European Resuscitation Council Guidelines 2021: Adult advanced life support

The physiology and potential of spectral amplitude area (AMSA) as a guide for resuscitation

Many studies aimed at understanding the electrophysiological mechanisms of ventricular fibrillation (VF) and defibrillation. Although many theories have been proposed about VF, we are still far from fully understanding it. Research has revealed significant insights provided by VF waveform, particularly through its amplitude of spectral area (AMSA). In fact, by potentially representing the energetic status of myocardial cells, AMSA has been shown in both animal and human studies to be a predictor of defibrillation success, return of spontaneous circulation (ROSC), early and long-term survival, and the presence of coronary artery disease underlying the cardiac arrest. The routine use of AMSA in the field could significantly improve resuscitation efforts and lead to a more advanced resuscitation technique by aiding in the selection of the appropriate timing and energy for defibrillation. The aim of this review is to explore what AMSA is and how real-time AMSA use could improve resuscitation directly from the field. If proven to improve patient outcomes, AMSA could significantly transform resuscitation practices, enabling more precise defibrillation strategies and enhanced patient survival.

Intravenous vs intraosseous administration of drugs for out of hospital cardiac arrest: A systematic review and meta-analysis

INTRODUCTION

Out-of-hospital cardiac arrest (OHCA) is a leading cause of global mortality. Timely drug administration via vascular access is critical, with intravenous (IV) and intraosseous (IO) routes being the primary options. Current guidelines prefer IV access but recommend IO when IV access is delayed. This systematic review and meta-analysis of randomized controlled trials (RCTs) evaluated the clinical effectiveness of IO compared to IV access in adults with OHCA.

METHODS

A comprehensive search of PubMed, Scopus, and Cochrane databases through November 2024 identified RCTs comparing IO and IV drug administration in OHCA patients aged ≥18 years. Outcomes included 30-day survival, sustained return of spontaneous circulation (ROSC), survival to hospital discharge, and survival with favorable neurological outcomes. Pooled odds ratios (ORs) with 95 % confidence intervals (CIs) were calculated using a random-effects model.

RESULTS

Three RCTs comprising 9293 patients were included. No significant differences were found between IO and IV routes for 30-day survival (OR: 1.00, 95 % CI: 0.76-1.34, p = 0.98), sustained ROSC (OR: 1.08, 95 % CI: 0.97-1.21, p = 0.18), survival to hospital discharge (OR: 1.03, 95 % CI: 0.84-1.25, p = 0.80), or favorable neurological outcomes (OR: 0.93, 95 % CI: 0.77-1.13, p = 0.49).

CONCLUSION

IV and IO access routes demonstrated comparable outcomes for survival and neurological function in OHCA. These findings support the flexibility to prioritize the most practical route in emergency settings, particularly when IV access is delayed or challenging. Further research should explore patient-level outcomes and health economic implications.

Vasopressin and steroids in addition to adrenaline in cardiac arrest (VAST-A) - A randomised pilot study

BACKGROUND

The potential benefit of combining adrenaline, vasopressin, and corticosteroids in in-hospital cardiac arrest (IHCA) needs to be confirmed in a large clinical trial. This pilot study assesses feasibility and safety of randomising patients to this combination therapy compared to standard care.

MATERIAL AND METHODS

A randomised, double-blind, placebo-controlled pilot study was conducted from December 2022 to June 2024 across three Swedish hospitals (NCT05139849). Witnessed IHCAs meeting criteria for adrenaline were randomised 1:1 to adrenaline, vasopressin, and corticosteroids (intervention) or adrenaline and placebo (control). Primary outcomes included feasibility (e.g., protocol adherence, event times, enrolment rate), and safety. Secondary outcome was return of spontaneous circulation.

RESULTS

Of 183 screened IHCAs, 39 patients (median age 77, 64% male) were randomised (16 intervention, 23 control), with an enrolment rate of 0.8 patients/hospital bed/month. Most cardiac arrests occurred in general wards (n = 17/39, 44%). In the feasibility analysis, four patients at the scene of the arrest and three patients in the intensive care unit experienced protocol deviations. Median time (minutes) from cardiac arrest to rapid response team arrival was similar between groups. Median time to adrenaline administration was 7:00 (IQR 3:00-10:00) (intervention) vs 5:00 (IQR 2:30-8:30) (control) and to vasopressin/placebo 10:30 (IQR 9:30-12:15) vs 9:00 (IQR 5:00-11:00). Return of spontaneous circulation occurred in 38% (6/16) in the intervention group and 17% (4/23) in controls.

CONCLUSION

In this IHCA pilot study, randomisation to adrenaline, vasopressin, and corticosteroids compared to controls was safe, but feasibility needs improvement for adequate enrolment in the VAST-A main study.

Effect of different airway devices on ventilation during cardiopulmonary resuscitation

PURPOSE

This study compared face mask, supraglottic airway device (SGA), and endotracheal tube (ETT) ventilation with mechanical ventilation (MV) during cardiopulmonary resuscitation (CPR) in the flat position and with head and thorax elevation (HTE).

METHODS

Using thawed, fresh-frozen human cadavers this randomized cross-over study compared face mask, SGA, and ETT ventilation using an automated ventilator in the flat and HTE positions. Tidal volume (TV) was set to 8 mL/kg ideal predicted body weight, and expiratory TV (VTe) (mL/kg) was the primary endpoint. Secondary endpoints included inspiratory TV (VTi), maximal inspiratory airway pressure (Pmax), and leakage between inspiratory and expiratory tidal volumes (VTi-VTe).

RESULTS

Data from 8 cadavers and 2302 ventilation cycles were analyzed. In the flat position, VTe was 7.66 ± 3.75 with ETT, 5.01 ± 3.14 with SGA, and 5.63 ± 2.83 with face mask, respectively. A mixed linear model showed the airway device significantly impacted VTe, VTi, Pmax, and VTi-VTe (p < 0.001 for each). Compared with intubation, both face mask and SGA ventilation resulted in lower VTe, lower Pmax, and higher VTi-VTe (p < 0.001 for each). No significant differences were observed between face mask and SGA ventilation. There were higher VTe and lower VTi-VTe values (p < 0.001 for each) with HTE versus the flat position (p < 0.001).

CONCLUSIONS

In human cadavers undergoing CPR, mechanical ventilation through a face mask or SGA versus an ETT was associated with lower VTe, lower Pmax, and higher leakage values in human cadavers during CPR. Head and thorax elevation reduce face mask and SGA airway leakage during CPR and increase VTe.

Risk factors for failure of the first intubation attempt during cardiopulmonary resuscitation in out-of-hospital emergency settings: What about chest compression?

INTRODUCTION

Previous studies have described interactions between the success rate of tracheal intubation (TI) and chest compression during resuscitation from cardiac arrest. However, it is not clear if chest compression increases the complexity of TI. The aim of this study was to determine the risk factors for difficulty with tracheal intubation during resuscitation of patients with out-of-hospital cardiac arrest, focusing in particular on the impact of ongoing chest compressions on the success of the first intubation attempt.

METHODS

We performed a secondary analysis of data obtained during an observational, prospective multicenter study. After each TI, the operator provided information on both the operator and the patient, and the TI environment. We included only OHCA data. The primary endpoint was failure of the first intubation attempt.

RESULTS

Data on a total of 848 OHCA patients were analyzed. A total of 291 first TI attempts failed (34.3%). Multivariate analysis revealed that six variables were associated with an increased risk of failure: an operator who had performed ≤ 50 prior intubations (odds ratio [OR] [95% confidence interval] = 2.0 [1.4-2.9]), male patient gender (OR = 1.5 [1.0-2.3]), a small inter-incisor space (OR = 3.4 [2.2-5.4]), ear, nose, and throat disease (OR = 2.8 [1.8-4.4]), vomiting (OR = 2.1 [1.4-3.2]), and continued chest compression during the TI attempt (OR = 1.6 [1.1-2.3]).

CONCLUSION

The first intubation attempt failed in 34% of cases, and ongoing chest compressions during intubation was one of six variables associated with the risk of failure. However, this must be weighed against the need for invasive airway management and the negative effects of interrupting chest compressions.

Associations of Manual Defibrillator compared to Automated External Defibrillator Usage with Defibrillation and Resuscitation Quality during In-hospital Cardiac Arrest

BACKGROUND

Manual Defibrillators and Automated external defibrillators (AEDs) are frequently used during in-hospital cardiac arrest (IHCA), yet comparisons of their performance remain limited. This study aimed to compare the accuracy of rhythm analyses and chest compression pause durations of manual defibrillator and AED usage during IHCA.

METHODS

In this multicenter cohort study, we analysed thoracic impedance data and electrocardiograms from manual defibrillators and AEDs used during IHCA occurring in the Central Denmark Region between April 2019 and March 2024. The primary outcome was the difference in accuracy of rhythm analyses, while secondary outcomes included chest compression pause duration for rhythm analysis and defibrillation.

