma T, Kunkes J, O'Sullivan D, Fernandez AB
Resuscitation: 29 Apr 2021; 162:251-256 | PMID: 33766667
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Impact:
Abstract

Effect of a resuscitation quality improvement programme on outcomes from out-of-hospital cardiac arrest.

Nehme Z, Ball J, Stephenson M, Walker T, Stub D, Smith K
Background
Many emergency medical service (EMS) agencies are implementing programmes to improve the quality and performance of resuscitation. We sought to examine the impact of a resuscitation quality improvement programme on outcomes following OHCA.
Methods
An interrupted time-series analysis of adult OHCA patients of medical aetiology. Patients treated after the implementation of a high-performance cardiopulmonary resuscitation (CPR) intervention between February 2019 and January 2020 were compared to historical controls between January 2015 and January 2019. The effect of the intervention on the risk-adjusted odds of survival were examined using logistic regression models, with and without adjustment for temporal trends.
Results
A total of 8270 and 2330 patients were treated in the control and intervention periods, respectively. Patients in the intervention period were older and less likely to arrest in public, present with an initial shockable rhythm, and receive mechanical CPR. After adjustment for arrest factors and temporal trends, there was a significant increase in the level of monthly survival to hospital discharge (AOR 1.50; 95% CI: 1.10, 2.04; p = 0.01), event survival (AOR 1.34; 95% CI: 1.09, 1.65; p = 0.006) and return of spontaneous circulation (AOR 1.38; 95% CI: 1.14, 1.65; p = 0.001). After removing the non-significant temporal trend, there was a 33% increase (AOR 1.33; 95% CI: 1.11, 1.58; p = 0.002) in the risk-adjusted odds of survival over the 12-month intervention period. The average marginal effect of the intervention resulted in 8.7 (95% CI: 3.2, 14.1) additional survivors per million population.
Conclusion
A resuscitation quality improvement programme consisting of high-performance CPR was associated with a significant increase in survival following OHCA.

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

Resuscitation: 29 Apr 2021; 162:236-244
Nehme Z, Ball J, Stephenson M, Walker T, Stub D, Smith K
Resuscitation: 29 Apr 2021; 162:236-244 | PMID: 33766666
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Impact:
Abstract

Continuous flow insufflation of oxygen for cardiac arrest: Systematic review of human and animal model studies.

Groulx M, Emond M, Boudreau-Drouin F, Cournoyer A, ... Blanchard PG, Mercier E
Objective
To synthetize the evidence regarding the effect of constant flow insufflation of oxygen (CFIO) on the rate of return of spontaneous circulation (ROSC) and other clinical outcomes during cardiac arrest (CA).
Methods
A systematic review was performed using four databases (PROSPERO: CRD42020071960). Studies reporting on adult CA patients or on animal models simulating CA and assessing the effect of CFIO on ROSC or other clinical outcomes were considered.
Results
A total of 3540 citations were identified, of which 16 studies were included. Four studies (two randomized controlled trials (RCT), two cohort studies), reported on humans while 12 studies used animal models. No meta-analysis was performed due to clinical heterogeneity. There were no differences in the ROSC (18.9% vs 20.8%, p = 0.99; 27.1% vs 21.3%, p = 0.51) and sustained ROSC rates (16.1% vs 17.3%, p = 0.81; 12.5% vs 14.9%, p = 0.73) with CFIO compared to intermitant positive pressure ventilation (IPPV) in the two human RCTs. Survival to ICU discharge was similar between CFIO (2.3%) and IPPV (2.3%) in the largest RCT (p = 0.96). Human studies were at serious or high risk of bias. In animal models\' studies, ROSC rates were presented in seven RCTs. CFIO was superior to IPPV in one trial, but was associated with similar ROSC rates using different ventilation strategies in the remaining six studies.
Conclusions
No definitive association between CFIO and ROSC, sustained ROSC or survival compared to other ventilation strategies could be demonstrated. Future studies should assess CFIO effect on post-survival neurological functions and patient-important CA outcomes.

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

Resuscitation: 29 Apr 2021; 162:292-303
Groulx M, Emond M, Boudreau-Drouin F, Cournoyer A, ... Blanchard PG, Mercier E
Resuscitation: 29 Apr 2021; 162:292-303 | PMID: 33766663
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Impact:
Abstract

Outcomes of patients with OHCA of presumed cardiac etiology that did not achieve prehospital restoration of spontaneous circulation: The All-Japan Utstein Registry experience.

