Out-of-hospital cardiac arrest survival improving over time: Results from the Resuscitation Outcomes Consortium (ROC)

Plasma trimethylamine levels predict adverse cardiovascular events in sudden cardiac arrest Survivors: A prospective cohort study

BACKGROUND

The trimethylamine N-oxide (TMAO) pathway has been associated with multiple cardiovascular diseases, yet its prognostic value for sudden cardiac arrest (SCA) survivors remains unknown.

METHODS

Patients who survived SCA and received implantable cardioverter defibrillators (ICDs) were prospectively enrolled. We evaluated the associations between plasma concentrations of TMAO-related metabolites and long-term adverse clinical events, including recurrent lethal ventricular arrhythmia (VA).

RESULTS

A total of 75 SCA survivors were included in the study. During a median follow-up of 1099 days, 34 (45.3 %) patients experienced adverse clinical events, including 24 (32.2 %) with life-threatening VA, 12 (16.0 %) with heart failure rehospitalization, and 5 (6.7 %) with cardiovascular death. Trimethylamine (TMA), carnitine, choline, and creatinine showed strong correlations with clinically significant parameters such as left ventricular ejection fraction (LVEF), New York Heart Association functional class, and N-terminal pro-brain natriuretic peptide (NT-proBNP). These four metabolites demonstrated positive associations with adverse clinical events, with higher median level of TMA associated with more than a threefold increased risk after adjusting for age, sex, LVEF, kidney function, and NT-proBNP levels (hazard ratio = 3.36, 95 % confidence interval [CI]: 1.18-9.59; P = 0.024). A scoring system, VT-C3, incorporating LVEF, TMA, and the weighted sum of TMA-related metabolites (Choline, Carnitine, Creatinine), showed significant predictive capacity for both adverse events (area under the curve [AUC]: 0.75, 95 % CI: 0.64-0.85) and recurrent lethal VA (AUC: 0.73, 95 % CI: 0.62-0.84). No significant prognostic values were observed for TMAO and betaine.

CONCLUSIONS

Our findings suggest that plasma concentrations of TMA, choline, carnitine, and creatinine are associated with an increased risk of subsequent adverse clinical events among SCA survivors. A simple scoring system comprising LVEF and these biomarkers could enhance current risk stratification and improve secondary prevention strategies based on ICD implantation.

The significance of possible non-occlusive mesenteric ischemia in relation to neurological outcomes in patients with refractory cardiac arrest - Secondary analysis of the Prague OHCA study

BACKGROUND

Intestinal injury as a consequence of ischemia-reperfusion injury after refractory cardiac arrest is not fully understood. This study evaluates the occurrence of clinical signs reflecting possible non-occlusive mesenteric ischemia (NOMI) to outcomes in patients with refractory cardiac arrest.

METHODS

In a post-hoc analysis of a randomized, prospective Prague OHCA study comparing ECPR vs. CPR approaches in refractory out-of-hospital CA, all patients who survived longer than one hour after hospital admission were analyzed. We assessed possible NOMI based on clinical signs (mainly profuse diarrhea and abdominal distension) and their onset within 12 h of admission. Its occurrence was correlated with neurologically unfavorable outcome (Cerebral Performance Category (CPC) Scale 3-5) at 180 days. Cox regression was used to evaluate the relationship of particular variables to adverse neurological outcomes.

RESULTS

Of the 256 study participants, 61 developed possible NOMI: 46 (51.7%) in the ECPR group and 15 (16.5%) in the CPR group. Adverse neurological outcomes occurred in 41 (89%) and nine (60%) patients, respectively. The number of patients developing possible NOMI was higher in those treated with ECPR (p > 0.01). Its occurrence correlated with cardiac arrest length, elevated levels of neuron-specific enolase and procalcitonin at 48 and 72 h. It was independently associated with adverse outcomes. In Cox regression, possible NOMI was associated with poor neurological outcomes in ECPR patients.

CONCLUSION

The development of profuse diarrhea, abdominal distension and other signs suggesting non-occlusive mesenteric ischemia in patients with refractory out-of-hospital cardiac arrest are observed more frequently in patients with poor neurological outcome at day 180, especially in patients treated with ECPR.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01511666.

Bystander interventions and clinical outcomes among adult out-of-hospital cardiac arrest victims in South Korea over a decade: Sex-based disparities

OBJECTIVE

Delivering bystander interventions is key to improving out-of-hospital cardiac arrest (OHCA) outcomes. Despite reports on sex disparities in bystander interventions and clinical outcomes, comprehensive national-scale assessments in South Korea remain insufficient. Therefore, this study aimed to evaluate nationwide trends over a decade and examine sex disparities in bystander interventions among adult victims of OHCA in South Korea.

STUDY DESIGN

Population-based cohort study.

METHODS

We analysed bystander interventions and clinical outcomes among adult OHCA using data from the government's Out-of-Hospital Cardiac Arrest Surveillance between January 2009 and December 2019. We further assessed sex-based differences according to the arrest location, bystander type, and age group.

RESULTS

This study included a total of 209,901 victims of OHCA. The rate of bystander cardiopulmonary resuscitation (BCPR) improved from 3 % in 2009 to 25 % in 2019. Over the past decade, the usage rate of automated external defibrillators (AEDs) has consistently remained below 1 %. Compared to males, females received BCPR at an odds ratio (OR) of 1·05. However, in public locations, when the bystander was a non-family member, and for those over the age of 65 years, the ORs were 0·80, 0·88, and 0·96, respectively. A gap in sex disparity was observed annually when cardiac arrests occurred in public locations and the bystander was not a family member.

CONCLUSIONS

Sex disparities in BCPR are pronounced based on arrest location and bystander type. BCPR education programmes should be designed to address OHCA cases across sexes, and improvements in AED usage should be made.

Intra-Arrest Transport and Neurological Outcomes in Out-of-Hospital Cardiac Arrest with Initial Shockable Rhythm Who Failed the First Defibrillation: A Nationwide Study in Limited Prehospital Advanced Cardiac Life Support (ACLS) Settings

OBJECTIVES

Early hospital transport may benefit out-of-hospital cardiac arrest (OHCA) patients with shockable rhythms who are refractory to defibrillation, particularly in settings with limited advanced on-scene interventions. However, its impact in emergency medical service (EMS) systems with limited advanced cardiac life support (ACLS) capabilities remain unclear. This study aimed to assess the association between intra-arrest transport and survival outcomes in OHCA patients with initial shockable rhythms who remained in refractory shockable rhythms despite the first defibrillation attempt.

METHODS

Using a nationwide OHCA registry from a country with an intermediate prehospital service level where interventions such as prehospital anti-arrhythmic drugs or double sequential defibrillation are not feasible, adult medical OHCA patients with initial shockable rhythms who failed the first defibrillation between January 1, 2015, and December 31, 2022 were analyzed. The primary outcome was good neurological recovery. Time-dependent propensity score matching was performed to assess the association between intra-arrest transport and survival outcomes. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated, and stratified analyses were performed based on matched time intervals after the first defibrillation.

RESULTS

Of 10 246 eligible patients, 8131 underwent intra-arrest transport. After 1:1 time-dependent propensity score matching, 2332 patients each in the intra-arrest transport and on-scene resuscitation groups were included. In the matched cohort, intra-arrest transport was not associated with good neurological recovery (11.7% and 11.5% in the intra-arrest transport and on-scene resuscitation groups, respectively; RR [95% CI] 0.97 [0.91-1.07]). In the stratified analyses based on matched time intervals after the first defibrillation, intra-arrest transport within 5 min after the first defibrillation was associated with poorer neurological outcomes (RR [95% CI] 0.86 [0.77-0.97]).

CONCLUSIONS

In an EMS setting with a limited-service level, intra-arrest transport showed no benefit for OHCA patients with an initial shockable rhythm who remained in refractory shockable rhythms despite the first defibrillation attempt. High-quality on-scene management is crucial before the initiation of hospital transport. Further research is needed to develop integrated systems ensuring effective prehospital and hospital care.

Impact of the COVID-19 pandemic on poisoning induced out of hospital cardiac arrest in South Korea retrospective observational study

Poisoning-induced out-of-hospital cardiac arrest has characteristics distinct from cardiogenic out-of-hospital cardiac arrest, with external factors such as patient intent and environmental influences playing crucial roles. The coronavirus disease 2019 (COVID-19) pandemic has altered societal and healthcare dynamics, potentially influencing poisoning-induced out-of-hospital cardiac arrest outcomes. This study aimed to evaluate the impact of the pandemic on poisoning-induced out-of-hospital cardiac arrest characteristics and survival in South Korea. Participants: Adult patients (aged ≥ 19 years) who experienced poisoning-induced out-of-hospital cardiac arrest before and during the COVID-19 pandemic. This study utilized data from the Out-of-Hospital Cardiac Arrest Surveillance Database from 2016 to 2022. Poisoning-induced out-of-hospital cardiac arrest cases were compared before and during the pandemic by analyzing patient demographics, poisoning agents, prehospital interventions, and outcomes. Multivariate logistic regression identified predictors of survival. During the pandemic, poisoning-induced out-of-hospital cardiac arrest cases involving alcohol, organic solvents, and unspecified drugs increased, while pesticide-related cases declined. Bystander cardiopulmonary resuscitation rates rose, yet survival rates fell (adjusted OR 0.59, CI 0.44-0.80). Prehospital return of spontaneous circulation and witnessed arrests remained the strongest predictors of survival (adjusted OR 13.93 and 4.09, respectively). The COVID-19 pandemic initially impacted poisoning-induced out-of-hospital cardiac arrest outcomes, particularly during its early stages, while later outcomes showed resilience in the emergency medical system. These findings highlight the importance of adaptable public health strategies to address vulnerabilities during large-scale crises.