RESULTS

A total of 529 cardiac arrests were analysed, yielding 1715 rhythm analyses from manual defibrillators and 602 AED analyses. The difference in the accuracy of rhythm analyses between a manual defibrillator and an AED was statistically not significant with an adjusted odds ratio (aOR) of 0.5 (95%-CI: 0.2; 1.3). Manual defibrillator use was associated with 3.2 seconds (95%-CI: 1.7; 4.9) shorter pauses for rhythm analysis and 7.9 seconds (95%-CI: 5.9; 9.9) shorter peri-shock pauses.

CONCLUSION

Using manual defibrillators compared to AEDs was not associated with a higher accuracy of rhythm analyses, but with shorter chest compression pause durations for rhythm analysis and shorter peri-shock pauses.

Clinical state transitions in shock-refractory ventricular fibrillation: an observational study

AIM

To characterise clinical state transitions in patients with out-of-hospital cardiac arrest (OHCA) from refractory ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) and their association with clinical outcomes.

METHODS

We conducted an exploratory observational study of refractory VF/pVT OHCA cases treated by emergency medical services (EMS) between 2010 and 2019 in Victoria, Australia, was conducted. Refractory VF/pVT OHCA was defined as initial VF/pVT arrests with at least three consecutive defibrillation attempts. Adjusted logistic regression analyses were conducted to examine predictors of clinical state transitions and secondary VF/pVT.

RESULTS

3,018 cases met the inclusion criteria. Of these, 35.8% transitioned into ROSC, 36.6% transitioned into PEA, and 17.5% transitioned into asystole. secondary VF/pVT occurred in 41.7% of patients. The proportion of patients discharged alive was significantly higher in the ROSC group (60.0%) compared to the PEA (11.3%) and asystole groups (3.2%). Predictors of achieving ROSC included being witnessed by bystanders or EMS and bystander CPR. Predictors of secondary VF/pVT included male gender, increased resuscitation duration and administering adrenaline prior to the first clinical state transition. Transitioning into ROSC was associated with reduced odds of secondary VF/pVT, while transitioning into PEA increased the odds of secondary VF/pVT.

CONCLUSION

Understanding clinical state transitions during the resuscitation of refractory VF/pVT patients may allow for the development of tailored treatment strategies.

Out-of-hospital cardiac arrest: A 10-year analysis of survival and neurological outcomes

Background Out-of-hospital cardiac arrest (OHCA) is a major public health issue with low survival rates. Objective Identification of predictors for survival and good neurological outcomes following OHCA. Methods This retrospective study included all OHCA patients between January 2014 and December 2023. Data was collected from the local resuscitation registry and hospital electronic medical records. Neurological outcomes were measured using the Cerebral Performance Category (CPC) scale. Results At hospital admission return of spontaneous circulation (ROSC) was achieved in 36 % of cases (411/1128), with overall survival rates of 29 % (328/1128) at 24 h and 16 % (178/1128) at 30 days, respectively. Good neurological outcomes (CPC 1 and 2) were observed in 13 % (144/1128) of patients. The main suspected cause of cardiac arrest was cardiac origin (54 %, 608/1128), followed by hypoxia (11 %, 127/1128). Survivors were significantly younger (60 vs 71 years, p < 0.001), were less disabled (p < 0.001), had a higher incidence of witnessed cardiac arrest (80 % vs 69 %, p = 0.018), received more often bystander cardiopulmonary resuscitation (CPR, 62 % vs 47 %, p = 0.003) or Dispatcher Assisted-CPR (44 % vs 32 %, p = 0.004). Moreover, patients who survived at least 30 days had a higher incidence of shockable initial rhythm (57 % vs 24 %, p < 0.001). Conclusions Patients who survived at least 30 days were younger and male, had less disability, a shockable initial rhythm, and a cardiac arrest in public.

Real-time hemodynamic responses to epinephrine and their association with ROSC in out-of-hospital cardiac arrest

AIM

This study investigated the association between changes in diastolic blood pressure (DBP), mean arterial pressure (MAP), systolic blood pressure (SBP) following epinephrine administration and return of spontaneous circulation (ROSC) in patients with Out-of-hospital cardiac arrest (OHCA).

METHODS

This retrospective observational study included patients with OHCA treated at a tertiary hospital. Invasive arterial blood pressure monitoring data were recorded during resuscitation in the emergency department. The primary outcome was sustained ROSC, defined as ROSC maintained for at least 20 min. Blood pressure changes were analysed at 15 s intervals. Delta blood pressure was defined as the difference between each blood pressure at 15-0 s before and 165-180 s after epinephrine administration. The association between delta DBP, delta MAP, delta SBP, and sustained ROSC was analysed.

RESULTS

Among 160 patients included in the analysis, patients who achieved sustained ROSC exhibited significantly greater changes in DBP and MAP than those who did not. Median differences in delta DBP and delta MAP between ROSC and no-ROSC groups were 13.7 mmHg (95% confidence interval (CI): 11.3-13.8, p = 0.001) and 14.9 mmHg (95% CI: 12.6-15.7, p = 0.001), respectively. A restricted cubic spline curve showed positive associations of delta DBP and delta MAP with sustained ROSC probability. Multivariable analysis showed adjusted odds ratios of 1.02 (95% CI: 1.00-1.04, p = 0.040) for delta DBP and 1.01 (95% CI: 1.00-1.03, p = 0.010) for delta MAP.

CONCLUSION

Greater delta DBP and delta MAP following epinephrine administration during cardiopulmonary resuscitation were associated with higher likelihood of achieving sustained ROSC in patients with OHCA.

Fluid balance and outcome in cardiac arrest patients admitted to intensive care unit

BACKGROUND

Although shock following cardiac arrest is common and contributes significantly to mortality, the influence of the modalities used to manage the hemodynamic situation, particularly with regard to fluid balance, remains unclear. We evaluated the association between positive fluid balance and outcome after out-of-hospital cardiac arrest (OHCA).

METHODS

We conducted a multicenter study from August 2020 to June 2022, which consecutively enrolled adult OHCA patients in 17 intensive care units. The primary endpoint was 90-day survival. Multivariate Cox analysis, propensity score matching and landmark analysis were performed, along with several sensitivity analyses.

RESULTS

Of the 816 patients included in our study, 74% had a positive fluid balance, and 291 of 816 patients (36%) were alive at 90-day. A positive fluid balance was associated with mortality after adjusted multivariate analysis (HR = 1.8 [1.3 - 2.3], p < 0.001), after propensity score matching (n = 193 matched patient pairs, HR = 1.6 [1.1 - 2.1], p = 0.005) and after landmark analysis. We reported a dose-dependent association between fluid balance and mortality. Patients with a positive fluid balance were more likely to need renal replacement therapy (10% vs. 2%, p = 0.001) and had a lower minimum PaO2/FiO2 ratio in the first seven days (158 vs. 180, p < 0.001).

CONCLUSIONS

After cardiac arrest, a positive fluid balance is consistently associated with a worse outcome. Pending further data, a restrictive fluid therapy strategy may be beneficial in post-OHCA patients.

TRIAL REGISTRATION

ClinicalTrial.gov cohort AfterROSC-1 NCT04167891 registered November 13th, 2019, ethics committees 2019-A01378-49 and CPP-SMIV 190901.

Emergency Ultrasound in the Context of Cardiac Arrest and Circulatory Shock: "How to Avoid Cardiac Arrest"

In the recently published 2021 European Resuscitation Council Guidelines on Adult Advanced Life Support, focused echocardiography was upgraded to a target recommendation. Several key recommendations were made, including that point-of-care ultrasound (POCUS) should only be used during CPR performed by experienced users and prolonged interruptions longer than 10 s (as accepted for pulse checking) during chest compressions should be avoided. Ultrasound does not replace clinical evaluation nor awareness of the clinical scenario. However, in addition to other assessments such as laboratory analyses, ultrasound can help to directly identify a cause for the peri-arrest state. The advantage of ultrasound is that examinations can be performed at the bedside while other tests are being carried out and repeated as frequently as required. This article focusses on how to use ultrasound during peri-arrest situations, requirements for ultrasound equipment, reversible causes of cardiac arrest, and the use of the RUSH protocol, focused echocardiography, and "deresuscitation" (post resuscitation/return of spontaneous circulation).

