International Resuscitation Network Registry: design, rationale and preliminary results

[Ethics of resuscitation and end of life decisions]

These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.

European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions

These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.

Korean Cardiac Arrest Research Consortium (KoCARC): rationale, development, and implementation

OBJECTIVE

This study aimed to describe the conceptualization, development, and implementation processes of the newly established Korean Cardiac Arrest Resuscitation Consortium (KoCARC) to improve out-of-hospital cardiac arrest (OHCA) outcomes.

METHODS

The KoCARC was established in 2014 by recruiting hospitals willing to participate voluntarily. To enhance professionalism in research, seven research committees, the Epidemiology and Preventive Research Committee, Community Resuscitation Research Committee, Emergency Medical System Resuscitation Research Committee, Hospital Resuscitation Research Committee, Hypothermia and Postresuscitation Care Research Committee, Cardiac Care Resuscitation Committee, and Pediatric Resuscitation Research Committee, were organized under a steering committee. The KoCARC registry was developed with variables incorporated in the currently existing regional OHCA registries and Utstein templates and were collected via a web-based electronic database system. The KoCARC study population comprises patients visiting the participating hospitals who had been treated by the emergency medical system for OHCA presumed to have a cardiac etiology.

RESULTS

A total of 62 hospitals volunteered to participate in the KoCARC, which captures 33.0% of the study population in Korea. Web-based data collection started in October 2015, and to date (December 2016), there were 3,187 cases compiled in the registry collected from 32 hospitals.

CONCLUSION

The KoCARC is a self-funded, voluntary, hospital-based collaborative research network providing high level evidence in the field of OHCA and resuscitation. This paper will serve as a reference for subsequent KoCARC manuscripts and for data elements collected in the study.

Internet-based animation for instruction in cardiopulmonary resuscitation

We have trialled the use of computer animation for teaching basic life support (BLS) to the general public. Two resuscitation scenarios were selected. The first was adult CPR and the second was the management of foreign body airway obstruction using the Heimlich manoeuvre. A manikin was used as the patient. The exact motions performed by the participants during a simulated resuscitation were digitized by using a motion capture technique. Twenty students who had not previously received BLS education were given one hour of traditional instructor-based skill training, and another group of 20 was given one hour of skill practice via the Internet-based animation, which was displayed on a PC monitor. A skill meter on the manikin was used to evaluate the accuracy of CPR skills. Two items, ventilation and compression skills, were assessed and showed no significant differences between the two groups. The results suggest that by using computer animation of BLS through a PDA or a mobile phone, members of the public could maintain their CPR skills.

Ethical and regulatory considerations in the design of traumatic brain injury clinical studies

Research is essential for improving outcomes after traumatic brain injury (TBI). However, the ubiquity, variability, and nature of TBI create many ethical issues and accompanying regulations for research. To capture the complexity and importance of designing and conducting TBI research within the framework of key ethical principles, a few highly relevant topics are highlighted. The selected topics are: (1) research conducted in emergency settings; (2) maintaining equipoise in TBI clinical trials; (3) TBI research on vulnerable populations; and (4) ethical considerations for sharing data. The topics aim to demonstrate the dynamic and multifaceted challenges of TBI research, and also to stress the value of addressing these challenges with the key ethical principles of respect, beneficence, and justice. Much has been accomplished to ensure that TBI research meets the highest ethical standards and has fair and enforceable regulations, but important challenges remain and continued efforts are needed by all members of the TBI research community.

Outcome of out-of-hospital cardiac arrests in Beijing, China

AIM

The purpose of this study was to assess the outcome of out-of-hospital cardiac arrests (OHCAs) in Beijing, China.

METHODS

In this prospective study, data were collected according to the Utstein style on all cases of OHCA that occurred between January and December 2012 in urban areas covered by Beijing Emergency Medical Services (EMS). The cases were followed-up for 1 year.

RESULTS

Out of the 9897 OHCAs recorded, cardiopulmonary resuscitation (CPR) was initiated in 2421 patients (24.4%). Among the CPR-receivers (n=2421), 1804 patients (74.5%) had collapsed at home, while 375 patients (15.5%) at a public place. The average time interval from call to EMS arrival at the collapse location was 16 min (range, 4-43 min). Of the 1693 OHCA cases with cardiac aetiology, 1246 cases (73.6%) were witnessed, and basic CPR was performed by bystanders before arrival of the EMS personnel in 193 patients (11.4%). Of the OHCAs with cardiac aetiology, 1054 patients (62.3%) had asystole, 131 patients (7.7%) had shockable rhythms, restoration of spontaneous circulation was achieved in 85 patients (5.0%), 71 patients (4.2%) were admitted to the hospital alive, and of the 22 patients (1.3%) who were discharged alive, 17 patients (1%) had good neurological outcomes. At 1 year post-OHCA, 17 patients were alive.