International Consensus on Evidence Gaps and Research Opportunities in Extracorporeal Cardiopulmonary Resuscitation for Refractory Out-of-Hospital Cardiac Arrest: A Report From the National Heart, Lung, and Blood Institute Workshop

The increased accessibility of extracorporeal membrane oxygenation following the COVID-19 pandemic and the publication of the first randomized trial of extracorporeal cardiopulmonary resuscitation (ECPR) prompted the National Heart, Lung, and Blood Institute to sponsor a workshop on ECPR. Two more randomized trials have since been published in 2022 and 2023. Based on the combined findings and review of the evidence, an international panel of authors identified gaps in science, inequities in care and diversity in outcomes, and suggested research opportunities and next steps. The science pertaining to ECPR would benefit from the United States contributing uniform data to existing registries and sharing common data with the ELSO (Extracorporeal Life Support Organization) international registry to increase the sample size for observational research. In addition, well-designed efficacy trials, recruiting across different regions of care evaluating long-term follow-up, including patient reported outcomes, cost effectiveness, and equity measures, would contribute significantly to the body of science. Workshop participants defined the population of patients with out-of-hospital cardiac arrest most likely to benefit from ECPR. ECPR-eligible patients include those aged 18 to 75 years functioning independently without comorbidity; before suffering a witnessed out-of-hospital cardiac arrest and without any obvious cause of the cardiac arrest; presenting in a shockable rhythm and transported with mechanical cardiopulmonary resuscitation to an ECPR-capable institute within 30 minutes, which is recommended after 3 rounds of advanced life support treatment without return of spontaneous circulation. There are significant inequities in out-of-hospital cardiac arrest care that need to be addressed such that outcomes are optimized for each target region before implementing ECPR in a clinical or implementation trial.

Implementing an Educational Model for Cardiac Arrest Patients During Interfacility Transfers

Background Out-of-hospital cardiac arrest (OHCA) is a significant health concern in the United States, particularly in rural areas where patient care often depends on interfacility transfers (IFTs) to tertiary medical centers. In Maine, OHCA outcomes vary widely across regions, with no standardized education or protocols for the IFT of these patients. A key step toward improving care for this population is providing emergency medical service (EMS) personnel with education on essential aspects of post-return of spontaneous circulation (ROSC) management. To address this need, we developed a pilot virtual curriculum focused on post-ROSC care during IFT. The curriculum was designed to be virtual due to restrictions on in-person didactics at the time of implementation during the COVID-19 pandemic. This study aims to evaluate the feasibility of implementing a virtual curriculum that can be easily distributed. Additionally, we seek to analyze pre- and post-survey data from EMS personnel to assess changes in confidence, anxiety, and knowledge related to post-ROSC care. Methods Two local EMS departments, which handle the majority of IFTs for our institution, were invited to participate in the virtual educational model. The model consisted of a 27-minute recorded session divided into sections and distributed via an online platform in collaboration with Maine EMS. To assess the impact of the curriculum, EMS personnel completed electronic surveys administered through REDCap. A pre-survey was conducted before the curriculum, followed by a post-survey after its completion. The survey included questions measured on a 5-point Likert scale, covering confidence in resuscitation (five questions), anxiety during resuscitation (six questions), knowledge about post-ROSC care (eight questions), and attitudes toward the curriculum (three questions). Data analysis was performed using the Wilcoxon paired signed rank test to evaluate changes across these variables. Results A total of 18 EMS personnel participated in the curriculum (18/24; 75%), with all 18 completing the pre-survey and 10 completing the post-survey. Among those who completed both surveys, 70% agreed or strongly agreed that the IFT curriculum would improve patient care. Regarding knowledge of post-ROSC care, participants showed a mean improvement of +2.125 correct answers across the eight knowledge-based questions, with an average post-survey score of 6/8 (75%). However, there were no significant changes in confidence, skill, or anxiety levels, as indicated by a p-value of >0.9. Conclusions This pilot curriculum demonstrated the feasibility of delivering and completing a virtual educational model for EMS personnel on a topic not currently covered by Maine's state protocols or existing educational programs. Pre-post survey results indicated some improvement in participants; knowledge of post-ROSC care, and 70% believed the curriculum would enhance patient care. Future efforts are underway to integrate this content as a permanent component of local EMS education, given the significant role of ROSC management during IFTs.

Effects of Emergency Medical Service Response Time on Survival Rate of Out-of-Hospital Cardiac Arrest Patients: a 5-Year Retrospective Study

Introduction

Emergency medical service (EMS) response time is a critical factor in managements of out-of-hospital cardiac arrest (OHCA) cases. This study aimed to investigate the effects of EMS response time on survival of OHCA patients.

Methods

This study employed a retrospective cohort design focused on prognosis research. Data was collected from the Erawan EMS Dispatch Center of the Bangkok Metropolitan Administration from January 2019 to December 2023. All OHCA cases visited by dispatched prehospital teams in Bangkok were included. Multivariable logistic regression was used to analyze the effect of response time on survival at scene, survival to emergency department (ED), and survival to hospital discharge of OHCA cases.

Results

Among the 5,433 OHCA patients included in the study, 29.17% achieved return of spontaneous circulation at the scene, 6.9% survived to ED, and 1% survived to hospital discharge. Each 1-minute increase in response time decreased the likelihood of survival at the scene by 6% (OR: 0.94, p < 0.001), survival to ED admission by 4% (OR: 0.96, p < 0.001), and survival to hospital discharge by 6% (OR: 0.94, p = 0.006). Response times under 8 minutes significantly improved outcomes, with survival at the scene increasing by 2.31 times (p < 0.001), survival to ED by 1.76 times (p < 0.001), and survival to hospital discharge by 2.09 times (p = 0.048).

Conclusions

A maximum response time of 8 minutes significantly enhances survival outcomes, including survival at the scene, survival to ED, and survival to hospital discharge. Furthermore, each 1-minute increase in response time is associated with a 6% reduction in the likelihood of survival to hospital discharge.

The New Health Educational Method of the COVID-19 Pandemic: The Experience from Wuhan, China

The pandemic of Coronavirus Disease 2019 (COVID-19) threatens people's lives, and they pay more attention to health than ever before. Medical workers and other members of society need to have knowledge of responding to medical emergencies, as does the public. With the improvement of the public's health literacy, we will have more chances to prevent the development of the pandemic. The fifth-generation Pavilion of Health Emergency Experience (Wuhan, China) provides a new health interactive platform. It introduces advanced technology to present how these events happen, how they evolve, and how they are handled. With a deep understanding of the construction and structure of pavilions in this field both at home and abroad, we will know our limitations and make efforts to innovate. Therefore, we should make full use of the advanced technology of public health to benefit the people. And the fifth-generation pavilion deserves to generalize in other areas.

Chest Compressions Synchronized to Native Cardiac Contractions are More Effective than Unsynchronized Compressions for Improving Coronary Perfusion Pressure in a Novel Pseudo-PEA Swine Model

OBJECTIVES

Pulseless electrical activity (PEA) arrest, which includes pseudo-PEA, is increasingly common and survival remains dismal. We hypothesized that mechanical chest compressions synchronized to native cardiac contractions improve coronary perfusion pressure (CPP) during pseudo-PEA resuscitation.

METHODS

We developed a model of pseudo-PEA by infusing high dose esmolol intravenously into anesthetized, intubated, and central arterial and venous catheterized swine to a goal of 45 mm Hg mean arterial blood pressure (MAP). We performed a randomized unblinded repeated crossover trial by administering alternating synchronized and unsynchronized chest compressions for 52 s preceded by 8 s breaks consecutively 4 times. We repeated the protocol approximately 4 times with 1 min breaks. Synchronized compressions were provided 1:1 with native contractions during systole and unsynchronized compressions were provided at 100 beats per minute (BPM). We measured average CPP, MAP, and heartrate (HR) for 5 beats immediately preceding the chest compression onset and for 30 s 10 s after compression onset. We computed the difference in continuous CPP during compressions compared to the immediately preceding baseline for each interval. We developed a mixed linear model with outcome average CPP during compressions minus baseline, fixed variable compression type, and random variable animal.

RESULTS

We included 6 animals. Mean baseline HR was 76.0 BPM, MAP 49.9, and CPP 36.2. Chest compressions increased CPP from baseline an average 1.7 mm Hg when unsynchronized and 5.6 mm Hg synchronized. The adjusted difference was 4.0 mm Hg (95% CI 2.4-5.5).

CONCLUSIONS

Synchronized chest compressions increased CPP 4.0 mm Hg (135%) more than unsynchronized compressions despite a lower compression rate in medication-induced pseudo-PEA. Further refinement and eventual application to patients suffering pseudo-PEA arrest appear warranted.

Iron Deficiency in Collegiate Athletes Obtaining Preparticipation Hemoglobinopathy Screening in the Upper Midwest

OBJECTIVE

Iron and other biologically important metals are essential to mitochondrial function but are not routinely evaluated. Their equilibrium is critical to the optimal performance of cells with high metabolic activity such as neurons, cardiomyocytes, and skeletal myocytes. Teenagers are at a high risk of iron deficiency even without anemia. Metal ion imbalances can cause cognitive impairments, muscle weakness, and sudden cardiac death. We aim to assess the current prevalence of iron deficiency among collegiate athletes in the Upper Midwest.

METHODS

Our study is a multicenter, retrospective chart review of outpatient clinics in a regional healthcare system between January 2012 and December 2023, and a national public database between 2017 and March 2020. We reviewed the ferritin concentrations of regional collegiate athletes having preparticipation sport evaluations and nationally in the NHANES database.

RESULTS

We identified 643 unique individuals aged 16-21 years with 253 having ferritin screening. Iron deficiency (ferritin <20 mcg/L) was present in 24.5% and hypoferritinemia (ferritin <50 mcg/L) was present in 66.7% of collegiate athletes. From the NHANES database, 12.7% of active sampled participants aged 16-21 years were iron deficient.

CONCLUSION

Our study findings suggest the need for universal screening for iron deficiency among collegiate athletes given the high prevalence of iron deficiency in both the retrospective chart review and NHANES database analysis. Given the critical role of metal ion homeostasis to optimal mitochondrial function, these findings may warrant the inclusion of ferritin testing in cardiac, neurological, and skeletal muscle evaluations.

Investigating BLS instructors' ability to evaluate CPR performance: focus on compression depth, rate, and recoil

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) presents significant challenges with low survival rates, emphasizing the need for effective bystander CPR training. In Basic Life Support (BLS) training, the role of instructors is pivotal as they assess and correct learners' cardiopulmonary resuscitation (CPR) techniques to ensure proficiency in life-saving skills. This study evaluates the concordance between CPR quality assessments by Basic Life Support (BLS) instructors and those determined through Quantitative CPR (QCPR) devices, utilizing data from BLS courses conducted at National Cheng Kung University Hospital from October 2017 to April 2018.

METHODS

The study analyzed existing data from BLS courses, comparing CPR quality assessments made by instructors with those recorded by QCPR devices. Key metrics such as chest compression speed, depth, and recoil were examined to identify the degree of consistency between human and automated evaluations.