Sudden cardiac death, arrhythmogenic cardiomyopathy and intercalated disc pathology due to reduced filamin C protein levels: a matter of life and death

Mutations in the human FLNC gene encoding filamin C (FLNc) cause a broad spectrum of sporadic and familial cardiomyopathies and myopathies. We report on the genetic, clinical, morphological and biochemical findings in a German family harboring an FLNC variant that leads to severe cardiac disease comprising sudden cardiac death and arrhythmogenic cardiomyopathy. Genetic analysis identified a novel heterozygous FLNC variant in exon 16 (NM_001458.4:c.2495_2498delAGTA, het; p.K832TfsX45) in i) the index patient suffering from dilated cardiomyopathy necessitating heart transplantation, ii) a son, who died from sudden cardiac death, iii) a second son, who survived an episode of sudden cardiac arrest and iv) a third son affected by isolated skeletal muscle myopathy. FLNc protein levels were markedly reduced in cardiac tissue obtained from the index patient, implying that the p.K832TfsX45 FLNc variant most probably caused nonsense-mediated decay of the corresponding mRNA. Morphological analysis of the diseased cardiac tissue revealed extensive fibrotic remodeling, and marked degenerative changes of the contractile apparatus of cardiomyocytes and severe structural alterations of intercalated discs. Connexin-43 signal intensity at intercalated discs was diminished and FLNc labelling of myofibrils was attenuated or even absent. Proteome analyses demonstrated complex alterations of extracellular matrix and intercalated disc proteins. Our findings demonstrate that this novel, truncating FLNC mutation likely leads to haploinsufficiency, thereby causing a deleterious sequence of degenerative changes of cardiac tissue with extensive fibrotic remodeling and intercalated disc pathology as the structural basis for FLNC-related cardiomyopathy with life-threatening cardiac arrhythmias.

Cold aortic flush after ventricular fibrillation cardiac arrest reduces inflammatory reaction but not neuronal loss in the pig cerebral cortex

This study aims to retrospectively compare two resuscitation methods (extracorporeal cardiopulmonary resuscitation (ECPR) vs. emergency preservation and resuscitation (EPR)) by pathohistologically assessing pig brains in a ventricular fibrillation cardiac arrest (VFCA) model. In prospective studies from 2004 to 2006, swine underwent VFCA for 13 (n = 6), 15 (n = 14) or 17 (n = 6) minutes with ECPR (ECPR13, ECPR15 and ECPR17). Another 15 min VFCA group (n = 8) was resuscitated with EPR and chest compressions (EPR15 + CC). Brains of animals surviving for nine days (ECPR13 n = 4, ECPR15 n = 2, ECPR17 n = 1, EPR15 + CC n = 7) were harvested. Eight different brain regions were analyzed with the image analysis software QuPath using HE-staining, GFAP- and Iba1-immunohistochemistry. Only ECPR13 and EPR15 + CC animals were included in statistical analysis, due to low survival rates in the other groups. All VFCA samples showed significantly fewer viable neurons compared to shams, but no significant differences between ECPR13 and EPR15 + CC animals were observed. ECPR13 animals showed significantly more glial activation in all cerebral cortex regions compared to shams and in occipital, temporal and parietal cortex compared to EPR15 + CC. In conclusion, EPR + CC resulted in a significantly reduced inflammatory reaction in cerebral cortex compared to ECPR but did not influence the extent of neuronal death after VFCA.

Association between post-arrest 12-lead electrocardiographic features and neurologically intact survival for patients of in-hospital cardiac arrest

Twelve-lead electrocardiogram (ECG) may provide prognostic information for in-hospital cardiac arrest (IHCA). This study aimed to identify post-arrest ECG features and their temporal changes associated with IHCA outcomes. This single-center retrospective study included patients experiencing IHCA between 2005 and 2022. Post-arrest ECGs were obtained within 48 h after an IHCA, admission ECGs upon hospital admission, and pre-arrest ECGs within 72 h before an IHCA. Multivariable logistic regression analyses were conducted to identify ECG features associated with neurologically intact survival. A total of 708 patients were included, with 131 (18.5%) achieving neurologically intact survival. The median age was 70.4 years (interquartile range: 59.2-82.6), and 362 (62.7%) patients were male. Four post-arrest ECG features were associated with survival: sinus rhythm (odds ratio [OR]: 1.81, 95% confidence interval [CI]: 1.11-2.93), QRS duration between 80 and 120 ms (OR: 1.91, 95% CI 1.19-3.08), low QRS voltage (OR: 0.50, 95% CI 0.25-0.99), and prolonged QTc (OR: 1.89, 95% CI 1.08-3.28). Comparing with admission ECGs, new-onset right bundle branch block (OR: 0.39, 95% CI 0.16-0.95) and increases in the number of leads with ST depression (OR: 0.85, 95% CI 0.77-0.94) on post-arrest ECGs were inversely associated with survival. Compared with pre-arrest ECGs, increases in the number of leads with ST depression (OR: 0.91, 95% CI 0.88-0.96) on post-arrest ECGs were also inversely associated with survival. Post-arrest ECGs may serve as a valuable prognostic tool for IHCA. Further exploration is warranted to determine whether incorporating these ECG features can enhance the performance of prediction models for IHCA outcomes.

Escalating vs Fixed Energy Defibrillation in Out-of-Hospital Cardiac Arrest Ventricular Fibrillation

Importance

There is limited evidence on whether higher-energy defibrillation is preferred in patients experiencing out-of-hospital cardiac arrest (OHCA) with shockable rhythms.

Objective

To investigate the optimal energy regimen for initial and subsequent defibrillation delivered by biphasic waveform automated external defibrillators (AEDs) in OHCA ventricular fibrillation (VF).

Design, Setting, and Participants

This cohort study was conducted in 48 cities across China, from 2017 to 2023, among 342 patients with OHCA who experienced at least 1 shock.

Exposures

Escalating higher-energy (200-300-360 J) defibrillation or fixed low-energy (200-200-200 J) defibrillation according to the AED program available for use.

Main Outcome and Measures

Sustained and transient termination of VF and establishment of an organized rhythm after defibrillations were the main clinical outcomes.

Results

A total of 342 patients with OHCA were included (mean [SD] age, 57.2 [20.6] years; 273 male [79.8%]) with 782 VF defibrillations; 218 patients (63.8%) with a total of 480 instances (61.4%) of VF rhythm received AED with escalating higher-energy regimens. Most VF episodes were effectively terminated transiently at the first shock (200 J in both groups) (94% in the escalating higher-energy group vs 93% in the fixed lower-energy group; P = .64), but only half remained terminated until the next rhythm analysis (49% vs 47%; P = .68). Comparatively, VF that received escalating higher-energy regimens were more likely to establish sustained organized rhythm (34% vs 25%; P = .008; absolute difference, 9% [95% CI, 2% to 16%]). In refractory VF rhythms, the percentage of cases where sustained organized rhythms were established was significantly greater in escalating higher-energy regimens after second shocks and above (24% vs 13%; P = .008; absolute difference, 11% [95% CI, 3% to 19%]) and third shocks and above (35% vs 18%; P = .003; absolute difference 17% [95% CI, 5% to 27%]).

Conclusions and Relevance

In this retrospective cohort study of patients experiencing OHCA-VF, both the escalating higher-energy (200-300-360 J) regimen and the fixed low-energy (200-200-200 J) regimen were effective for transient VF termination at first shock, whereas the escalating higher-energy regimens were more likely to maintain termination and restore an organized rhythm. Higher-energy regimens were associated with better outcomes after all shocks, especially in patients with refractory VF.

Use of transoesophageal echocardiography in the pre-hospital setting to determine compression position in out of hospital cardiac arrest

BACKGROUND

A proportion of patients due to anatomical variation do not receive chest compressions over the left ventricle. Transoesophageal echocardiography (TOE) has the potential to impact survival rates by identifying the area of maximal compression (AMC), potentially improving forward flow and systemic perfusion in cardiac arrest. There is a paucity of data regarding the use of TOE during out of hospital cardiac arrest (OHCA) in the pre-hospital setting, with most data coming from studies performed in hospital. We therefore set out to retrospectively review patients who had received TOE as part of their resuscitation care by a pre-hospital medical team.

METHODS

A retrospective cohort study of OHCA patients treated by a specialist pre- hospital medical team who had received TOE as part of cardiac arrest management. Patients were identified over a 6-month period and their medical records reviewed. The primary outcome was to identify the proportion of patients in whom the AMC was not over the LV. The secondary outcomes were to describe the proportion of patients where information provided by the TOE clinically influenced patient management; to describe the temporal relationship between change in compression position and change in clinical findings including timing of ROSC or change in rhythm and to describe any associations between the AMC and physiological signs.

RESULTS

Nineteen patients were identified who had received TOE as part of cardiac arrest management over a 6 month period. Intra-arrest TOE identified 17 (89%) patients in whom compressions were not being performed over the left ventricle. Improved echocardiography evidence of left ventricular compression occurred in 13/17 (76%) patients, resulting in return of spontaneous circulation in 6 patients and change in rhythm in 10 patients. TOE was able to change management or confirm diagnosis in 17/19 (89%) patients.

CONCLUSIONS

We present a retrospective cohort study of 19 patients who received pre- hospital intra-arrest TOE. Pre-hospital intra-arrest TOE is feasible and contributed significantly to optimising compression position to increase forward flow without interrupting chest compressions. Future studies are needed to correlate clinical findings with compression position as identified on TOE.