CONCLUSION

In the urban areas of Beijing with EMS services, survival rate after OHCA was unsatisfactory. Improvements are required in every link of the 'chain of survival'.

Passive leg raising during cardiopulmonary resuscitation results in improved neurological outcome in a swine model of prolonged ventricular fibrillation

OBJECTIVE

The objective was to evaluate whether passive leg raising during cardiopulmonary resuscitation in a porcine model of prolonged ventricular fibrillation improves hemodynamics, return of spontaneous circulation, 24-hour survival, and neurological outcome.

METHODS

Ventricular fibrillation was induced in 20 healthy Landrace/Large White piglets, which were subsequently left untreated for 8 minutes. Ten animals were randomly assigned into the control group and were resuscitated according to the 2005 European Resuscitation Council guidelines, and 10 piglets were assigned into the passive leg raising group and were resuscitated with the legs passively raised at 45° with the aid of a special purpose-made metallic device. End points were either return of spontaneous circulation or asystole.

RESULTS

Return of spontaneous circulation was observed in 6 and 9 animals from the control and the passive leg raising group, respectively (P = .121; odds ratio = 0.16; 95% confidence interval, 0.01-1.87). Just prior to the first defibrillation attempt, coronary perfusion pressure was significantly higher in the passive leg raising group (22.8 ± 9.5 vs 10.6 ± 6.5 mm Hg, P < .004); but no subsequent significant differences were observed. Although all animals that restored spontaneous circulation survived for 24 hours, neurologic alertness score was significantly better in the animals treated with passive leg raising (90 ± 10 vs 76.6 ± 12.1, P = .037).

CONCLUSIONS

Passive leg raising during cardiopulmonary resuscitation significantly increased coronary perfusion pressure in the minute prior to the first shock. Return of spontaneous circulation and 24-hour survival rate were comparable between groups. However, the animals in the passive leg raising group exhibited significantly higher neurological scores.

Cardiac arrest: a public health perspective

This article reviews out-of-hospital cardiac arrest from a public health perspective. Case definitions are discussed. Incidence, outcome, and fixed and modifiable risk factors for cardiac arrest are described. There is a large variation in survival between communities that is not explained by patient or community factors. Study of variation in outcome in other related conditions suggest that this is due to differences in organizational culture rather than processes of care. A public health approach to improving outcomes is recommended that includes ongoing monitoring and improvement of processes and outcome of care.

Resuscitation of the written word: meeting the standard for cardiac arrest documentation

The aim of this study was to audit cardiac arrest documentation within a UK teaching hospital, survey the regional use of proformas for data collection, and consider the need for a standardised national template. A prospective audit comparing cardiac arrest documentation to General Medical Council (GMC) professional standards and the 'Utstein' fields was carried out, along with a survey of regional resuscitation officers for the use of standardised templates. The main outcome measures were the design of 'best practice' template using GMC guidelines and the 'Utstein' fields. An audit of medical notes involving a cardiac arrest call against the template was performed. There was limited documentation concerning process, events and outcome of arrest calls, as well as minimal regional use of standard templates or consensus on the essential content of medical documentation. Documentation of cardiac arrests in the Leeds Teaching Hospitals does not meet the 'Utstein' recommendations to provide enough information for audit of cardiac arrest procedure. The regional survey indicates that this problem is likely to be widespread.

Pan-Asian Resuscitation Outcomes Study (PAROS): rationale, methodology, and implementation

Disease-based registries can form the basis of comparative research to improve and inform policy for optimizing outcomes, for example, in out-of-hospital cardiac arrest (OHCA). Such registries are often lacking in resource-limited countries and settings. Anecdotally, survival rates for OHCA in Asia are low compared to those in North America or Europe, and a regional registry is needed. The Pan-Asian Resuscitation Outcomes Study (PAROS) network of hospitals was established in 2009 as an international, multicenter, prospective registry of OHCA across the Asia-Pacific region, to date representing a population base of 89 million in nine countries. The network's goal is to provide benchmarking against established registries and to generate best practice protocols for Asian emergency medical services (EMS) systems, to impact community awareness of prehospital emergency care, and ultimately to improve OHCA survival. Data are collected from emergency dispatch, ambulance providers, emergency departments, and in-hospital collaborators using standard protocols. To date (March 2011), there are a total of 9,302 patients in the database. The authors expect to achieve a sample size of 13,500 cases over the next 2 years of data collection. The PAROS network is an example of a low-cost, self-funded model of an Asia-Pacific collaborative research network with potential for international comparisons to inform OHCA policies and practices. The model can be applied across similar resource-limited settings.