RESULTS

In this study, CPR performance was analyzed using QCPR devices and BLS instructors across metrics like speed, depth, and recoil. Employing the Cohen kappa statistic revealed moderate to low interrater reliability, the kappa value is 0.65 (95% C.I. 0.65-0.65) for depth, 0.56 (95% C.I. 0.33-0.79) for speed, and 0.50 (95% C.I.0.28-0.71) for recoil. Correlation analysis visualized in a heatmap indicated a higher consistency in depth evaluations (correlation coefficient = 0.7) compared to speed and recoil, suggesting a need for improved alignment in CPR training assessments.

CONCLUSIONS

The study underscores the importance of refining CPR training methods and adopting advanced technological aids to enhance the reliability of CPR skill assessments. By improving the accuracy of these evaluations, the training can be better tailored to increase the effectiveness of life-saving interventions, potentially boosting survival rates in out-of-hospital cardiac arrest scenarios.

Association between neurological outcomes and prehospital time in patients with out-of-hospital cardiopulmonary arrest

Introduction

Out-of-hospital cardiac arrest (OHCA) remains an important health care issue. Considering the importance of such a time course after cardiac arrest, detailed evaluation of the prehospital time (i.e., time from EMS contact to a patient to hospital arrival) is essential to improve the mortality and neurologic outcome of OHCA. In this study, we aimed to evaluate the impact of prehospital time on neurological outcomes in patients with OHCA.

Methods

This retrospective observational study included adult non-traumatic OHCA patients who were transported to 2 emergency centers in Tokyo from January 2015 to December 2020. The following data were obtained retrospectively from medical records.

Results

Of the 3120 OHCA patients who were transported during the study period, 2215 patients were evaluated via the inclusion and exclusion criteria. Sixty-nine patients were alive at hospital discharge with a good neurological outcome (i.e., CPC 1 or 2). The multivariate logistic regression model showed that prehospital time (time from EMS contact to hospital arrival) was an independent predictor for hospital discharge with good neurological outcome, in addition to age, bystander CPR, initial rhythm, and cause of cardiac arrest. The GAM plot showed that the adjusted odds ratio of prehospital time for the good neurological outcome was decreased linearly according to time, and the threshold was approximately 30 min.

Conclusion

The threshold of allowable prehospital time, including field activity and transport, for OHCA patients might be 30 min at least in a Japanese urban setting.

Advanced age and neurological recovery in elderly patients with out-of-hospital cardiac arrest treated with targeted temperature management: a nationwide population‑based registry study 2016-2020

The likelihood of neurological recovery after out-of-hospital cardiac arrest (OHCA) may be influenced by advanced age. This study aims to evaluate the impact of advanced age on neurological recovery in elderly OHCA survivors treated with targeted temperature management (TTM). This retrospective observational study, using a nationwide population-based OHCA registry, was conducted from January 2016 to December 2020. Non-traumatic elderly (≥ 65 years) comatose OHCA survivors treated with TTM were categorized according to age (65-69, 70-74, 75-79, and ≥ 80 years). Among 23,336 admitted OHCA patients, 3,398 were treated with TTM. Excluding 2,033 non-elderly patients, 1,365 were analyzed. Among the four groups, the rate of good neurological outcomes decreased by advanced age (24.2%, 16.1%, 11.4%, and 5.9%, respectively), which was also observed after subgroup analysis based on the initial shockable (40.6%, 31.5%, 28.6%, and 14.9%, respectively) and non-shockable rhythm (10.6%, 7.2%, 4.1%, and 3.4%, respectively). Multivariate analysis showed the adjusted odds ratio (aOR) for good neurological outcome decreased as age increased (65-69: reference, 70-74: aOR 0.70, 75-79: aOR 0.49, and ≥ 80 years: aOR 0.25). The optimal age cutoffs for good outcomes in elderly OHCA survivors with shockable and non-shockable rhythm were 77 and 72 years, respectively. The neurologic recovery rate in OHCA survivors treated with TTM gradually decreased with increasing age. However, even patients aged ≥ 80 years with shockable rhythm had a good neurologic outcome of 14.9% compared with patients aged 65-69 years with non-shockable rhythm (10.6%).

Trends in Cardiac Arrest Outcomes & Management in Children with Cardiac Illness Category Compared to Non-Cardiac Illness Category: An Analysis from the AHA Get With The Guidelines®-Resuscitation Registry

INTRODUCTION

Contemporary rates of survival after pediatric in-hospital CPR events and trends in survival over the last 20 years have not been compared based on illness category. We hypothesized that survival to hospital discharge for surgical-cardiac category is higher than the non-cardiac category, and rates of survival after in-hospital CPR increased over time in all categories.

METHODS

The AHA Get With The Guidelines®-Resuscitation registry was queried for index CPR events in children < 18 years of age from 2000 to 2021. Categories were surgical-cardiac (in-hospital CPR event following cardiac surgery); medical-cardiac (CPR event in non-surgical cardiac disease); and non-cardiac (CPR event in patients without cardiac disease). The primary outcome was survival to hospital discharge. We compared eras 2000-2004, 2005-2009, 2010-2014, and 2015-2021 with mixed logistic regression models, including event year as a continuous predictor and site as a random effect.

RESULTS

Of 16,241 index events, in-hospital CPR event rates by illness category were: 19 % surgical-cardiac, 18 % medical-cardiac, and 63 % non-cardiac. Surgical-cardiac category had the highest rate of survival to hospital discharge compared to medical-cardiac and non-cardiac categories (56 % vs. 44 % vs. 46 %; p < 0.001). After controlling for age, location of event, and hospital size, the odds of survival were highest for surgical-cardiac category (aOR 1.28, 95 % CI 1.17-1.41) and lower for medical-cardiac category (aOR 0.90, 0.82-0.98), compared to the non-cardiac category. Odds of survival increased for all illness categories from the 2000-2004 era to the 2015-2021 era. Rates of improvement differed among illness categories with medical-cardiac having the lowest increased odds per era. Surgical-cardiac patients had the highest rates of extracorporeal resuscitation (ECPR) (20 % across the cohort), though the greatest increase in ECPR utilization was in the non-cardiac population (52 % increased odds per era).

CONCLUSIONS

Over the last 20 years, both survival to hospital discharge and ECPR use has increased in all in-hospital CPR event illness categories. Children with surgical-cardiac CPR event have higher odds of survival to hospital discharge compared to non-cardiac CPR event categories, whereas odds of survival were lowest with medical-cardiac CPR events.

Out-of-hospital cardiac arrest in Bahrain: National retrospective cohort study

Aim

There is limited research on Out-of-hospital cardiac arrest (OHCA) in the Gulf Cooperation Council (GCC) and especially in Bahrain. This is the first study to describe the incidence, characteristics, and outcomes of OHCA in Bahrain.

Methods

This was a retrospective national observational study on OHCA patients in Bahrain using the Utstein framework for resuscitation. Data was collected between 1st July 2022 to 30th June 2023 from the electronic medical records of the only three governmental hospitals emergency departments (EDs) and National Ambulance (NA).

Results

The annual incidence of OHCA attended by (Emergency Medical Services) EMS was nearly 21 per 100,000 population. The majority were males (n = 228, 68.8 %) with median age of 65 years (IQR=49-78). Most OHCA cases were witnessed (n = 265, 81 %), with (n = 247, 76 %) happened at home/residence. Rates for bystander CPR was low (n = 122, 36.8 %) and bystander automated external defibrillator (AED) was not performed in any of the cases. The OHCA cases transported by the NA was (n = 314, 94.8 %), with median response time of 9 min (IQR=7-12). However, only (n = 20, 6.0 %) were witnessed by EMS, and (n = 7, 2.1 %) received EMS defibrillation for shockable rhythms. First monitored rhythms included shockable rhythm in (n = 28, 8.5 %) versus non-shockable rhythm in (n = 303, 91.5 %). In the EDs, return of spontaneous circulation was achieved in (n = 60, 18.1 %) cases. But survival rate to hospital discharge at 30-day was (n = 4, 1.2 %) and survival rate to hospital discharge with good neurological outcomes was (n = 0, 0 %). Conclusion: In Bahrain the estimated annual incidence of OHCA is 21 individuals per 100,000 population, with a very low survival rate. Solutions should focus on community-level CPR and AED training, evaluating OHCA care provided by EMS, and establishing OHCA registry.

Regional variation in temperature control after out-of-hospital cardiac arrest

Introduction

We evaluated hospitals for variation in temperature control (TC) use after out-of-hospital cardiac arrest (OHCA) in a regional emergency medical services system and assessed association of hospital-level TC utilization with survival.

Methods

A retrospective cohort study of adults with non-traumatic OHCA who survived to hospital admission from 2016 to 2018 in King County, Washington. Hospitals with < 80 OHCA cases were excluded. Primary exposure was hospital-level proportion of TC. Measured outcomes were survival to hospital discharge and neurologically favorable survival (defined as Cerebral Performance Category 1 or 2). Logistic regression modeling clustered patients by treating hospital and evaluated associations between TC and outcomes with covariate adjustment.

Results

Of 1,035 eligible patients admitted to eight hospitals, 69% were male, 38% had an initial shockable rhythm, and 61% had presumed cardiac etiology for OHCA. TC was initiated in 787 patients (74%) and ranged from 57 to 87% across hospitals. Overall, 34% of patients survived neurologically intact, 74% of whom received TC. In the adjusted model, public OHCA location (OR: 1.7 [95% CI 1.3-2.3]), witnessed arrest (OR: 1.6 [1.2-2.2]), and shockable rhythm (OR: 5.5 [3.9-7.8]) were more strongly associated with survival than TC utilization (OR: 0.6 [0.4-0.8]). Similar results were seen for neurologically favorable survival and did not vary significantly by hospital.

Conclusions

Hospital-level TC utilization was not associated with improved survival or neurologically favorable survival after OHCA. Future studies should examine which aspects of the post-cardiac arrest care bundle most strongly influence outcomes.

Adeno-associated Virus-mediated Ezh2 Knockdown Reduced the Increment of Newborn Neurons Induced by Forebrain Ischemia in Gerbil Dentate Gyrus

It is established that neurogenesis of dentate gyrus is increased after ischemic insult, although the regulatory mechanisms have not yet been elucidated. In this study, we focused on Ezh2 which suppresses gene expression through catalyzing trimethylation of lysine 27 of histone 3. Male gerbils were injected with adeno-associated virus (AAV) carrying shRNA targeting to Ezh2 into right dentate gyrus 2 weeks prior to forebrain ischemia. One week after ischemia, animals were injected with thymidine analogue to label proliferating cells. Three weeks after ischemia, animals were killed for histological analysis. AAV-mediated knockdown of Ezh2 significantly decreased the ischemia-induced increment of proliferating cells, and the proliferated cells after ischemia showed significantly longer migration from subgranular zone (SGZ), compared to the control group. Furthermore, the number of neural stem cells in SGZ significantly decreased after ischemia with Ezh2 knockdown group. Of note, Ezh2 knockdown did not affect the number of proliferating cells or the migration from SGZ in the non-ischemic condition. Our data showed that, specifically after ischemia, Ezh2 knockdown shifted the balance between self-renewal and differentiation toward differentiation in adult dentate gyrus.