Termination of Resuscitation Rules for In-Hospital Cardiac Arrest

Importance

There are no validated decision rules for terminating resuscitation during in-hospital cardiac arrest. Decision rules may guide termination and prevent inappropriate early termination of resuscitation.

Objective

To develop and validate termination of resuscitation rules for in-hospital cardiac arrest.

Design, Setting, and Participants

In this prognostic study, potential decision rules were developed using a national in-hospital cardiac arrest registry from Denmark (data from 2017 to 2022) and validated using registries from Sweden (data from 2007 to 2021) and Norway (data from 2021 to 2022). Six variables (age, initial rhythm, witnessed status, monitored status, intensive care unit location, and resuscitation duration) were considered based on their bedside availability. Prognostic metrics were computed for all possible variable combinations. CIs were obtained using bootstrapping. Rules with a false-positive rate below 1% (predicting death in patients who might otherwise survive) and a positive rate of more than 10% (proportion of all cases for whom termination is proposed) were considered appropriate.

Main Outcomes and Measures

The primary outcome was 30-day mortality.

Results

The cohorts included 9863 Danish, 12 781 Swedish, and 1308 Norwegian patients. The overall median (IQR) age was 74 (66-81) years, 63% were male, and the median (IQR) resuscitation duration was 13 (5-23) minutes. Of 53 864 possible termination rules, 5 were identified as relevant for clinical use. The best performing rule included 4 variables (unwitnessed, unmonitored, initial rhythm of asystole, and resuscitation duration more than or equal to 10 minutes). The rule proposed termination in 110 per 1000 cardiac arrests (positive rate, 11%; 95% CI, 10%-11%) and predicted 30-day mortality incorrectly in 6 per 1000 cases (false-positive rate, 0.6%; 95% CI, 0.3%-0.9%). All 5 rules performed similarly across all 3 cohorts.

Conclusions and Relevance

In this prognostic study, 5 termination of resuscitation rules were developed and validated for in-hospital cardiac arrest. The best performing rule had a low false-positive rate and a reasonable positive rate in all national cohorts. These termination of resuscitation rules may aid decision-making during resuscitation.

Amiodarone dose in patients with shockable out-of-hospital cardiac arrest

BACKGROUND

Amiodarone is used in shockable out-of-hospital cardiac arrest (OHCA), but the ideal dose is unknown.

METHODS

This was an analysis from the Resuscitation Outcomes Consortium Cardiac Epidemiologic Registry (2011-2015). Patients with shockable OHCA who received 5 or more defibrillation attempts and treatment with 300 or 450 mg of amiodarone were included. Outcomes were ROSC at ED arrival, survival at hospital discharge, and favorable neurologic function at discharge. Group-differences were adjusted for using inverse probability weighting and a multiple logistic regression model.

RESULTS

The present study included 910 patients; 426 received amiodarone 300 mg and 484 received amiodarone 450 mg. The amiodarone 300 mg group had a higher estimated probability of ROSC at ED arrival as compared with the amiodarone 450 mg group (30.8% [95% CI, 26.6-35.1] vs 24.2% [95% CI, 20.5-27.9], respectively; adjusted probability difference, 6.6% (0.9-12.3), p = 0.0234). The group differences in survival at hospital discharge (21.3% [95% CI, 17.2-25.4] vs 18.0% [95% CI, 14.6-21.5]; adjusted probability difference, 3.3% [-2.3-8.8]) and favorable neurologic outcome at discharge (16.5% [95% CI, 12.9-20.2] vs 12.7% [95% CI, 9.5-16.0]; adjusted probability difference, 3.8% [95% CI, -1.2-8.7]) did not reach statistical significance.

CONCLUSION

In patients with shockable OHCA who received 5 or more defibrillation attempts, a dose of amiodarone 300 mg was associated with a similar survival compared with a total dose of amiodarone 450 mg. Further study is needed to evaluate the need for a second administration of amiodarone in patients with shockable OHCA.

Using Functional Resonance Analysis Method (FRAM) Modelling to Assess the Factors That Slow or Prevent Clinicians in Performing Advanced Life Support (ALS) During Crash Calls to Park House Mental Health Hospital

This Quality Improvement Project (QIP) aimed to improve the response system for crash calls at Park House Mental Health Hospital, supported by the North Manchester General Hospital Crash Team. Using a functional resonance analysis method (FRAM), the team identified inefficiencies in the Advanced Life Support (ALS) process, with delayed responses increasing patient mortality risks. Interviews with staff helped create "work-as-imagined" (WAI) and "work-as-done" (WAD) models, highlighting the underperformed functions like ward entry protocols, and fully stocked crash trolleys. Recommendations, including access cards, stock changes, and live simulations, were implemented, in an aim to improve ALS provision.

Getting ON-TRAC, a team-centred design study of a reflexivity aid to support resuscitation teams' information sharing

BACKGROUND

Effective information sharing is crucial for emergency care teams to maintain an accurate shared mental model. This study describes the design, simulation-based testing and implementation of a team reflexivity aid to facilitate in-action information sharing during resuscitations.

METHODS

A five-phase team-centred iterative design process was employed. Phase 1 involved a literature review to identify in-action cognitive aids. Phase 2 focused on conceptual design, followed by simulation-based testing and modifications in phase 3. Implementation through simulation-based user training occurred in phase 4 at a large non-university teaching hospital. Phase 5 evaluated the aid among resuscitation team members in the emergency department after one year.

RESULTS

The phase 1 literature review identified 58 cognitive aids, with only 10 designed as 'team aid'. Studies using team information screens found increase team and task performance in simulation-based environments, with no evaluations in authentic workplaces. Phase 2 resulted in a three-section team reflexivity aid, iteratively modified in three rounds of simulation-based testing (N = 30 groups) phase 3 resulted in a team reflexivity aid containing five sections: resuscitation times and intervals, patient history, interventions on a longitudinal timeline, differential diagnosis and a quick review section. Phase 4 consisted of reflexivity aid user training with simulation-based education (N = 60 sessions) and the creation of a digital entry form to store data in the patient's electronic medical record. Evaluation after one year in phase 5, (N = 84) showed perceived improvements in communication (3.82 ± 0.77), documentation (4.25 ± 0.66), cognitive load (3.94 ± 0.68), and team performance (3.80 ± 0.76) on a 5-point Likert scale. Thematic analysis of user feedback identified improvements in both teamwork and taskwork. Teamwork enhancements included better situation awareness, communication and team participation. Taskwork improvements were seen in drug administration and clinical reasoning.

CONCLUSIONS

This study demonstrated the successful development and implementation of a Team Reflexivity Aid for Cardiac arrests using simulation methodology. This task-focused team tool improved perceived team situation awareness, communication, and overall performance. The research highlights the interplay between task- and teamwork in healthcare settings, underscoring the potential for taskwork-oriented tools to benefit team dynamics. These findings warrant further investigation into team-supportive interventions and their impact on resuscitation outcomes.

Prehospital antiplatelet therapy in patients with out-of-hospital cardiac arrest suspected of acute coronary syndrome

BACKGROUND

There are currently no specific guidelines for prehospital antiplatelet therapy in patients with out-of-hospital cardiac arrest (OHCA) associated with acute coronary syndrome (ACS). This study aims to evaluate the efficacy and safety of a prehospital antiplatelet loading dose in patients with OHCA suspected of ACS referred to a cardiac catheterization laboratory (cath lab).

METHODS

We included consecutive patients referred for coronary angiography within 24 h after OHCA from 2012 to 2024. Prehospital antiplatelet treatment was defined as prescribing aspirin alone and/or a P2Y12 inhibitor before admission to the cath lab. Outcomes included: all-cause death at 30 days, in-hospital major adverse cardiovascular events (MACE), defined as a composite of all-cause death, myocardial infarction, stent thrombosis, or stroke, and in-hospital major bleeding (BARC ≥ 3). An inverse probability weighting approach was used to compare outcomes between the two groups.

RESULTS

Of the 411 patients admitted to the cath lab within 24 h after OHCA, 217 (52.8%) received prehospital antiplatelet therapy, either aspirin alone (44.5%) or aspirin plus a P2Y12 inhibitor (8.3%). There was no difference in 30-day all-cause death between patients who received a prehospital treatment and those who did not (56.7%[50.0%;63.1%] vs 59.8%[52.8%;66.4%], p = 0.280). Rates of in-hospital MACE and major bleeding were not significantly different between the two strategies. Results appear to be consistent in subgroups of patients with ST-segment elevation or successfully resuscitated patients.

CONCLUSIONS

Prehospital antiplatelet therapy was safe, but showed no apparent improvement in survival or cardiovascular outcomes in patients with OHCA suspected of ACS.