Quality management in resuscitation--towards a European cardiac arrest registry (EuReCa)

BACKGROUND

Knowledge about the epidemiology of cardiac arrest in Europe is inadequate.

AIM

To describe the first attempt to build up a Common European Registry of out-of-hospital cardiac arrest, called EuReCa.

METHODS

After approaching key persons in participating countries of the European Resuscitation Council, five countries or areas within countries (Belgium, Germany, Andalusia, North Holland, Sweden) agreed to participate. A standardized questionnaire including 28 items, that identified various aspects of resuscitation, was developed to explore the nature of the regional/national registries. This comprises inclusion criteria, data sources, and core data, as well as technical details of the structure of the databases.

RESULTS

The participating registers represent a population of 35 million inhabitants in Europe. During 2008, 12,446 cardiac arrests were recorded. The structure as well as the level of complexity varied markedly between the 5 regional/national registries. The incidence of attempted resuscitation ranged between registers from 17 to 53 per 100,000 inhabitants each year whilst the number of patients admitted to hospital alive ranged from 5 to 18 per 100,000 inhabitants each year. Bystander CPR varied 3-fold from 20% to 60%.

CONCLUSION

Five countries agreed to participate in an attempt to build up a common European Registry for out-of-hospital cardiac arrest. These regional/national registries show a marked difference in terms of structure and complexity. A marked variation was found between countries in the number of reported resuscitation attempts, the number of patients brought to hospital alive, and the proportion that received bystander CPR. At present, we are unable to explain the reason for the variability but our first findings could be a 'wake-up-call' for building up a high quality registry that could provide answers to this and other key questions in relation to the management of out-of-hospital cardiac arrest.

Infliximab attenuates early myocardial dysfunction after resuscitation in a swine cardiac arrest model

OBJECTIVE

Left ventricular dysfunction after successful cardiopulmonary resuscitation contributes to early death after resuscitation. Proinflammatory cytokines are known to decrease myocardial function, and tumor necrosis factor-alpha has been shown to increase after successful resuscitation. We hypothesized that blocking the effects of tumor necrosis factor-alpha with infliximab would prevent or minimize postresuscitation cardiac dysfunction.

DESIGN

Randomized, placebo-controlled comparative study.

SETTING

Large animal research laboratory.

SUBJECTS

Twenty-eight anesthetized and instrumented domestic male swine (Yorkshire and Yorkshire/Hampshire mix; weight, 35-45 kg).

INTERVENTIONS

Infusion of infliximab (5 mg/kg) or normal saline after resuscitation from ventricular fibrillation cardiac arrest.

MEASUREMENTS AND MAIN RESULTS

Hemodynamic variables, indices of left ventricular function, and tumor necrosis factor-alpha were measured before and after 8 mins of cardiac arrest during the early postresuscitation period (3 hrs). Within 5 mins of restoration of spontaneous circulation, 14 animals received infliximab, 5 mg/kg, infused over 30 mins. Fourteen animals received an infusion of normal saline. Inotropes and vasopressors were not administered to either group after resuscitation. Tumor necrosis factor-alpha increased after restoration of circulation and remained elevated throughout the observation period. Differences between groups were not significant. Interleukin-1beta concentration did not change significantly during the observation period in either study group. Mean arterial pressure and stroke work were significantly greater in the infliximab group within 30 mins of resuscitation, and these differences were sustained throughout the 3-hr postresuscitation period. The effect of tumor necrosis factor-alpha blockade was evident only in animals with a significant increase (doubling) in plasma tumor necrosis factor-alpha at 30 mins after arrest.

CONCLUSION

Tumor necrosis factor-alpha plays a role in cardiac dysfunction after arrest and infliximab may attenuate or prevent postresuscitation myocardial dysfunction when administered immediately after resuscitation.

Using ontologies to integrate and share resuscitation data from diverse medical devices

OBJECTIVE

To propose a method for standardised data representation and demonstrate a technology that makes it possible to translate data from device dependent formats to this standard representation format.