The Interaction Effect of Age, Initial Rhythm, and Location on Outcomes After Out-of-Hospital Cardiac Arrest: A Retrospective Cohort Study

Background: Out-of-hospital cardiac arrest (OHCA) is a critical global health challenge and a leading cause of mortality. This study investigates the combined effect of initial cardiac arrest rhythm, patient age, and location on the return of spontaneous circulation (ROSC) in OHCA patients. Methods: This retrospective study analyzed medical records from the National Emergency Medical Service (EMS) in Poland between January 2021 and June 2022. Data from 33,636 patients with OHCA who received cardiopulmonary resuscitation (CPR) at the scene were included. Results: Public incidents were associated with higher ROSC rates (54.10% vs. 31.53%, p < 0.001). Initial shockable rhythms (VF/pVT) significantly increased the odds of ROSC (OR = 3.74, 95% CI 3.39-4.13, p < 0.001). Obesity decreased the odds of ROSC in at-home cases (OR = 0.85, 95% CI 0.73-0.99, p = 0.036) but had no significant effect in public cases. The effect of age on ROSC outcomes varied significantly depending on the location. In patients younger than 60 years, better ROSC outcomes were observed in at-home cases, while for those older than 60 years, the odds of ROSC were higher in public locations. Each additional year of age decreased the odds of ROSC by 1.62% in at-home incidents (p < 0.001) and by 0.40% in public incidents (p = 0.009). Sex differences were significant in public locations, with women having higher odds of ROSC compared to men (OR = 0.57, 95% CI 0.37-0.87, p = 0.009 for VF/pVT). Conclusions: The interaction between the location of OHCA, initial cardiac rhythm, and patient age significantly impacts ROSC outcomes. Public locations show higher ROSC rates, especially in cases with shockable rhythms (VF/pVT). Age modifies ROSC outcomes, with younger patients benefiting more at home, and older patients showing better outcomes in public places.

Assessing the Impact of the Pandemic on Treatment Outcomes for Cardiac Arrest Patients Utilizing Mechanical CPR: A Nationwide Population-Based Observational Study in South Korea

INTRODUCTION

Cardiopulmonary resuscitation with mechanical devices (MCPR) was developed to provide high-quality cardiopulmonary resuscitation (CPR) for patients with cardiac arrest. However, the effect of this procedure on treatment outcomes remains controversial. Nevertheless, during the coronavirus disease-19 (COVID-19) pandemic, in-hospital MCPR gained attention, owing to its advantages such as saving medical staff and preventing infection. This study compared the treatment outcomes of in-hospital MCPR and manual CPR for out-of-hospital cardiac arrest (OHCA) patients during the COVID-19 pandemic.

MATERIALS AND METHODS

This retrospective nationwide population-based study was conducted in South Korea. Data were collected from the Out-of-Hospital Cardiac Arrest surveillance database managed by the Korea Disease Control and Prevention Agency. We included adult OHCA patients transported by emergency medical services from 2016 to 2021. The study compared outcomes during the COVID-19 pandemic years (2020-2021) with the preceding non-pandemic years (2018-2019). The primary outcome was survival to hospital discharge, and the secondary outcomes were good neurological outcome and sustained return of spontaneous circulation (ROSC).

RESULTS

The entire study included 72,050 patients with OHCA and, in the multivariable analyses, MCPR was associated with lower survival rates compared to manual CPR (AOR 0.63; 95% CI 0.51-0.77; p < 0.001). Interestingly, during the COVID-19 pandemic, while MCPR use increased, the survival rate did not differ significantly between the MCPR and manual-CPR groups.

CONCLUSION

Our study findings suggest that while MCPR may offer potential benefits, such as decreased infection risk for healthcare workers, it did not demonstrate superior outcomes compared to manual CPR in our study population.

Assessing variations in care delivered to rural out of hospital cardiac arrest patients in the interfacility transfer setting

Objective

There is significant variation in out-of-hospital cardiac arrest (OHCA) outcomes between different regions. We sought to evaluate outcomes of OHCA patients in the interfacility transfer (IFT) setting, between critical care transport (LifeFlight) and community Emergency Medical Services (EMS), in the state of Maine.

Methods

This was a retrospective analysis of our institution's electronic medical record and the Maine EMS database. Data were collected from January 1, 2019, to December 31, 2021. Only adult OHCA encounters requiring an IFT for definitive post-cardiac-arrest care were included. Demographics, EMS agency, IFT vital signs, targeted temperature management (TTM) medications, cerebral performance category (CPC) scores, survival to discharge, and other descriptive variables were collected.

Results

Ninety-three patients met inclusion criteria, with LifeFlight transferring 30 of them (32.3%). LifeFlight was more likely to initiate TTM compared to other EMS agencies (p = 0.012), have run-sheets reported (p = 0.001), and serve rural areas (p = 0.036). LifeFlight was associated with more epinephrine (0.034) and norepinephrine (<0.001) use. Only 37% of IFTs had physician orders, with none (0.0%) of them defining vital sign targets. No difference in survival to discharge or CPC scores was observed between LifeFlight and other EMS agencies. No significant variation in comorbidities or vital signs was observed.

Conclusions

There was no difference in survival to discharge or CPC scores between LifeFlight and ad hoc EMS agency. LifeFlight was associated with more TTM and vasopressor utilization during IFT. Most IFT encounters did not have dedicated physician orders, and none of the orders included vital sign targets.

Do differences in emergency medical services (EMS) response time to an arrest account for the survival differences between EMS-witnessed and bystander-witnessed out of hospital cardiac arrest?

Introduction

Out-of-hospital cardiac arrests (OHCA) witnessed by Emergency Medical Services (EMS) are reported to have more favourable survival than bystander-witnessed arrests, even after adjusting for patient and arrest factors known to be associated with increased OHCA survival. This study aims to determine whether the survival advantage in EMS-witnessed arrests can be attributed to differences in the EMS response time to the arrest.

Methods

Using registry data we conducted a retrospective, population-based cohort study of bystander- and EMS-witnessed OHCAs of medical aetiology who received an EMS resuscitation attempt in Western Australia between 2018-2021. EMS response time to arrest was assumed to be zero for EMS-witnessed arrests. Multivariable logistic regression was used to compare 30-day OHCA survival by witness and bystander CPR (B-CPR) status, adjusting for EMS response time to arrest, and patient and arrest characteristics.

Results

Of 2,130 OHCA cases, 510 (23.9%) were EMS-witnessed and 1620 were bystander-witnessed: 1318/1620 (81.4%) with B-CPR, and 302/1620 (18.6%) with no B-CPR. The median EMS response time to bystander-witnessed arrests who received B-CPR was 9.9 [Q1,Q3: 7.4, 13.3] minutes. After adjusting for the EMS response time and patient and arrest factors, 30-day survival remained significantly lower in both the bystander-witnessed group with B-CPR (aOR 0.56; 95% CI 0.34 - 0.91) and bystander-witnessed group without B-CPR (aOR 0.23; 95% CI 0.11 - 0.46).

Conclusion

An increased EMS response time does not fully account for the higher OHCA survival in EMS-witnessed arrests compared to bystander-witnessed arrests.

Rib fractures and other injuries after cardiopulmonary resuscitation for non-traumatic cardiac arrest: a systematic review and meta-analysis

PURPOSE

This study aims to ascertain the prevalence of rib fractures and other injuries resulting from CPR and to compare manual with mechanically assisted CPR. An additional aim was to summarize the literature on surgical treatment for rib fractures following CPR.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Embase, Medline Ovid, Cochrane Central, Web of Science, and Google Scholar.

REVIEW METHODS

The databases were searched to identify studies reporting on CPR-related injuries in patients who underwent chest compressions for a non-traumatic cardiopulmonary arrest. Subgroup analysis was conducted to compare the prevalence of CPR-related injuries in manual versus mechanically assisted chest compressions. Studies reporting on surgery for CPR-related rib fractures were also reviewed and summarized.

RESULTS

Seventy-four studies reporting CPR-related injuries were included encompassing a total of 16,629 patients. Any CPR-related injury was documented in 60% (95% confidence interval [95% CI] 49-71) patients. Rib fractures emerged as the most common injury, with a pooled prevalence of 55% (95% CI 48-62). Mechanically assisted CPR, when compared to manual CPR, was associated with a higher risk ratio for CPR-related injuries of 1.36 (95% CI 1.17-1.59). Eight studies provided information on surgical stabilization of CPR-related rib fractures. The primary indication for surgery was the inability to wean from mechanical ventilation in the presence of multiple rib fractures.

CONCLUSION

Rib fractures and other injuries frequently occur in patients who undergo CPR after a non-traumatic cardiopulmonary arrest, especially when mechanical CPR is administered. Surgical stabilization of CPR-related rib fractures remains relatively uncommon.

LEVEL OF EVIDENCE

Level III, systematic review and meta-analysis.

A metabolic profile of xenon and metabolite associations with 6-month mortality after out-of-hospital cardiac arrest: A post-hoc study of the randomised Xe-Hypotheca trial

PURPOSE

Out-of-hospital cardiac arrest (OHCA) carries a relatively poor prognosis and requires multimodal prognostication to guide clinical decisions. Identification of previously unrecognized metabolic routes associated with patient outcome may contribute to future biomarker discovery. In OHCA, inhaled xenon elicits neuro- and cardioprotection. However, the metabolic effects remain unknown.

MATERIALS AND METHODS

In this post-hoc study of the randomised, 2-group, single-blind, phase 2 Xe-Hypotheca trial, 110 OHCA survivors were randomised 1:1 to receive targeted temperature management (TTM) at 33°C with or without inhaled xenon during 24 h. Blood samples for nuclear magnetic resonance spectroscopy metabolic profiling were drawn upon admission, at 24 and 72 h.

RESULTS

At 24 h, increased lactate, adjusted hazard-ratio 2.25, 95% CI [1.53; 3.30], p<0.001, and decreased branched-chain amino acids (BCAA) leucine 0.64 [0.5; 0.82], p = 0.007, and valine 0.37 [0.22; 0.63], p = 0.003, associated with 6-month mortality. At 72 h, increased lactate 2.77 [1.76; 4.36], p<0.001, and alanine 2.43 [1.56; 3.78], p = 0.001, and decreased small HDL cholesterol ester content (S-HDL-CE) 0.36 [0.19; 0.68], p = 0.021, associated with mortality. No difference was observed between xenon and control groups.