Intraosseous versus intravenous vascular access in out-of-hospital cardiac arrest: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Rapid and reliable vascular access is crucial during cardiopulmonary resuscitation for out-of-hospital cardiac arrest (OHCA). While intraosseous (IO) and intravenous (IV) access are used, their comparative effectiveness for patient outcomes remains uncertain.

METHODS

We searched PubMed, Embase, and ClinicalTrials.gov for RCTs comparing IO vs. IV access in adults with OHCA. The primary outcome was survival (30 days or until discharge), while secondary outcomes included sustained ROSC, favorable neurological outcome, successful first-attempt vascular access, and time from emergency medical service arrival to access. Pooled odds ratios (OR), mean differences (MD), and 95% confidence intervals (CI) were calculated.

RESULTS

Four RCTs with 9475 patients were included. No significant differences were found between IO and IV groups in survival (6.6% vs. 6.9%, OR 0.99, 95% CI 0.84-1.18) or favorable neurological outcome (4.7% vs. 4.6%, OR 1.07, 95% CI 0.88-1.30). The sustained ROSC rate was numerically, but not significantly, lower in IO vs. IV access (24.6% vs. 27.0%, OR 0.92, 95% CI 0.80-1.06). IO access had a higher first-attempt success rate (92.3% vs. 62.3%; OR 6.18, 95% CI 3.50-10.91) and was 15 s faster than IV for vascular access (IO: 11.03 ± 5.57, IV: 11.35 ± 6.16 min, MD - 0.25, 95% CI - 0.48 to - 0.01).

CONCLUSIONS

IO access had a higher first-attempt success rate and faster establishment than IV access, but no significant differences were found in survival or favorable neurological outcomes in adults with OHCA. Sustained ROSC was numerically lower with IO access than IV access, although the difference was not statistically significant.

Emergency medicine updates: Cardiac arrest medications

INTRODUCTION

Cardiac arrest is a serious condition frequently managed in the emergency department (ED). Medications are a component of cardiac arrest management.

OBJECTIVE

This paper evaluates key evidence-based updates concerning medications used for patients in cardiac arrest.

DISCUSSION

Several medications have been evaluated for use in cardiac arrest. Routes of administration may include intravenous (IV) and intraosseous (IO). IV administration is recommended, though if an attempt at IV access is unsuccessful, IO access can be utilized. Epinephrine is a core component of guidelines, which recommend 1 mg in those with shockable rhythms if initial CPR and defibrillation are unsuccessful, while in nonshockable rhythms, guidelines recommend that epinephrine 1 mg be administered as soon as feasible. While epinephrine may improve rates of ROSC, it is not associated with improved survival with a favorable neurologic outcome. Evidence suggests the combination of vasopressin, steroids, and epinephrine may improve ROSC among those with in-hospital cardiac arrest, but there is no improvement in survival to discharge and survival with a favorable neurologic outcome. Antiarrhythmics (e.g., amiodarone, lidocaine, procainamide) likely do not improve short-term or long-term survival or neurologic outcomes, though guidelines state that amiodarone may be used in those with cardiac arrest and refractory pulseless ventricular tachycardia (pVT)/ventricular fibrillation (VF). Calcium and sodium bicarbonate should not be routinely administered in those with cardiac arrest. Beta-blockers may be considered in those with shock-resistant pVT/VF.

CONCLUSIONS

An understanding of literature updates concerning medication use in cardiac can improve the ED care of these patients.

Influence of pulseless electrical activity and asystole on the prognosis of patients with traumatic cardiac arrest: A retrospective cohort study

BACKGROUND

Traumatic cardiac arrest (TCA) is associated with poor prognosis. Recent advancements in resuscitation techniques have improved outcomes; however, the prognostic value of the initial cardiac rhythm in TCA remains unclear. Pulseless electrical activity (PEA) is often a sign of life, leading to ongoing resuscitation efforts; however, its effect on survival remains controversial. This study aimed to clarify the prognostic impact of PEA and asystole in patients with TCA to inform decision-making.

METHODS

This retrospective cohort study was conducted in a tertiary trauma center in Tainan, Taiwan, between 2016 and 2022 and enrolled patients with TCA transported by emergency medical services. Exclusion criteria included patients aged < 18 years with prehospital return of spontaneous circulation (ROSC) or specific trauma etiologies. Only non-shockable rhythms (PEA and asystole) were analyzed. Data on patient characteristics, trauma mechanisms, and resuscitation interventions were collected from electronic medical records. The primary outcome was ROSC at any time after reaching hospital, with secondary outcomes including sustained ROSC (ROSC for over 20 min), survival to admission, survival to discharge, and the cerebral performance category scale. Statistical analyzes were performed using the chi-square test and multivariate logistic regression. Statistical significance was defined as p < 0.05.

RESULTS

Of the 2,029 out-of-hospital cardiac arrest cases, 182 were TCA, and 46 were excluded based on various criteria. The final analysis included 136 patients divided into the PEA (n = 78, 57 %) and asystole (n = 58, 43 %) groups. No significant differences were observed in patient demographics, clinical characteristics, or resuscitative interventions between the groups. The PEA group had a significantly higher rate of ROSC (49 % vs. 26 %, p = 0.007), although survival to discharge remained low. Multivariable analysis revealed that PEA was the only factor significantly associated with ROSC (odds ratio: 2.87, p = 0.007).

CONCLUSION

In patients with TCA presenting with non-shockable rhythms, PEA was significantly associated with achieving ROSC, but not sustained ROSC or survival to admission. As a subset of patients in the PEA group survived until discharge, the existing guidelines for termination of resuscitation in TCA cases may require further evaluation.

Chest compression synchronized ventilation during prolonged experimental cardiopulmonary resuscitation improves oxygenation but may cause pneumothoraces

Background

Chest compression synchronized ventilation (CCSV) has been proposed to provide superior ventilation and haemodynamics during cardiac arrest (CA) compared to conventional asynchronous ventilation and compressions. We compared arterial gas exchange, pH, lactate levels and haemodynamics between CCSV and manual asynchronous ventilation during prolonged experimental CA.

Methods

We randomized 30 pigs (weight ca. 55 kg) to receive CCSV with a MEDUMAT Standard2 ventilator or a manual bag valve targeting 10-12 ventilations per minute. Chest compressions were provided with a Lucas® 2 device. Arterial samples were drawn every 5 min and monitoring was recorded continuously. The animals underwent chest CT scans after death.

Results

The median intra-arrest arterial blood gas results for CCSV were PaO2 = 490 (86-570) mmHg, PaCO2 = 20 (10-35) mmHg and pH = 7.39 (7.19-7.53). In the manual ventilation group, the results were PaO2 = 304 (109-379), PaCO2 = 36 (28-47) and pH = 7.24 (7.12-7.34). The oxygen levels were significantly higher in the CCSV group compared to a linear mixed model (p = 0.046). The differences in CO2 and pH levels were not statistically significant. The minute volumes and positive end-expiratory pressures were higher in the CCSV (18.0 [15.3-19.8] l/min; 32.6 [29.2-35.6] cmH2O) group compared to the control group (5.7 [4.9-7.0] l/min; 2.8 [1.8-4.1] cmH2O). The CCSV group had 12 pneumothoraces compared to 3 in the control group (p = 0.008).

Conclusions

The CCSV protocol resulted in higher arterial oxygenation but more pneumothoraces.The study was approved by the Finnish National Animal Experiment Board (ESAVI-26974-2023).

The association between initial defibrillation dose and outcomes following adult out-of-hospital cardiac arrest resuscitation: A retrospective, multi-agency study

INTRODUCTION

Effective defibrillation is essential to out-of-hospital cardiac arrest (OHCA) survival. International guidelines recommend initial defibrillation energies between 120 and 360 Joules, which has led to widespread practice variation. Leveraging this natural experiment, we aimed to explore the association between initial defibrillation dose and outcome following OHCA.

METHODS

The ESO Data Collaborative (2018-2022) was used for this nationwide, retrospective study of adult (18-80 years of age) non-traumatic OHCA patients who presented with an initially shockable ECG rhythm. We excluded patients if they had ROSC prior to initial defibrillation, a resuscitation-limiting advanced directive, or were residents in a healthcare institution. The primary exposure was initial defibrillation dose, defined as Joules per kilogram of body weight, and the primary outcome was return of spontaneous circulation (ROSC). We included survival to discharge as a secondary outcome. We used multivariable logistic regression modeling to assess the relationship between defibrillation dose and outcome.

RESULTS

We analyzed data from 21,121 patients. Of the 12,160 patients linked to a defibrillator manufacturer, 7,240 (59.5%) were treated using a biphasic truncated exponential (BTE) waveform and 4,920 (40.5%) were treated using a rectilinear biphasic (RLB) waveform. Defibrillation dose (per 1 J/kg increase) was not associated with ROSC (BTE aOR: 0.97 [0.92, 1.01], n = 7,240; RLB aOR: 1.00 [0.92, 1.09], n = 4,920; all aOR: 1.01 [0.98, 1.04], 21,121) or survival (BTE aOR: 0.98 [0.87, 1.10], n = 1,245; RLB aOR: 0.89 [0.70, 1.12], n = 775; all aOR: 1.00 [0.92, 1.08], n = 2,981).