METHODS AND RESULTS

Outcome statistics vary between emergency medical systems organising resuscitation services. Such differences indicate a potential for improvement by identifying factors affecting outcome, but data subject to analysis have to be comparable. Modern technology for communicating information makes it possible to structure, store and transfer data flexibly. Ontologies describe entities in the world and how they relate. Letting different computer systems refer to the same ontology results in a common understanding on data content. Information on therapy such as shock delivery, chest compressions and ventilation should be defined and described in a standardised ontology to enable comparison and combining data from diverse sources. By adding rules and logic data can be merged and combined in new ways to produce new information. An example ontology is designed to demonstrate the feasibility and value of such a standardised structure.

CONCLUSIONS

The proposed technology makes possible capturing and storing of data from different devices in a structured and standardised format. Data can easily be transformed to this standardised format, compared and combined independent of the original structure.

The proinflammatory cytokine response following resuscitation in the swine model depends on the method of ventricular fibrillation induction

OBJECTIVES

A systemic inflammatory response has been reported following resuscitation from cardiac arrest. The purpose of this study was to compare the magnitude of the tumor necrosis factor-alpha (TNF-alpha) response in two different swine models of ventricular fibrillation (VF) arrest.

METHODS

This was a randomized comparative trial conducted with domestic swine (N = 28, mean weight 40 kg, range 34-49 kg) of both genders. Anesthetized and instrumented swine were randomized to electrically induced VF (n = 14) or spontaneous VF induced by occlusion of a coronary artery (n = 14). After 8 minutes of VF, countershocks were given and standard advanced cardiac life support was initiated. Resuscitated animals were observed for 3 hours, and hemodynamics, base excess, and TNF-alpha concentrations were measured at intervals.

RESULTS

TNF-alpha concentrations were significantly greater in the ischemic VF group throughout the postresuscitation period. Multivariate modeling demonstrated that the TNF-alpha level was dependent on the method of VF induction and correlated with ischemia time (untreated VF period plus time to restoration of circulation) and the degree of postresuscitation hypoperfusion as reflected in base excess measurements.

CONCLUSIONS

This study demonstrates that TNF-alpha concentrations increase after resuscitation from cardiac arrest and that the TNF-alpha response is more profound in animals subjected to ischemic, spontaneous VF. The observed differences may be due to a longer resuscitation time and persistent postresuscitation hypoperfusion in the ischemic VF group. These differences need to be considered in studies evaluating mechanisms of postresuscitation organ dysfunction and defining mortality markers.

Rationale, development and implementation of the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest

OBJECTIVE

To describe the development, design and consequent scientific implications of the Resuscitation Outcomes Consortium (ROC) population-based registry; ROC Epistry-Cardiac Arrest.

METHODS

The ROC Epistry--Cardiac Arrest is designed as a prospective population-based registry of all Emergency Medical Services (EMSs)-attended 9-1-1 calls for patients with out-of-hospital cardiac arrest occurring in the geographical area described by the eight US and three Canadian regions. The dataset was derived by an North American interdisciplinary steering committee. Enrolled cases include individuals of all ages who experience cardiac arrest outside the hospital, with evaluation by organized EMS personnel and: (a) attempts at external defibrillation (by lay responders or emergency personnel), or chest compressions by organized EMS personnel; (b) were pulseless but did not receive attempts to defibrillate or CPR by EMS personnel. Selected data items are categorized as mandatory or optional and undergo revisions approximately every 12 months. Where possible all definitions are referenced to existing literature. Where a common definition did not exist one was developed. Optional items include standardized CPR process data elements. It is anticipated the ROC Epistry--Cardiac Arrest will enroll between approximately 9000 and 13,500 treated all rhythm arrests and 4000 and 5000 ventricular fibrillation arrests annually and approximately 8000 EMS-attended but untreated arrests.

CONCLUSION

We describe the rationale, development, design and future implications of the ROC Epistry--Cardiac Arrest. This paper will serve as the reference for subsequent ROC manuscripts and for the common data elements captured in both ROC Epistry--Cardiac Arrest and the ROC trials.