CONCLUSIONS

In OHCA patients receiving TTM with or without xenon, high lactate and alanine and decreased BCAAs and S-HDL-CE associated with increased mortality. It remains to be established whether current observations on BCAAs, and possibly alanine and lactate, could reflect neural damage via their roles in the metabolism of the neurotransmitter glutamate. Xenon did not significantly alter the measured metabolic profile, a potentially beneficial attribute in the context of compromised ICU patients.

TRIAL REGISTRATION

Trial Registry number: ClinicalTrials.gov Identifier: NCT00879892.

Association Between QRS Characteristics in Pulseless Electrical Activity and Survival Outcome in Cardiac Arrest Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

Recent studies have shown inconsistent results regarding the association between QRS characteristics and survival outcomes in patients with cardiac arrest and pulseless electrical activity (PEA) rhythms. This meta-analysis aimed to identify the usefulness of QRS width and frequency as prognostic tools for outcomes in patients with cardiac arrest and PEA rhythm.

METHODS

Extensive searches were conducted using Medline, Embase, and the Cochrane Library to find articles published from database inception to 4 June 2023. Studies that assessed the association between the QRS characteristics of cardiac arrest patients with PEA rhythm and survival outcomes were included. The Newcastle-Ottawa Scale was used to assess the methodological quality of the included studies.

RESULTS

A total of 9727 patients from seven observational studies were included in this systematic review and meta-analysis. The wide QRS group (QRS ≥ 120 ms) was associated with significantly higher odds of mortality than the narrow QRS group (QRS < 120 ms) (odds ratio (OR) = 1.86, 95% confidence interval (CI) = 1.11-3.11, I2 = 58%). The pooled OR for mortality was significantly higher in patients with a QRS frequency of < 60/min than in those with a QRS frequency of ≥ 60/min (OR = 1.90, 95% CI = 1.19-3.02, I2 = 65%).

CONCLUSIONS

Wide QRS width or low QRS frequency is associated with increased odds of mortality in patients with PEA cardiac arrest. These findings may be beneficial to guide the disposition of cardiac arrest patients with PEA during resuscitation.

Implementation of an extracorporeal resuscitation (ECPR) program for out-of-hospital cardiac arrest in Stockholm, Sweden: Feasibility, safety, and outcome

Background

The aim of this study was to evaluate the implementation of a novel extra corporeal cardiopulmonary (ECPR) program in the greater Stockholm area with focus on feasibility, safety aspects and clinical outcomes.

Methods

Prospective observational study of ECPR program including patients with OHCA from January 2020 to December 2022, fulfilling ECPR criteria: age 18-65 years, initial shockable rhythm or pulseless electrical activity, witnessed arrest, bystander cardiopulmonary resuscitation and refractory arrest after three cycles of advance cardiac life support. The predefined time threshold from collapse to extracorporeal membrane oxygenation (ECMO) initiation was set at 60 min.

Results

We included 95 patients. Of these, 22/95 (23%) had return of spontaneous circulation before ECMO initiation, 39/95 (41%) were excluded for ECMO and 34/95 (36%) had ECMO initiated out of which 23 patients were admitted alive to the ICU. ECMO-initiation within 60 min was met in 9%. In 6 patients vascular access was complicated, 2 patients had severe bleeding at access site requiring intervention. Survival to discharge among all cases was 25% (24/95). Among patients admitted to ICU on ECMO 39% (9/23) survived to discharge, of these 78% had cerebral performance category scale score 1-2 within 12 months. 8 out of 9 survivors had time from OHCA to ECMO-initiation >60 min.

Conclusion

The implementation of an ECPR protocol was feasible without any major, unexpected safety aspects but did not meet the intended target time intervals. Despite this, survival rates were similar to previous studies although most survivors had >60 min to ECMO-initiation.

Out-of-Hospital Cardiac Arrest in the Eye of the Beholder and Emergency Medical Service

Purpose

Out-of-hospital cardiac arrest (OHCA) remains a global healthcare problem, with low survival and bystander cardiopulmonary resuscitation (CPR) rates. This study aimed to identify event-related factors in OHCA and their impact on return of spontaneous circulation (ROSC) achievement and maintenance until hospital admission.

Patients and Methods

All data were collected from Utstein Resuscitation Registry Template for OHCA from The Institute of Emergency Medicine of Zagreb from January 2012 to August 2022. This cross-sectional research analyzed 2839 Utstein reports, including 2001 male, 836 female, and 8 subjects of unknown gender. The average age was 65.4 ± 16.2 years.

Results

The most frequent place of collapse was private residence, and 27% of collapses were unwitnessed. Dispatcher-provided CPR instructions were provided in 39.7% of cases until the arrival of the emergency service team, which showed a very strong effect on bystander-provided CPR, and were followed in 68.4% of cases, while non-instructed bystander CPR was provided in only 7.9% of cases. Bystander CPR is more likely to be provided in public places than in private residences, often with both compression and ventilation. Bystander CPR was also more likely to be provided to men. Cases with bystander CPR, and compressions with ventilation compared to compression only CPR, showed a significantly greater success in maintaining ROSC later in CPR, both with moderate effects.

Conclusion

Bystander CPR has been shown to have a significant role in achieving and maintaining ROSC until hospital admission. However, our results showed a location-dependent nature of bystanders' willingness to perform CPR as well as sex disparities in patients receiving CPR. With deficient education in basic life support in Croatia, dispatchers need to insist on and instruct bystander CPR performance.

Challenges & barriers for real-time integration of drones in emergency cardiac care: Lessons from the United States, Sweden, & Canada

Importance

Out-of-hospital cardiac arrest (OHCA) is a leading cause of morbidity and mortality in the US and Europe (∼600,000 incident events annually) and around the world (∼3.8 million). With every minute that passes without cardiopulmonary resuscitation or defibrillation, the probability of survival decreases by 10%. Preliminary studies suggest that uncrewed aircraft systems, also known as drones, can deliver automated external defibrillators (AEDs) to OHCA victims faster than ground transport and potentially save lives.

Objective

To date, the United States (US), Sweden, and Canada have made significant contributions to the knowledge base regarding AED-equipped drones. The purpose of this Special Communication is to explore the challenges and facilitators impacting the progress of AED-equipped drone integration into emergency medicine research and applications in the US, Sweden, and Canada. We also explore opportunities to propel this innovative and important research forward.

Evidence review

In this narrative review, we summarize the AED-drone research to date from the US, Sweden, and Canada, including the first drone-assisted delivery of an AED to an OHCA. Further, we compare the research environment, emergency medical systems, and aviation regulatory environment in each country as they apply to OHCA, AEDs, and drones. Finally, we provide recommendations for advancing research and implementation of AED-drone technology into emergency care.

Findings

The rates that drone technologies have been integrated into both research and real-life emergency care in each country varies considerably. Based on current research, there is significant potential in incorporating AED-equipped drones into the chain of survival for OHCA emergency response. Comparing the different environments and systems in each country revealed ways that each can serve as a facilitator or barrier to future AED-drone research.

Conclusions and relevance

The US, Sweden, and Canada each offers different challenges and opportunities in this field of research. Together, the international community can learn from one another to optimize integration of AED-equipped drones into emergency systems of care.

Statewide implementation of the cardiac arrest registry to enhance survival in Ohio

Objective

Public health surveillance is essential for improving community health. The Cardiac Arrest Registry to Enhance Survival (CARES) is a surveillance system for out-of-hospital cardiac arrest (OHCA). We describe results of the organized statewide implementation of Ohio CARES.

Methods

We performed a retrospective analysis of CARES enactment in Ohio. Key elements included: establishment of statewide leadership, appointment of a dedicated coordinator, conversion to a statewide subscription, statewide dissemination of information, fundraising from internal and external stakeholders, and conduct of resuscitation academies. We identified all adult (≥18 years) OHCA reported in the registry during 2013-2020. We evaluated OHCA characteristics before (2013-2015) and after (2016-2019) statewide implementation using chi-square test. We evaluated trends in OHCA outcomes using the Cochran-Armitage test of trend.

Results

Statewide CARES promotion increased participation from 2 (urban) to 136 (129 urban, 7 rural) EMS agencies. Covered population increased from 1.2 M (10% of state) to 4.8 M (41% of state). After statewide implementation, OHCA populations increased male (58.1% vs 60.8%, p < 0.01), white (50.1% vs 63.7%, p < 0.01), bystander witnessed (26.9% vs 32.9%, p < 0.01) OHCAs. Bystander CPR (34.7% vs 33.2%, p = 0.22), bystander AED (13.5% vs 12.3%, p = 0.55) and initial rhythm (shockable 18.0% vs 18.3%, p = 0.32) did not change. From 2013 to 2019 there were temporal increases in ROSC (29.7% to 31.9%, p-trend = 0.028), survival (7.4% to 12.3%, p-trend < 0.001) and survival with good neurologic outcome (5.6% to 8.6%, p-trend = 0.047).

Conclusion

The organized statewide implementation of CARES in Ohio was associated with marked increases in community uptake and concurrent observed improvements in patient outcomes. These results highlight key lessons for community-wide fostering of OHCA surveillance.

Supraglottic Airway Versus Tracheal Intubation for Airway Management in Out-of-Hospital Cardiac Arrest: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Controlled Trials

OBJECTIVES

Given the uncertainty regarding the optimal approach for airway management for adult patients with out-of-hospital cardiac arrest (OHCA), we conducted a systematic review and meta-analysis to compare the use of supraglottic airways (SGAs) with tracheal intubation for initial airway management in OHCA.

DATA SOURCES

We searched MEDLINE, PubMed, Embase, Cochrane Library, as well as unpublished sources, from inception to February 7, 2023.

STUDY SELECTION

We included randomized controlled trials (RCTs) of adult OHCA patients randomized to SGA compared with tracheal intubation for initial prehospital airway management.

DATA EXTRACTION

Reviewers screened abstracts, full texts, and extracted data independently and in duplicate. We pooled data using a random-effects model. We used the modified Cochrane risk of bias 2 tool and assessed certainty of evidence using the Grading Recommendations Assessment, Development, and Evaluation approach. We preregistered the protocol on PROSPERO (CRD42022342935).