CONCLUSIONS

Initial defibrillation dose was not associated with outcome in this nationwide cohort.

Pre-arrest atrial fibrillation and neurological recovery after cardiac arrest among hospitalized patients: A retrospective cohort study

BACKGROUND

New-onset atrial fibrillation (AF) is associated with an increased risk of stroke in hospitalized patients with severe sepsis. Post-cardiac arrest patients experience conditions similar to sepsis. This study investigated whether pre-arrest AF is associated with poor neurological recovery following in-hospital cardiac arrest (IHCA).

METHODS

This single-centre retrospective study included patients experiencing IHCA between 2005 and 2020. Pre-arrest electrocardiograms (ECGs) were reviewed, including twelve-lead ECGs and ECG strips. New-onset AF was defined as AF absent on electronic health records (EHRs, including admission diagnosis, past medical history and hospitalization notes) but present on pre-arrest ECG. Without considering EHRs, AF-presence was defined as AF present on pre-arrest ECG.

RESULTS

A total of 2466 patients were included, including 93 (3.8%) with new-onset AF and 131 (5.3%) with evidence of AF on pre-arrest ECG. The median age was 67.6 (interquartile range [IQR]: 22.3) years and the median CHA₂DS₂-VASc score was 3.0 (IQR: 3.0). A total of 405 (16.4%) patients survived to hospital discharge, with 228 (9.2%) patients achieving favourable neurological recovery. Multivariable logistic regression analysis indicated that both new-onset AF (odds ratio [OR]: .34, 95% confidence interval [CI]: .12-.94, p-value: .04) and AF-presence (OR: .35, 95% CI: .15-.85, p-value: .02) were inversely associated with favourable neurological recovery in the primary and sensitivity analyses, respectively.

CONCLUSIONS

Pre-arrest AF is a significant risk factor for poor neurological recovery following IHCA. Further research is needed to understand the underlying mechanisms, which could inform the development of strategies to improve outcomes in this patient subgroup.

Defibrillation pad placement accuracy among Advanced Life Support instructors: A manikin-based observational study examining experience, self-evaluation, and actual performance

Background

Ventricular fibrillation is common in patients with out-of-hospital cardiac arrest. Early and effective defibrillation is important for their survival. Effective defibrillation depends highly on correct positioning of the defibrillation pads. Teaching this correctly by ALS instructors is therefore crucial.

Methods

Fifty certified advanced life support instructors were recruited from a large training institute. Participants were asked to place defibrillation pads on an anatomically and real-weight (90 kg) manikin. Primary outcome was the placement of defibrillation pads placed in the sternal-apical and anterior-posterior positions. Secondary outcomes were performance self-assessment, defibrillation experience, self-perceived competence and self-efficacy in teaching defibrillation. These measures were evaluated using an 11-point Likert scale.

Results

A total of 31 medical doctors and 19 registered nurses were enrolled in this study. Defibrillation pads were placed (mean ± SD) 42 ± 21 mm, 38 ± 23 mm, 35 ± 19 mm and 61 ± 48 mm from the reference point for the sternal, apical, anterior and posterior pads respectively, resulting in a respectively correct placement of 18%, 20%, 32% and 28%. The average number of correctly applied pads per instructor was 0.98 ± 0.74 out of four.Self-assessment of defibrillation pads placed by the participants were 8.56 ± 1.33 and 7.88 ± 1.64 for the sternal-apical and anterior-posterior positions respectively. Personal defibrillation experience showed that the majority had applied over 20 standard defibrillations. Experience with anterior-posterior pad placement was less and experience with bi-axillary and double sequential external defibrillation positions were absent in most participants. Self-perceived competence for the sternal-apical, anterior-posterior, bi-axillary and dual external synchronized positions were 8.68 ± 1.06, 8.08 ± 1.37, 5.57 ± 2.95 and 5.11 ± 2.67 respectively. Self-efficacy score for teaching defibrillation was 8.59 ± 0.81. No association was found between the number of correctly applied pads and any of the participants' variables.

Conclusion

This study corroborates and expands upon existing knowledge regarding the challenges of defibrillator pad placement, revealing substantial variation in placement accuracy among instructors. Our novel analysis of pad angles and anterior-posterior analysis demonstrates that a significant portion of pads are incorrectly placed. These findings highlight the need for standardized approaches and improved training methodologies in defibrillator pad placement.

Emergency Care for High-Altitude Trekking and Climbing

van Veelen, Michiel J., Rudolf Likar, Markus Tannheimer, Konrad E. Bloch, Silvia Ulrich, Michael Philadelphy, Barbara Teuchner, Thomas Hochholzer, Jacqueline Pichler Hefti, Urs Hefti, Peter Paal, and Martin Burtsche. Emergency Care for High-Altitude Trekking and Climbing. High Alt Med Biol. 26:70-86, 2025. Introduction: High altitude regions are characterized by harsh conditions (environmental, rough terrain, natural hazards, and limited hygiene and health care), which all may contribute to the risk of accidents/emergencies when trekking or climbing. Exposure to hypoxia, cold, wind, and solar radiation are typical features of the high altitude environment. Emergencies in these remote areas place high demands on the diagnostic and treatment skills of doctors and first-aiders. The aim of this review is to give insights on providing the best possible care for victims of emergencies at high altitude. Methods: Authors provide clinical recommendations based on their real-world experience, complemented by appropriate recent studies and internationally reputable guidelines. Results and Discussion: This review covers most of the emergencies/health issues that can occur when trekking or during high altitude climbing, that is, high altitude illnesses and hypothermia, freezing cold injuries, accidents, for example, with severe injuries due to falling, cardiovascular and respiratory illnesses, abdominal, musculoskeletal, eye, dental, and skin issues. We give a summary of current recommendations for emergency care and pain relief in case of these various incidents.

To shock or not to shock - The accuracy of cardiac arrest rhythm assessment by paramedics in a simulated environment

PURPOSE

Defibrillation in shockable rhythm is a well-known key intervention in cardiopulmonary resuscitation (CPR). The aim of this study was to analyze accuracy (the sum of the numbers of true positive results and true negative results, divided by the number of total results) of deciding by paramedics whether the rhythm was shockable or non-shockable.

METHODS

In this study 103 paramedics from various regions of Poland participated voluntarily. Study participants were presented with 22 simulated various electrocardiogram (ECG) recordings based on 10-s videos. These rhythms were also assessed using a manual defibrillator with shock-advisory mode known as automated external defibrillator (AED) mode.

RESULTS

Among the 103 participants, the mean of correct answers (correct decision to defibrillate or correct decision not to defibrillate) was 18/22 (83.7 ​%). The highest possible score was achieved by the participant with 22/22 (100 ​%) correct answers, while the lowest was 10/22 (45.5 ​%). The highest score obtained for single rhythm was 97.1 ​% and the lowest was 32 ​%. Mean accuracy of shock-advisory mode was 77.3 ​%.

CONCLUSIONS

Improving the quality of paramedic training and continuous quality monitoring (e.g., by analyzing ECG recordings from resuscitations) is essential to improve the accuracy of defibrillation rhythm recognition. The role of the AED mode can be advisory, but is not a substitute for assessment by medical professionals in Emergency Medical Service.

Effect of hypercapnia on neurologic outcomes after cardiac arrest: A systematic review and meta-analysis

BACKGROUND

Brain injury often occurs after cardiac arrest, and the regulation of PaCO2 plays a crucial role in mediating cerebral blood flow. The current guidelines recommend maintaining normocapnia through ventilation in post-arrest patients. However, the effects of hypercapnia on neurological outcomes remain controversial. To address this issue, we undertook a meta-analysis to compare the effects of hypercapnia and normocapnia on the neurological outcomes in patients with cardiac arrest.

METHODS

As of December 5, 2023, we conducted a search on eligible studies, including EMBASE, PubMed, and WOS databases. Our primary outcome of interest was a good neurological outcome, and two authors independently screened the studies and extracted relevant data. For analysis, a fixed effects model was used when the I2 values were less than 50 %, whereas a random effects model was used for higher I2 values.

RESULTS

From the 2137 studies initially identified, seven studies involving 2770 patients were ultimately included. Compared with normocapnia, hypercapnia significantly improved the neurological outcomes of patients with cardiac arrest (OR 0.73; 95 % CI 0.56-0.96; P = 0.02). According to the subgroup analysis, the hypercapnic group achieved better neurological outcomes in the short-term than did the normocapnia group (OR 0.61; 95 % CI 0.42-0.88; P = 0.008), whereas no significant difference was observed in long-term (OR 0.91; 95 % CI 0.76-1.10; P = 0.35). Moreover, there was no significant difference in mortality between the two groups (OR 1.03; 95 % CI 0.65-1.63; P = 0.91).