Essential features of designating out-of-hospital cardiac arrest as a reportable event: a scientific statement from the American Heart Association Emergency Cardiovascular Care Committee; Council on Cardiopulmonary, Perioperative, and Critical Care; Council on Cardiovascular Nursing; Council on Clinical Cardiology; and Quality of Care and Outcomes Research Interdisciplinary Working Group

The 2010 impact goal of the American Heart Association is to reduce death rates from heart disease and stroke by 25% and to lower the prevalence of the leading risk factors by the same proportion. Much of the burden of acute heart disease is initially experienced out of hospital and can be reduced by timely delivery of effective prehospital emergency care. Many patients with an acute myocardial infarction die from cardiac arrest before they reach the hospital. A small proportion of those with cardiac arrest who reach the hospital survive to discharge. Current health surveillance systems cannot determine the burden of acute cardiovascular illness in the prehospital setting nor make progress toward reducing that burden without improved surveillance mechanisms. Accordingly, the goals of this article provide a brief overview of strategies for managing out-of-hospital cardiac arrest. We review existing surveillance systems for monitoring progress in reducing the burden of out-of-hospital cardiac arrest in the United States and make recommendations for filling significant gaps in these systems, including the following: 1. Out-of-hospital cardiac arrests and their outcomes through hospital discharge should be classified as reportable events as part of a heart disease and stroke surveillance system. 2. Data collected on patients' encounters with emergency medical services systems should include descriptions of the performance of cardiopulmonary resuscitation by bystanders and defibrillation by lay responders. 3. National annual reports on key indicators of progress in managing acute cardiovascular events in the out-of-hospital setting should be developed and made publicly available. Potential barriers to action on cardiac arrest include concerns about privacy, methodological challenges, and costs associated with designating cardiac arrest as a reportable event.

Exclusion of a patient assessment interval and extension of the CPR interval both mitigate post-resuscitation myocardial dysfunction in a swine model of cardiac arrest

AIM OF STUDY

Interruptions in cardiopulmonary resuscitation (CPR), particularly as guided by automated external defibrillators, have been implicated in poor survival from cardiac arrest. Interruptions of CPR may be reduced by eliminating repetition of shocks between periods of CPR, elimination of the interval for patient assessment before CPR, and extension of the periods of CPR.

MATERIALS AND METHODS

The effects of exclusion of a 30s post-shock assessment interval prior to CPR and use of a longer interval (180s versus 90s) of CPR on resuscitation and post-resuscitation function were assessed in a factorial design using an established swine model of cardiac arrest. Repetitive shocks were excluded. Ventricular fibrillation was induced ischemically and maintained untreated for 5min.

RESULTS

All subjects were resuscitated, 95% survived 3 days, and 97% of survivors had full neurological recovery. Exclusion of the assessment interval reduced the delay to first return of spontaneous circulation by 33.1s (P=0.004) and the delay to sustained resuscitation by 99.2s (P=0.004), reduced post-resuscitation ECG ST elevation by 0.12mV (P=0.03), and alleviated transient post-resuscitation ejection fraction reduction (P<0.0001). Extension of the CPR interval reduced transient post-resuscitation fractional area change impairment (P=0.003).

CONCLUSIONS

Exclusion of an interval for assessment of airway, breathing and signs of circulation mitigates post-resuscitation dysfunction in a swine model of cardiac arrest. Extension of the period of CPR independently provides measurable, though less comprehensive, mitigation as well.

Hatzolah emergency medical responder service: to save a life

"First responders" are people trained in advanced first aid who can respond at the same time as, and often more quickly than, ambulance services to suspected medical emergencies. Hatzolah is a volunteer First Responder group, based on halakhic (Jewish legal) principles, in a localised area of metropolitan Melbourne with the highest density of Holocaust survivors outside Israel. Low numbers of "call-outs" to Victoria's Metropolitan Ambulance Service (MAS) from this community suggested that many were reluctant to make contact with a "uniformed" external agency. Hatzolah is an autonomous organisation operating under adapted MAS clinical practice guidelines and clinical governance processes. Hatzolah responders undergo an 18-month MAS training course comprising first aid, cardiopulmonary resuscitation, the use of semiautomated defibrillators, and oxygen therapy. We describe the first 11 years (1995-2005) of the Hatzolah service. The number of patients attended to annually has risen steadily, peaking at 867 in 2005. The most frequent reasons for call-outs were falls (19.4%), chest pain (9.7%), or respiratory distress (7.6%). Hatzolah's median response times were 2 or 3 min for all cases. They attended 35 patients with cardiac arrest (median response time, 2 min), and arrived before the MAS to 29 call-outs (83%). Nineteen patients (54%) with cardiac arrest were resuscitated and transported from the scene alive. Among those transported, significantly more had a shockable cardiac rhythm (50% v 13%, P = 0.03). Five (14%) survived to hospital discharge. Hatzolah has evolved into an organisation providing a complementary service to the MAS. It serves as a model for the establishment of other metropolitan community First Responder groups.