DATA SYNTHESIS

We included four RCTs ( n = 13,412 patients). Compared with tracheal intubation , SGA use probably increases return of spontaneous circulation (ROSC) (relative risk [RR] 1.09; 95% CI, 1.02-1.15; moderate certainty) and leads to a faster time to airway placement (mean difference 2.5 min less; 95% CI, 1.6-3.4 min less; high certainty). SGA use may have no effect on survival at longest follow-up (RR 1.06; 95% CI, 0.84-1.34; low certainty), has an uncertain effect on survival with good functional outcome (RR 1.11; 95% CI, 0.82-1.50; very low certainty), and may have no effect on risk of aspiration (RR 1.04; 95% CI, 0.94 to 1.16; low certainty).

CONCLUSIONS

In adult patients with OHCA, compared with tracheal intubation, the use of SGA for initial airway management probably leads to more ROSC, and faster time to airway placement, but may have no effect on longer-term survival outcomes or aspiration events.

Adverse Safety Events in Emergency Medical Services Care of Children With Out-of-Hospital Cardiac Arrest

Importance

Survival for children with out-of-hospital cardiac arrest (OHCA) remains poor despite improvements in adult OHCA survival.

Objective

To characterize the frequency of and factors associated with adverse safety events (ASEs) in pediatric OHCA.

Design, Setting, and Participants

This population-based retrospective cohort study examined patient care reports from 51 emergency medical services (EMS) agencies in California, Georgia, Oregon, Pennsylvania, Texas, and Wisconsin for children younger than 18 years with an OHCA in which resuscitation was attempted by EMS personnel between 2013 and 2019. Medical record review was conducted from January 2019 to April 2022 and data analysis from October 2022 to February 2023.

Main Outcomes and Measure

Severe ASEs during the patient encounter (eg, failure to give an indicated medication, 10-fold medication overdose).

Results

A total of 1019 encounters of EMS-treated pediatric OHCA were evaluated; 465 patients (46%) were younger than 12 months. At least 1 severe ASE occurred in 610 patients (60%), and 310 patients (30%) had 2 or more. Neonates had the highest frequency of ASEs. The most common severe ASEs involved epinephrine administration (332 [30%]), vascular access (212 [19%]), and ventilation (160 [14%]). In multivariable logistic regression, the only factor associated with severe ASEs was young age. Neonates with birth-related and non-birth-related OHCA had greater odds of a severe ASE compared with adolescents (birth-related: odds ratio [OR], 7.0; 95% CI, 3.1-16.1; non-birth-related: OR, 3.4; 95% CI, 1.2-9.6).

Conclusions and Relevance

In this large geographically diverse cohort of children with EMS-treated OHCA, 60% of all patients experienced at least 1 severe ASE. The odds of a severe ASE were higher for neonates than adolescents and even higher when the cardiac arrest was birth related. Given the national increase in out-of-hospital births and ongoing poor outcomes of OHCA in young children, these findings represent an urgent call to action to improve care delivery and training for this population.

Regional variation in accessibility of automated external defibrillators in British Columbia

OBJECTIVES

Bystander-applied Automated External Defibrillators (AED) improve outcomes for out-of-hospital cardiac arrest. AED placement is often driven by private enterprise or non-for-profit agencies, which may result in inequitable access. We sought to compare AED availability between four regions in British Columbia (BC).

METHODS

We identified AEDs (confirmed to be operational) and emergency medical system (EMS)-treated out-of-hospital cardiac arrests (OHCA) from provincial registries. We compared AED availability between BC's four most populous regions. The primary outcome was the total regional weekly accessible AED-hours per 100,000 population. We also examined: AEDs per 100,000 population and per km2, the ratio of AEDs to OHCA, and the distance from each OHCA to the closest AED.

RESULTS

From provincial registries, we included 879 AEDs from BC's four most populous regions, where 9333 EMS-treated OHCA occurred over a 5-year period. The most common AED location types were stores, public community centres, and office buildings. Ten percent of AEDs were accessible for all hours. Weekly accessible AED-hours/100,000 population in the four regions were: 3845, 1734, 1594, and 1299. AEDs/100,000 population ranged from 22 to 48, and AEDs/km2 ranged from 0.0048 to 0.20. The number of OHCAs per AED per year ranged from 1.1 to 2.8. The median OHCA-to-closest AED distance ranged from 503 (IQR 244, 947) to 925 (IQR 455, 1501) metres. The regional mean accessibility of individual AEDs ranged between 59 and 79 h per week.

CONCLUSION

BC's four most populous regions demonstrate substantial variability in AED accessibility. Further benefit could be derived from AEDs if placed in locations accessible all hours. Our data may encourage community planning efforts to use data-based strategies to systematically place AEDs in optimal locations with strategies to maximize accessibility.

Association between PaCO2 and outcomes in patients who underwent extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest

Aim

The optimal arterial partial pressure of carbon dioxide (PaCO2) for patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) remains unknown. We aimed to investigate the association between post-resuscitation PaCO2 and neurological outcomes.

Methods

This retrospective cohort study analyzed data from the Study of Advanced Life Support for Ventricular Fibrillation with Extracorporeal Circulation in Japan, a multicenter registry study across 36 hospitals in Japan, including patients with out-of-hospital cardiac arrest (OHCA) admitted to intensive care units (ICU) after ECPR between 2013 and 2018. Good PaCO2 management status was defined as a PaCO2 value of 35-45 mmHg. We classified patients into four groups (poor-poor, poor-good, good-poor, and good-good) according to their PaCO2 management status upon admission at the ICU and the following day. The primary outcome was a favorable neurological outcome, defined as cerebral performance category 1 or 2, 30 days after cardiac arrest. The secondary outcome was survival 30 days after cardiac arrest.

Results

We classified 885 eligible patients into poor-poor (n = 361), poor-good (n = 231), good-poor (n = 155), and good-good (n = 138) groups. No significant association was observed between PaCO2 management and favorable 30-day neurological outcomes. Compared with the poor-poor group, the poor-good, good-poor, and good-good groups had adjusted odds ratios of 0.87 (95% confidence interval, 0.52-1.44), 1.17 (0.65-2.05), and 0.95 (0.51-1.73), respectively. The 30-day survival rates among the four groups did not differ significantly.

Conclusion

PaCO2 values were not significantly associated with 30-day neurological outcomes or survival of patients with OHCA after ECPR.

Temporal trends in out-of-hospital cardiac arrest with an initial non-shockable rhythm in Singapore

AIM

Out-of-hospital cardiac arrest (OHCA) with an initial non-shockable rhythm is the predominant form of OHCA in adults. We evaluated its 10-year trends in epidemiology and management in Singapore.

METHODS

Using the national OHCA registry we studied the trends of 20,844 Emergency Medical Services-attended adult OHCA from April 2010 to December 2019. Survival to hospital discharge was the primary outcome. Trends and outcomes were analyzed using linear and logistic regression, respectively.

RESULTS

Incidence rates of adult OHCAs increased during the study period, driven by non-shockable OHCA. Compared to shockable OHCA, non-shockable OHCAs were significantly older, had more co-morbidities, unwitnessed and residential arrests, longer no-flow time, and received less bystander cardiopulmonary resuscitation (CPR) and in-hospital interventions (p < 0.001). Amongst non-shockable OHCA, age, co-morbidities, residential arrests, no-flow time, time to patient, bystander CPR and epinephrine administration increased during the study period, while presumed cardiac etiology decreased (p < 0.05). Unlike shockable OHCA, survival for non-shockable OHCA did not improve (p < 0.001 for trend difference). The likelihood of survival for non-shockable OHCA significantly increased with witnessed arrest (adjusted odds ratio (aOR) 2.02) and bystander CPR (aOR 3.25), but decreased with presumed cardiac etiology (aOR 0.65), epinephrine administration (aOR 0.66), time to patient (aOR 0.93) and age (aOR 0.98). Significant two-way interactions were observed for no-flow time and residential arrest with bystander CPR (aOR 0.96 and 0.40 respectively).

CONCLUSION

The incidence of non-shockable OHCA increased between 2010 and 2019. Despite increased interventions, survival did not improve for non-shockable OHCA, in contrast to the improved survival for shockable OHCA.

Improving EMS response times for out-of-hospital cardiac arrest in urban areas using drone-like vertical take-off and landing air ambulances: An international, simulation-based cohort study

BACKGROUND

Advances in vertical take-off and landing (VTOL) technologies may enable drone-like crewed air ambulances to rapidly respond to out-of-hospital cardiac arrest (OHCA) in urban areas. We estimated the impact of incorporating VTOL air ambulances on OHCA response intervals in two large urban centres in France and Canada.

METHODS

We included adult OHCAs occurring between Jan. 2017-Dec. 2018 within Greater Paris in France and Metro Vancouver in Canada. Both regions utilize tiered OHCA response with basic (BLS)- and advanced life support (ALS)-capable units. We simulated incorporating 1-2 ALS-capable VTOL air ambulances dedicated to OHCA response in each study region, and computed time intervals from call reception by emergency medical services (EMS) to arrival of the: (1) first ALS unit ("call-to-ALS arrival interval"); and (2) first EMS unit ("call-to-first EMS arrival interval").

RESULTS

There were 6,217 OHCAs included during the study period (3,760 in Greater Paris and 2,457 in Metro Vancouver). Historical median call-to-ALS arrival intervals were 21 min [IQR 16-29] in Greater Paris and 12 min [IQR 9-17] in Metro Vancouver, while median call-to-first EMS arrival intervals were 11 min [IQR 8-14] and 7 min [IQR 5-8] respectively. Incorporating 1-2 VTOL air ambulances improved median call-to-ALS arrival intervals to 7-9 min and call-to-first EMS arrival intervals to 6-8 min in both study regions (all P < 0.001).

CONCLUSION

VTOL air ambulances dedicated to OHCA response may improve EMS response intervals, with substantial improvements in ALS response metrics.

Factors associated with willingness to perform basic life support in the community setting in Yogyakarta, Indonesia

BACKGROUND

Cardiac arrest is one of the fatal medical emergencies which need to be treated immediately. Poor survival rates in the community settings are common because of limited and ineffective bystander basic life support (BLS). This study aimed to identify factors that are associated with the willingness to perform BLS in communities in Yogyakarta, Indonesia METHODS: A descriptive study was conducted with a cross-sectional design. Participants (n = 251) were enrolled from the general population consisting of teachers, security personnel, and police officers recruited through cluster random sampling. Data were gathered using both digital or printed questionnaires. Ordinal logistic regression with adjusted odds ratio (AOR) was used to analyze the association between BLS predictors and willingness to perform BLS.