CONCLUSION

Our results suggest that hypercapnia is associated with a good neurological prognosis, especially in the short-term setting. However, further well-powered randomized controlled trials are necessary to confirm the optimal PaCO2 targets.

PROSPERO

CRD42023457027. Registered 3 September 2023.

Effectiveness of ultra-rapid (20 min) high-frequency in-situ cardiac arrest simulations in a high-volume operating department - A tool for evaluating and implementing emergency routines

Background

In-situ simulations are effective in identifying latent safety threats. In high-volume elective operating departments, cardiac arrests are rare due to strict patient selection. Implementing in-situ cardiac arrest simulations in these settings is crucial to evaluate adherence to cardiopulmonary resuscitation (CPR) guidelines and enhance patient safety by detecting and managing safety threats.

Method

From October 2023 to June 2024, a 20-minute in-situ cardiac arrest simulation with debriefing was conducted bi-weekly in a high-volume orthopedic surgery ward with seven operating rooms, without additional staffing. Latent safety threats were identified and addressed. Time to call for help, start of compressions, and first defibrillation was measured, as was airway management choice by anesthesia. Staff confidence was assessed via an anonymous 11-step Likert-scale questionnaire before and after the project, ranging from 0 (no confidence) to 10 (highest confidence).

Results

22 simulations were conducted. Multiple safety improvements were implemented, including role clarification and development of an amiodarone kit. Adherence to cardiopulmonary resuscitation guidelines was strong, achieving time goals in 21 simulations (95%). Anesthesia intubated in 100% of cases when present (16/22, 73%). The questionnaire response rate was 72% (38/53). Staff confidence significantly improved after the project, with median scores increasing from 4.5 to 7.0 (IQR 2.25-7 before, 6-8 after) for personal ability (p < 0.001) and 6.5 to 8.5 (IQR 4-7.25 before, 8-9 after) for team ability (p < 0.001).

Conclusions

A 20-minute in-situ cardiac arrest simulation with debriefing is feasible in a high-volume operating department. Mitigating safety threats and achieving guideline adherence demonstrates functional emergency routines. Staff confidence in managing cardiac arrests significantly increased.

Incidence and temporal trends of out-of-hospital cardiac arrest in Shenzhen, China (2011-2018)

Background

Out-of-hospital cardiac arrest (OHCA) is a significant global public health issue, few studies describe characteristics and trends in China. This study examines OHCA features and trends in Shenzhen, one of the fastest-growing cities.

Methods

This retrospective study analysed data from the Shenzhen Emergency Center database (2011-2018), including ambulance dispatch and pre-hospital medical records. Descriptive statistics and temporal trends were used to examine the incidence, patients characteristics, pre-hospital treatment, and outcome.

Results

Among 18,772 medical cause OHCA cases, the crude incidence rate was 17.4 per 100,000 population, with an age-standardised rate of 38.4. Incidence increased over time. Resuscitation was attempted in 43.8% of cases, with a median patient age of 56 years and 73.5% being male. Most arrest (69.0%) occurred at home, and 82% were presumed to be cardiac cause.The median response time was 11.2 min. Bystander cardiopulmonary resuscitation (CPR) rates increased from 4.6% in 2011 to 14.5% in 2018, while bystander automated external defibrillator (AED) use remained low (0.2%). Pre-hospital electrocardiogram (ECG) recording improved from 40.6% to 91.9%, with shockable rhythms 2.2%. Intravenous access was established in 69.7% of patients, 51.9% received epinephrine, 19.29% received pre-hospital defibrillation, and 16.4% underwent advanced airway management. The pre-hospital Return of Spontaneous Circulation (ROSC) rate increased from 2.7% to 5.8%, with a total ROSC rate of 3.11%.

Conclusions

OHCA incidence in Shenzhen is lower than both domestic and international levels but increasing. Low bystander intervention rated and prolonged response times contribute to poor outcome, underscoring the need for system improvements.

[VA-ECMO-assisted resuscitation for refractory cardiac arrest]

Extracorporeal cardiopulmonary resuscitation (ECPR) is an invasive medical intervention using mechanical circulatory support for treating cardiac arrest beyond the limits of conventional cardiopulmonary resuscitation (CCPR). ECPR uses veno-arterial extracorporeal membrane oxygenation (VA-ECMO) to maintain organ perfusion while treating reversible causes of cardiac arrest. Commonly applied criteria to select suitable patients include witnessed cardiac arrest, early bystander CPR, and a time frame of less than 60 minutes from collapse to ECPR initiation.A meta-analysis by Low et al. (2023), which included 11 studies with 4,595 ECPR and 4,597 CCPR patients, demonstrated that ECPR was not only associated with higher survival rates, but also better long-term neurological outcomes. Additionally, a higher number of ECPR procedures per center was linked to reduced mortality rates. A 2024 updated meta-analysis confirmed these findings and demonstrated further that ECPR significantly reduced in-hospital mortality in patients with out-of-hospital cardiac arrest (OHCA).Further insights on this topic can be gained from the individual studies on ECPR for treatment of OHCA: In general, there are several different modalities of how ECPR can be deployed, ranging from implantation at the site of the index event vs. implantation in the hospital, and even the place of implantation in the hospital varies. However, it seems that the actual pathway of how the VA-ECMO is implanted is of lower importance, and highly depends on the local infrastructure of a given hospital (rural area vs. municipal area), while achieving the lowest possible low-flow time should be the primary goal.The available data also shows that, despite all the advances, ECPR is still a high-risk intervention which is very demanding on the personnel and requires an abundance of resources.Overall, ECPR is a promising therapy for patients with OHCA to improve survival with good neurological outcome, but only if applied in a highly structured and standardized way, and in carefully selected patients.

In OHCA, IO-first and IV-first vascular access strategies for drug administration did not differ for 30-d survival

CLINICAL IMPACT RATINGS

Emergency Med: [Formula: see text] Cardiology: [Formula: see text].

Impact of the COVID-19 Pandemic on Out-of-Hospital Cardiac Arrests Occurring in the Workplace

Background The impact of the coronavirus disease 2019 (COVID-19) pandemic on out-of-hospital cardiac arrest (OHCA) occurring in this setting remains unclear. Objective The objective of this study is to elucidate the impact of the COVID-19 pandemic on the prehospital characteristics and outcomes of OHCA occurring in the workplace. Methods This nationwide observational study in Japan was a retrospective analysis and included 16,364 non-emergency medical service witnessed and adult workplace OHCAs. The characteristics and outcomes of workplace OHCAs were compared between the pre-pandemic period (2016-2019) and the pandemic period (2020-2021). Furthermore, subgroup analyses were performed for workplace location (office vs. non-office) and infection burden region. Results During the pandemic period, no significant changes were observed in incidence, public access defibrillation (PAD) provision rates, one-month survival rates, or neurologically favorable survival rates. However, increases were observed for bystander cardiopulmonary resuscitation (CPR) (crude odds rate (cOR), 95% confidence interval (CI): 1.10, 1.02-1.16; P<0.001), particularly compression-only CPR. The multivariable analysis revealed that the impact of the pandemic was similarly seen in an increase in bystander CPR (adjusted OR, 95% CI: 1.14, 1.06-1.22; P<0.001). Furthermore, the monthly changes in only PAD were altered biennially (PAD: P=0.02, bystander CPR: P=0.52, one-month survival: P=0.26, and neurologically favorable one-month survival: P=0.48). Analysis restricted to high-infection burden regions revealed that only the PAD rate decreased (P=0.03). Conclusion The COVID-19 pandemic had no impact on OHCA survival in workplaces and had a limited positive impact on bystander responses. This may be attributed to previous positive CPR training experiences and routine preparation for health crises.

Adrenaline has a limited effect on myocardial microvascular blood flow: A randomised experimental study in a porcine cardiac arrest model

Background

Adrenaline (ADR) is a cornerstone of advanced life support (ALS) in cardiac arrest (CA), although its neurologically favourable survival outcomes remain unclear. ADR increases coronary perfusion pressure (CPP), with levels >15 mmHg associated with successful defibrillation. This study aimed to elucidate the relationship between ADR, myocardial microvascular blood flow, and resuscitation outcomes using a porcine CA model simulating refractory ventricular fibrillation (VF).

Methods

This study involved 24 domestic pigs. After instrumentation, intubation, and baseline measurements, the animals were randomised into the ADR or control (saline) groups. VF was induced, and cardiopulmonary resuscitation was initiated using continuous mechanical chest compressions and ventilation. ADR or saline was administered following ALS guidelines. After 21 min of ALS, defibrillation was performed. Continuous measurements of arterial and venous blood pressures using an electrocardiogram and index of myocardial resistance (IMR) and transit mean time (Tmn) 1 min before and after each injection or peak blood pressure were recorded and compared between the groups. CPP-IMR, amplitude spectrum area (AMSA)-IMR, CPP-Tmn, and AMSA-Tmn correlations were assessed.