Onoe A, Kajino K, Daya MR, Ong MEH, ... Ikegawa H, Kuwagata Y
Background
Correct identification of futile prehospital resuscitation for out-of-hospital cardiac arrest (OHCA) may reduce unnecessary transports. Prehospital return of spontaneous circulation (ROSC) is considered by many to be an important predictor of outcome. The purpose of this study was to evaluate OHCA victims without prehospital ROSC characteristics and their outcomes in relation to the universal Termination of Resuscitation (TOR) rule.
Methods
A retrospective, population-based review of OHCA victims without prehospital ROSC from January 1, 2010 to December 31, 2017 in the All-Japan Utstein Registry. We compared those that met the universal TOR rule and those that did not for the primary outcome: one-month survival with neurologically favorable Cerebral Performance Category (CPC) 1 or 2.
Results
989,929 OHCA cases, 18 years of age or older, were registered in the All-Japan Utstein Registry and 525,801 cases were of presumed cardiac origin and had no prehospital ROSC. Of these, the one-month CPC was 1 or 2 for 3957 cases (0.8%). In the \'no ROSC\' group who also met the TOR rule, the number of cases was 433,571 with a one-month survival of 0.9% (3799 cases), and the proportion with a CPC 1or 2 was 0.2% (699 cases).
Conclusions
Continued resuscitation and transport of cases with no field ROSC who fulfill the TOR rule is futile and could be considered for adoption in Japan.

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

Resuscitation: 29 Apr 2021; 162:245-250
Onoe A, Kajino K, Daya MR, Ong MEH, ... Ikegawa H, Kuwagata Y
Resuscitation: 29 Apr 2021; 162:245-250 | PMID: 33766662
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Impact:
Abstract

Impact of controlled normothermia following hypothermic targeted temperature management for post-rewarming fever and outcomes in post-cardiac arrest patients: A propensity score-matched analysis from a multicentre registry.

Kim K, Lee BK, Park JS, Choi SP, Jang TC, Oh JS
Aim of the study
We investigated whether controlled normothermia (CN) after the rewarming phase of targeted temperature management (TTM) is associated with preventing post-rewarming fever and outcomes 6 months after out-of-hospital cardiac arrest (OHCA).
Methods
This was an analysis of a prospective registry comprising OHCA patients treated with TTM at 22 academic hospitals between October 2015 and December 2018. We calculated the incremental area under the curve (iAUC) for body temperature greater than or equal to 37.5 °C for each patient during the first 24 h after the end of rewarming. The relationships among CN and iAUC, 6-month survival and good neurological outcome were analysed. To minimize differences in the baseline characteristics of the patients, we used propensity score-matched analysis.
Results
In total, 1144 patients were enrolled. After propensity score matching, 646 patients (comprising 323 pairs) were obtained. In the unmatched cohort, post-rewarming CN was significantly associated with a lower iAUC (0.34 [1.38] vs. 1.19 [2.27]; p < 0.001) but not 6-month survival (adjusted odds ratio (OR): 1.121; 95% confidence interval (CI): 0.836-1.504; p = 0.446) and good neurological outcome (adjusted OR: 1.030; 95% CI: 0.734-1.446; p = 0.863). The results were similar in the propensity score-matched cohort (0.38 [1.56] vs. 1.03 [2.21], p < 0.001, OR: 1.347, 95% CI: 0.989-1.835, p = 0.059 and OR: 1.280, 95% CI 0.925-1.772, p = 0.137, respectively).
Conclusion
Post-rewarming CN prevents high fever in the normothermia phase of TTM. However, our data suggest the lack of association between CN and the patient\'s 6-month survival and good neurological outcome.

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

Resuscitation: 29 Apr 2021; 162:284-291
Kim K, Lee BK, Park JS, Choi SP, Jang TC, Oh JS
Resuscitation: 29 Apr 2021; 162:284-291 | PMID: 33766661
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Impact:
Abstract

National Institutes of Health investment into cardiac arrest research: A study for the CARES Surveillance Group.

Coute RA, Kurz MC, Mader TJ
Objective
To calculate and compare the National Institutes of Health (NIH) research investment for cardiac arrest (CA) to other leading causes of disability-adjusted life years (DALY) in the United States (U.S.).
Methods
A search within NIH RePORTER for 2017 was performed using single common resuscitation terms. Grants were individually reviewed and categorized as CA research (yes/no) using predefined criteria. DALY were calculated as the sum of years of life lost (YLL) and years lived with disability (YLD) using all adult non-traumatic out-of-hospital CA (OHCA) from the CARES database for 2017. Total DALY for the study population were extrapolated to a national level. Leading causes of DALY were obtained from the Global Burden of Disease study and funding data were extracted from the NIH Categorical Spending Report for comparison. The outcome measure was U.S. dollars invested per annual DALY.
Results
The search yielded 290 grants, of which 87 (30%) were classified as CA research. Total funding for CA research in 2017 was $37.1M. A total of 73,915 (97%) cases from CARES met study inclusion criteria for the DALY analysis. The total DALY following adult OHCA in the U.S. population were 4,335,949 (YLL 4,332,166, YLD 3784). Per annual DALY, the NIH invested $287 for diabetes, $92 for stroke, $55 for ischemic heart disease, and $9 for CA research.
Conclusion
The NIH investment into CA research is far less than other comparable causes of death and disability in the U.S. These results should help inform utilization of limited resources to improve public health.

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

Resuscitation: 29 Apr 2021; 162:271-273
Coute RA, Kurz MC, Mader TJ
Resuscitation: 29 Apr 2021; 162:271-273 | PMID: 33781872
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Impact:
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