RESULTS

Most participants were willing to perform BLS for all genders (55.55%). The inability to perform BLS and fear of causing harm were the main barriers to performing BLS accounting for 61.35% and 43.82%, respectively. Compared to other independent predictors, ages 40-59 were found to be the highest predictors of willingness to perform BLS (AOR:1.44) followed by experience of seeing real or simulation of the emergency case (AOR:1.38) CONCLUSIONS: More than half of the respondents were eager to perform BLS although some barriers were also found. This study provides some understanding of the predictor factors associated with BLS performance and shows respondents with some training or experience were more likely to perform BLS. The results inform policymakers to develop a strategic plan for increasing willingness to apply BLS in the community. WC:250.

Role of coronary arteries in patients with Acute Coronary Syndrome

Objective

To assess the role of coronary arteries in acute coronary syndrome patients who have survived sudden cardiac arrest.

Method

A cross-sectional study was conducted in Department of Cardiology at Chaudhary Pervaiz Elahi Institute of Cardiology, Multan from 1st May 2021 to 1st October 2021. A total of 203 patients who were diagnosed with sudden cardiac arrest were included as subjects of the study. Baseline data of all patients including age, sex, body mass index, history of smoking, diabetes and hypertension was noted. Coronary angiography was performed in all patients within five days after admission in hospital due to SCA.

Results

The average age of patients was 52.61±11.09 years. There were 140 (68.97%) male and 63 (31.03%) female patients. There were 131 (64.53%) patients with STEMI and 72 (35.47%) patients with Non-STEMI. LMCAD were diagnosed in 29 (14.29%) patients, RCA in 88 (43.35%) patients, LAD in 174 (85.71%) Patients and LCX in 41 (20.20%) patients.

Conclusion

LAD has the most involvement among the coronary arteries (85.71%) in patients with sudden cardiac arrest.

Cognitive impairment and psychopathology in sudden out-of-hospital cardiac arrest survivors: Results from the REVIVAL cohort study

AIM

To investigate cognitive impairment and psychopathology in out-of-hospital cardiac arrest (OHCA) survivors using a screening procedure during hospitalisation and examine the evolution of these parameters at three-month follow-up.

METHODS

This multicentre cohort study screened for cognitive impairment using the Montreal Cognitive Assessment (MoCA), for symptoms of anxiety, depression and traumatic distress using the Hospital Anxiety and Depression Scale (HADS) and the Impact of Event Scale-revised (IES-R) during hospitalisation. At three-month follow-up, we evaluated cognitive impairment with a neuropsychological test battery and symptoms of psychopathology were re-assessed using HADS and IES-R. Logistic regression models were applied to examine associations between screening results and outcomes.

RESULTS

This study included 297 OHCA survivors. During hospitalisation, 65% presented with cognitive impairment, 25% reported symptoms of anxiety, 20% symptoms of depression and 21% symptoms of traumatic distress. At follow-up, 53% reported cognitive impairment, 17% symptoms of anxiety, 15% symptoms of depression and 19% symptoms of traumatic distress. Cognitive impairment during hospitalisation was associated with higher odds (OR (95% CI) 2.55 (1.36-4.75), p = .02) of an unfavorable cognitive outcome at follow-up, and symptoms of psychopathology during hospitalisation were associated with higher odds of psychopathology at follow-up across all three symptom groups; anxiety (6.70 (2.40-18.72), p < .001), depression (4.69 (1.69-13.02), p < .001) and traumatic distress (7.07 (2.67-18.73), p < .001).

CONCLUSION

OHCA survivors exhibited both cognitive impairment and symptoms of psychopathology during hospitalisation comparable to previous studies, which were associated with unfavorable mental health outcomes at three-month follow-up.

Predictors, Prevalence, and Clinical Outcomes of Out-of-Hospital Cardiac Arrests in Croatia: A Nationwide Study

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) remains a pivotal health challenge globally. In Croatia, there has been a knowledge gap regarding the prevalence, predictors, and outcomes of OHCA patients. This study aims to determine the prevalence, prediction, and outcomes of OHCA patients in Croatia.

METHODS

An extensive one-year analysis was performed on all OHCA treated by the Emergency Medical Service in Croatia, based on the Utstein recommendations. Data were extracted from Croatian Institute of Emergency Medicine databases, focusing on adult individuals who experienced sudden cardiac arrest in out-of-hospital settings in Croatia.

RESULTS

From 7773 OHCA cases, 9.5% achieved spontaneous circulation pre-hospital. Optimal outcomes corresponded to EMS intervention within ≤13 min post-arrest onset AUC = 0.577 (95% CI: 0.56-0.59; p < 0.001) and female gender OR = 1.81 (95% CI: 1.49-2.19; p < 0.001). Northern Croatia witnessed lower success rates relative to the capital city Zagreb OR = 0.68 (95% CI: 0.50-0.93; p = 0.015).

CONCLUSIONS

Early intervention by EMS, specifically within a 13-min period following the onset of a cardiac arrest, significantly enhances the probability of achieving successful OHCA outcomes. Gender differences and specific initial heart rhythms further influenced the likelihood of successful outcomes. Regional disparities, with reduced success rates in northern Croatia compared to the City of Zagreb, were evident.

The Lancet Commission to reduce the global burden of sudden cardiac death: a call for multidisciplinary action

Despite major advancements in cardiovascular medicine, sudden cardiac death (SCD) continues to be an enormous medical and societal challenge, claiming millions of lives every year. Efforts to prevent SCD are hampered by imperfect risk prediction and inadequate solutions to specifically address arrhythmogenesis. Although resuscitation strategies have witnessed substantial evolution, there is a need to strengthen the organisation of community interventions and emergency medical systems across varied locations and health-care structures. With all the technological and medical advances of the 21st century, the fact that survival from sudden cardiac arrest (SCA) remains lower than 10% in most parts of the world is unacceptable. Recognising this urgent need, the Lancet Commission on SCD was constituted, bringing together 30 international experts in varied disciplines. Consistent progress in tackling SCD will require a completely revamped approach to SCD prevention, with wide-sweeping policy changes that will empower the development of both governmental and community-based programmes to maximise survival from SCA, and to comprehensively attend to survivors and decedents' families after the event. International collaborative efforts that maximally leverage and connect the expertise of various research organisations will need to be prioritised to properly address identified gaps. The Commission places substantial emphasis on the need to develop a multidisciplinary strategy that encompasses all aspects of SCD prevention and treatment. The Commission provides a critical assessment of the current scientific efforts in the field, and puts forth key recommendations to challenge, activate, and intensify efforts by both the scientific and global community with new directions, research, and innovation to reduce the burden of SCD worldwide.

Defibrillation strategies for refractory ventricular fibrillation out-of-hospital cardiac arrest: A systematic review and network meta-analysis

BACKGROUND AND OBJECTIVE

Double sequential external defibrillation (DSED) and vector-change defibrillation (VCD) have been suggested to enhance clinical outcomes for patients with ventricular fibrillation (VF) refractory of standard defibrillation (SD). Therefore, this network meta-analysis aims to evaluate the comparative efficacy of DSED, VCD, and SD for refractory VF.

METHODS

A systematic review and network meta-analysis synthesizing randomized controlled trials (RCTs) and comparative observational studies retrieved from PubMed, EMBASE, WOS, SCOPUS, and Cochrane through November 15th, 2022. R software netmeta and netrank package (R version 4.2.0) and meta-insight software were used to pool dichotomous outcomes using odds ratio (OR) presented with the corresponding confidence interval (CI). Our protocol was prospectively published in PROSPERO with ID: CRD42022378533.

RESULTS

We included seven studies with a total of 1632 participants. DSED was similar to SD in survival to hospital discharge (OR: 1.14 with 95% CI [0.55, 2.83]), favorable neurological outcome (modified Rankin scale ≤2 or cerebral performance category ≤2) (OR: 1.35 with 95% CI [0.46, 3.99]), and return of spontaneous circulation (ROSC) (OR: 0.81 with 95% CI [0.43; 1.5]). In addition, VCD was similar to SD in survival to hospital discharge (OR: 1.12 with 95% CI [0.27, 4.57]), favorable neurological outcome (OR: 1.01 with 95% CI [0.18, 5.75]), and ROSC (OR: 0.88 with 95% CI [0.24; 3.15]).

CONCLUSION

Double sequential external defibrillation and VCD were not associated with enhanced outcomes in patients with refractory VF out-of-hospital cardiac arrest, compared to SD. However, the current evidence is still inconclusive, warranting further large-scale RCTs.

Pathophysiology and treatment of adults with arrhythmias in the emergency department, part 2: Ventricular and bradyarrhythmias

PURPOSE

This is the second article in a 2-part series reviewing the pathophysiology and treatment considerations for arrhythmias. Part 1 of the series discussed aspects related to treating atrial arrhythmias. Here in part 2, the pathophysiology of ventricular arrhythmias and bradyarrhythmias and current evidence on treatment approaches are reviewed.

SUMMARY

Ventricular arrhythmias can arise suddenly and are a common cause of sudden cardiac death. Several antiarrhythmics may be effective in management of ventricular arrhythmias, but there is robust evidence to support the use of only a few of these agents, and such evidence was largely derived from trials involving patients with out-of-hospital cardiac arrest. Bradyarrhythmias range from asymptomatic mild prolongation of nodal conduction to severe conduction delays and impending cardiac arrest. Vasopressors, chronotropes, and pacing strategies require careful attention and titration to minimize adverse effects and patient harm.

CONCLUSION

Ventricular arrhythmias and bradyarrhythmias can be consequential and require acute intervention. As experts in pharmacotherapy, acute care pharmacists can participate in providing high-level intervention by aiding in diagnostic workup and medication selection.

The Influence of Cardiac Arrest Floor-Level Location within a Building on Survival Outcomes

This nationwide, population-based observational study investigated the association between the floor level of out-of-hospital cardiac arrest (OHCA) incidence and survival outcomes in South Korea, notable for its significant high-rise apartment living. Data were collected retrospectively from OHCA patients through the South Korean Out-of-Hospital Cardiac Arrest Surveillance database. The study incorporated cases that included the OHCA's building floor information. The primary outcome assessed was survival to discharge, analyzed using multivariate logistic regression, and the secondary outcome was favorable neurological outcome. Among 36,977 patients, a total of 29,729 patients were included, and 1680 patients were survivors. A weak yet significant correlation between floor level and hospital arrival time was observed. Interestingly, elevated survival rates were noted among patients from higher floors despite extended emergency medical service response times. Multivariate analysis identified age, witnessed OHCA, shockable rhythm, and prehospital return of spontaneous circulation (ROSC) as primary determinants of survival to discharge. The floor level's impact on survival was less substantial than anticipated, suggesting residential emergency response enhancements should prioritize witness interventions, shockable rhythm management, and prehospital ROSC rates. The study underscores the importance of bespoke emergency response strategies in high-rise buildings, particularly in urban areas, and the potential of digital technologies to optimize response times and survival outcomes.