Results

Compared with six animals in the control group, three in the ADR group achieved a return of spontaneous circulation. No difference was observed in IMR or AMSA; however, significant increases in CPP and arterial end-diastolic blood pressure were observed at several time points. Tmn differed between groups only at two time points.

Conclusion

Repeated ADR doses during prolonged ALS simulating refractory VF did not improve myocardial microvascular blood flow, as measured using IMR, despite leading to an increase in CPP.

Neuroprotection with hypothermic reperfusion and extracorporeal cardiopulmonary resuscitation - A randomized controlled animal trial of prolonged ventricular fibrillation cardiac arrest in rats

Extracorporeal cardiopulmonary resuscitation (ECPR) facilitates resuscitation with immediate and precise temperature control. This study aimed to determine the optimal reperfusion temperature to minimize neurological damage after ventricular fibrillation cardiac arrest (VFCA). Twenty-four rats were randomized (n = 8 per group) to normothermia (NT = 37°C), mild hypothermia (MH = 33°C) or moderate hypothermia (MOD = 27°C). The rats were subjected to 10 minutes of VFCA, before 15 minutes of ECPR at their respective target temperature. After ECPR weaning, rats in the MOD group were rapidly rewarmed to 33°C, and temperature maintained at 33°C (MH/MOD) or 37°C (NT) for 12 hours before slow rewarming to normothermia (MH/MOD). The primary outcome was 30-day survival with overall performance category (OPC) 1 or 2 (1 = normal, 2 = slight disability, 3 = severe disability, 4 = comatose, 5 = dead). Secondary outcomes included awakening rate (OPC ≤ 3) and neurological deficit score (NDS, from 0 = normal to 100 = brain dead). The survival rate did not differ between reperfusion temperatures (NT = 25%, MH = 63%, MOD = 38%, p = 0.301). MH had the lowest NDS (NT = 4[IQR 3-4], MH = 2[1-2], MOD = 5[3-5], p = 0.044) and highest awakening rate (NT = 25%, MH = 88%, MOD = 75%, p = 0.024). In conclusion, ECPR with 33°C reperfusion did not statistically significantly improve survival after VFCA when compared with 37°C or 27°C reperfusion but was neuroprotective as measured by awakening rate and neurological function.

In OHCA, IO-first and IV-first vascular access strategies did not differ for sustained ROSC or 30-d survival

CLINICAL IMPACT RATINGS

Emergency Med: [Formula: see text].

Analysis of 67,975 Emergency Deployments in a Major German City - Criteria for More Efficient Dispatching of Emergency Physicians

OBJECTIVES

Efficient dispatching of physician-staffed vehicles in emergency medical services requires clear criteria to ensure timely allocation of resources, improve patient outcomes, and minimize response time under high-pressure conditions. The aim of this study was to identify criteria ensuring that emergency physicians are safely managed and efficiently deployed.

METHODS

Rescue service deployments in the city of Dresden, Germany (01/01/2021-12/31/2021), were analyzed retrospectively. The rescue mission indications determined by the telecommunicator, along with the presence of vital sign abnormalities at site - such as airway, breathing, circulation, and disability - based on the ABCDE approach from the Advanced Life Support and Advanced Trauma Life Support algorithms, were analyzed. Specific emergency medical procedures carried out in the particular mission were assigned to the respective competence level (CL): CL1: invasive measures reserved for physicians; CL2: invasive measures that paramedics are trained to use independently in emergency situations; CL3: standard measures; CL4: counseling only; and CL5: no measures.

RESULTS

In all, 67,975 missions were analyzed. Missions were most frequently dispatched for internal indications, such as cardiovascular and pulmonary emergencies (28.4%), and traumatological indications (20.4%). Despite the physician being dispatched in 36.5% of cases, invasive measures (CL1/CL2) were only used in 13.9% of missions. Internal indications (11.8%) and resuscitation (19.6%) frequently required CL1 measures. CL2 measures were more frequently applied than CL1 measures for allergic (44.2% vs. 1.9%), neurological (12.5% vs. 3.4%), and psychological (6.1% vs. 0.7%) indications. In most interventions (62.2%), only the standard competencies (CL3) were used as the highest level of competence. For most mission indications, the probability of invasive measures (CL1/CL2) increased significantly in the presence of at least one vital sign abnormality.

CONCLUSIONS

The results show opportunities for optimizing emergency physician dispatch. The presence of a vital sign abnormality should be given greater consideration in the future. Query algorithms for detecting cases with a high probability of requiring CL1/CL2 measures could support efficient dispatching. Furthermore, emergencies requiring CL2 but rarely CL1 measures could be handled independently by emergency paramedics, particularly if they have access to the support of a tele-emergency physician for situations where CL1 measures become necessary.

Weakness acquired in the cardiac intensive care unit: still the elephant in the room?

Over the past two decades, the cardiac critical care population has shifted to increasingly comorbid and elderly patients often presenting with nonprimary cardiac conditions that exacerbate underlying advanced cardiac disease. Consequently, the modern cardiac intensive care unit (CICU) patient has poor outcome regardless of left ventricular ejection fraction. Importantly, delayed liberation from organ support, independent from premorbid health status and admission severity of illness, has been associated with increased morbidity and mortality up to years post-general critical care. Although a constellation of several acquired morbidities is at play, the most prominent enactor of poor long-term outcome in this population appears to be intensive care unit acquired weakness. Although the specific burden of ICU-acquired morbidities in CICU patients is yet to be clearly defined, it seems unfathomable that patients will not accrue some sort of ICU-related morbidity. There is hence an urgent need to better establish the exact benefit and cost of resource-intensive strategies in both short- and long-term survival of the CICU patient. Consequent and standardized documentation of admission comorbidities, severity of illness indicators, relevant ICU-related complications including weakness, and long-term post-ICU morbidity outcomes can help our understanding of the disease continuum and how to better care for the CICU survivor and their families and caregivers. Given increasing budgetary pressure on healthcare systems worldwide, interventions targeting CICU patients should focus on improving patient-centred long-term outcomes in a cost-effective manner. It will require a holistic and transmural continuity of care model to meet the challenges associated with treating critically ill cardiac patients in the future.

Effects of very early hyperoxemia on neurologic outcome after out-of-hospital cardiac arrest: A secondary analysis of the TTM-2 trial

PURPOSE

Hyperoxemia is common in patients resuscitated after out-of-hospital cardiac arrest (OHCA) admitted to the intensive care unit (ICU) and may increase the risk of mortality. However, the effect of hyperoxemia on functional outcome, specifically related to the timing of exposure to hyperoxemia, remains unclear.

METHODS

The secondary analysis of the Target Temperature Management 2 (TTM-2) randomized trial. The primary aim was to identify the best cut-off of partial arterial pressure of oxygen (PaO2) to predict poor functional outcome within the first 24 h from admission, with this period further separated into 'very early' (0-4 h), 'early' (8-24 h), and 'late' (28-72 h) periods. Hyperoxemia was defined as the highest PaO2 recorded during each period. Poor functional outcome was defined as a 6 months modified Rankin Score (mRS) of 4 to 6.

RESULTS

A total of 1,631 patients were analysed for the 'very early' and 'early' periods, and 1,591 in the 'late period'. In a multivariate logistic regression model, a PaO2 above 245 mmHg during the very early phase was independently associated with a higher probability of poor functional outcome (Odds Ratio, OR = 1.63, 95 % Confidence Interval, CI 1.08-2.44, p = 0.019). No significant associations were found for the later periods.

CONCLUSIONS

Very early hyperoxemia after ICU admission is associated with higher risk of poor functional outcome after OHCA. Avoiding hyperoxia in the initial hours after resuscitation should be considered.

Towards a common terminology of ventilation during cardiopulmonary resuscitation

Manual and mechanical ventilation during cardiopulmonary resuscitation are critical yet poorly understood components of resuscitation care. In recent years, intra-arrest ventilation has been the subject of a growing number of laboratory and clinical investigations. Essential components to accurately interpret or reproduce original investigations are the exact measurement and transparent reporting of key ventilation parameters, such as volumes and airway pressures obtained during ongoing cardiopulmonary resuscitation. Chest compressions lead to frequent intrathoracic and intrapulmonary pressure rises which interact with artificial ventilation. The resulting unique phenomena during continuous chest compressions with asynchronous ventilation and an advanced airway necessitate a nuanced conceptualization supported by a common terminology. Based on previous original investigations and observations, we describe intra-arrest ventilation parameters and propose a common terminology integrating established and novel concepts. The proposed terminology may serve as a methodological and reporting consideration for future research of intra-arrest ventilation. Additionally, it may serve as a foundation for an authoritative scientific consensus process, which may further facilitate the transparent reporting and reproducible science needed to understand cardiopulmonary resuscitation and improve survival for cardiac arrest patients.