Prognostic predictors in patients with cardiopulmonary arrest: A novel equation for evaluating the 30-day mortality

BACKGROUND

Early prediction of outcomes after cardiopulmonary arrest (CPA) is important for considering the best support. Our purpose was to evaluate predictors of the 30-day mortality in patients with CPA after return of spontaneous circulation (ROSC) and to assess an equation for calculating the 30-day mortality using clinical parameters.

METHODS

We retrospectively analyzed the data of 194 consecutive patients with CPA and ROSC in a derivation study (2015-2022). We compared clinical parameters between the survived (n = 78) and dead (n = 116) patients. We derived an equation for estimated probability of death based on clinical parameters, using multivariate logistic regression analysis. The reliability of the equation was validated in 80 additional patients with CPA.

RESULTS

The 30-day mortality was associated with sex, witnessed cardiac arrest, bystander cardiopulmonary resuscitation (CPR), CPA due to acute myocardial infarction, pupil diameter, Glasgow Coma Scale score (GCS), presence of light reflex, arterial or venous pH, lactate levels, initial ventricular fibrillation (VF), CPA time, and age. The derived logistic regression equation was as follows: Estimated probability of death = 1 / (1 + e-x), x = (0.25 × bystander CPR) + (0.44 × pupil diameter) - (0.14 × GCS) + (0.09 × lactate) - (1.87 × initial VF) + (0.07 × CPA time) + (0.05 × age) - 7.03. The cut-off value for estimated probability of death calculated by this equation was 54.5 %, yielding a sensitivity, specificity, and accuracy of 86.2 %, 80.8 %, and 84.5 %, respectively. In the validation model, these values were 81.8 %, 85.7 %, and 82.5 %, respectively.

CONCLUSIONS

The 30-day mortality may be calculated after ROSC in patients with CPA using simple clinical parameters. This equation may facilitate further best support for patients with CPA.

Characteristics and Treatment Outcomes of Out-of-Hospital Cardiac Arrests Occurring in Public Places: A National Population-Based Observational Study

Sudden cardiac arrest, particularly out-of-hospital cardiac arrest (OHCA), is a global public health concern. However, limited research exists on the epidemiology of OHCAs occurring in public places, trends and impact of bystander intervention, and influence of extraordinary circumstances. This study investigated the epidemiological factors, bystander characteristics, and outcomes of OHCAs that occurred in public places in South Korea from 2016 to 2021 and analyzed the impact of the coronavirus disease 2019 (COVID-19) pandemic. A retrospective analysis was conducted using an Out-of-Hospital Cardiac Arrest Surveillance database, including 33,206 cases of OHCA that occurred in public places. Cases with do-not-resuscitate orders or insufficient data were excluded. A steady increase in bystander-performed cardiopulmonary resuscitation over the years and a constant decrease in bystander automated external defibrillator (AED) use were observed. Survival-to-discharge rates for OHCAs remained relatively steady until a marginal decrease was observed during the pandemic (pandemic, 13.1%; pre-pandemic, 14.4%). Factors affecting survival included the presence of a shockable rhythm, witnessed arrest, cardiac arrest due to disease, use of bystander AED, and period relative to the COVID-19 pandemic. These findings emphasize the critical role of bystanders in outcomes of OHCAs and inform public health strategies on better management of OHCAs in public places.

Prediction of Out-of-Hospital Cardiac Arrest Survival Outcomes Using a Hybrid Agnostic Explanation TabNet Model

Survival after out-of-hospital cardiac arrest (OHCA) is contingent on time-sensitive interventions taken by onlookers, emergency call operators, first responders, emergency medical services (EMS) personnel, and hospital healthcare staff. By building integrated cardiac resuscitation systems of care, measurement systems, and techniques for assuring the correct execution of evidence-based treatments by bystanders, EMS professionals, and hospital employees, survival results can be improved. To aid in OHCA prognosis and treatment, we develop a hybrid agnostic explanation TabNet (HAE-TabNet) model to predict OHCA patient survival. According to the results, the HAE-TabNet model has an “Area under the receiver operating characteristic curve value” (ROC AUC) score of 0.9934 (95% confidence interval 0.9933–0.9935), which outperformed other machine learning models in the previous study, such as XGBoost, k-nearest neighbors, random forest, decision trees, and logistic regression. In order to achieve model prediction explainability for a non-expert in the artificial intelligence field, we combined the HAE-TabNet model with a LIME-based explainable model. This HAE-TabNet model may assist medical professionals in the prognosis and treatment of OHCA patients effectively.

Serum neurofilament light chain as a predictive marker of neurologic outcome after cardiac arrest: a meta-analysis

OBJECTIVE

Recently, an increasing number of studies have suggested using serum neurofilament light (NfL) chain to predict the neurologic outcome after cardiac arrest. However, the predictive ability of this approach remains inconclusive. Meta-analysis was performed on related studies to assess the ability of serum NfL to predict the neurologic outcome after cardiac arrest.

MATERIALS AND METHODS

PubMed, ScienceDirect and Embase were systematically searched from the date of their inception until June 2022. Data were extracted to calculate the area under the receiver operating characteristic curve (AUC), the sensitivity, the specificity and the publication bias to evaluate the predictive power of serum NfL using Stata 14.0.

RESULTS

Nine studies were included in the present meta-analysis. Seven studies involving 1296 participants reported serum NfL 24 h post arrest for predicting the neurological outcome, and the AUC was 0.92 (77% sensitivity and 96% specificity). Seven studies involving 1020 participants reported serum NfL 48 h post arrest for predicting the neurological outcome, and the AUC was 0.94 (78% sensitivity and 98% specificity). Four studies involving 804 participants reported serum NfL 72 h post arrest for predicting the neurological outcome, and the AUC was 0.96 (90% sensitivity and 98% specificity). No significant publication bias was observed among the included studies.

CONCLUSION

The present meta-analysis results support the potential use of serum NfL as an early biomarker of neurologic outcome, especially 72 h post arrest.

Evaluation of the effectiveness of potassium chloride in the management of out-of hospital cardiac arrest by refractory ventricular fibrillation: Study protocol of the POTACREH study

PURPOSE

Out-of-hospital cardiac arrest (OHCA) has a poor prognosis, with an overall survival rate of about 5% at discharge. Shockable rhythm cardiac arrests (ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT)) have a better prognosis. In case of shockable rhythm, treatment is based on defibrillation, and thereafter, in case of failure of 3 external electric shocks (EES), on direct intravenous administration of 300 mg amiodarone, or lidocaine when amiodarone is unavailable or inefficient. During surgical procedures under extracorporeal circulation, a high potassium cardioplegia solution is administered to interrupt cardiac activity and facilitate surgical procedure. By extension, direct intravenous administration of potassium chloride (KCl) has been shown to convert VF, resulting in return to a hemodynamically efficient organized heart rate within a few minutes. The aim of this study is to provide clinical evidence that direct intravenous injection of KCl, into a patient presenting with OHCA due to refractory VF although 3 EES, should interrupt this VF and then allow rapid restauration of an organized heart rhythm, and thus return of spontaneous circulation (ROSC).

METHODS

A multicenter, prospective, single group, phase 2 study will be conducted on 81 patients presenting with refractory VF. After failure of 3 EES, each patient will receive direct intravenous injection of 20 mmol KCl instead of amiodarone. The primary outcome will be survival rate at hospital admission. Major secondary outcomes will include ROSC and time to ROSC in the prehospital setting, number of VF recidivism after KCl injection, survival rate at hospital discharge with a good neurologic prognostic, and survival rate 3 months after hospital discharge with a good neurologic prognostic.

RESULTS

No patient is currently included in the study.

DISCUSSION

Conventional guideline strategy based on antiarrhythmic drug administration, i.e. amiodarone or lidocaine, for OHCA due to shockable rhythm, has not yet demonstrated an increase in survival at hospital admission or at hospital discharge. This may be related to the major cardiodepressant effect of those drugs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04316611. Registered on March 2020. AP-HP180577 / N° EUDRACT: 2019-002544-24. Funded by the French Health Ministry. https://clinicaltrials.gov/ct2/show/NCT04316611.

Association between the number of prehospital defibrillation attempts and a sustained return of spontaneous circulation: a retrospective, multicentre, registry-based study

BACKGROUND

Currently, there is no consensus on the number of defibrillation attempts that should be made before transfer to a hospital in patients with out-of-hospital cardiac arrest (OHCA). This study aimed to evaluate the association between the number of defibrillations and a sustained prehospital return of spontaneous circulation (ROSC).

METHODS

A retrospective analysis of a multicentre, prospectively collected, registry-based study in Republic of Korea was conducted for OHCA patients with prehospital defibrillation. The primary outcome was sustained prehospital ROSC, and the secondary outcome was a good neurological outcome at hospital discharge, defined as Cerebral Performance Category score 1 or 2. Cumulative incidence of sustained prehospital ROSC and good neurological outcome according to number of defibrillations were examined. Multivariable logistic regression analysis was used to examine whether the number of defibrillations was independently associated with the outcomes.

RESULTS

Excluding 172 patients with missing data, a total of 1983 OHCA patients who received prehospital defibrillation were included. The median time from arrest to first defibrillation was 10 (IQR 7-15) min. The numbers of patients with sustained prehospital ROSC and good neurological outcome were 738 (37%) and 549 (28%), respectively. Sustained ROSC rates decreased as the number of defibrillation attempts increased from the first to the sixth (16%, 9%, 5%, 3%, 2% and 1%, respectively). The cumulative sustained ROSC rate, and good neurological outcome rate from initial defibrillation to sixth defibrillation were 16%, 25%, 30%, 34%, 36%, 36% and 11%, 18%, 22%, 25%, 26%, 27%, respectively. With adjustment for clinical characteristics and time to defibrillation, a higher number of defibrillations was independently associated with a lower chance of a sustained ROSC (OR 0.81, 95% CI 0.76 to 0.86) and a lower chance of good neurological outcome (OR 0.86, 95% CI 0.80 to 0.92).

CONCLUSIONS

We observed no significant increase in ROSC after five defibrillations, and no absolute increase in ROSC after seven defibrillations. These data provide a starting point for determination of the optimal defibrillation strategy prior to consideration for prehospital extracorporeal cardiopulmonary resuscitation (ECPR) or conveyance to a hospital with an ECPR capability.

TRIAL REGISTRATION NUMBER

NCT03222999.