Part 1: Executive Summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Elucidating cognitive processes in cardiac arrest team leaders: a virtual reality-based cued-recall study of experts and novices

BACKGROUND

Team leadership during medical emergencies like cardiac arrest resuscitation is cognitively demanding, especially for trainees. These cognitive processes remain poorly characterized due to measurement challenges. Using virtual reality simulation, this study aimed to elucidate and compare communication and cognitive processes-such as decision-making, cognitive load, perceived pitfalls, and strategies-between expert and novice code team leaders to inform strategies for accelerating proficiency development.

METHODS

A simulation-based mixed methods approach was utilized within a single large academic medical center, involving twelve standardized virtual reality cardiac arrest simulations. These 10- to 15-minutes simulation sessions were performed by seven experts and five novices. Following the simulations, a cognitive task analysis was conducted using a cued-recall protocol to identify the challenges, decision-making processes, and cognitive load experienced across the seven stages of each simulation.

RESULTS

The analysis revealed 250 unique cognitive processes. In terms of reasoning patterns, experts used inductive reasoning, while novices tended to use deductive reasoning, considering treatments before assessments. Experts also demonstrated earlier consideration of potential reversible causes of cardiac arrest. Regarding team communication, experts reported more critical communications, with no shared subthemes between groups. Experts identified more teamwork pitfalls, and suggested more strategies compared to novices. For cognitive load, experts reported lower median cognitive load (53) compared to novices (80) across all stages, with the exception of the initial presentation phase.

CONCLUSIONS

The identified patterns of expert performance - superior teamwork skills, inductive clinical reasoning, and distributed cognitive strategiesn - can inform training programs aimed at accelerating expertise development.

Disparities in Emergency Medical Services Termination of Resuscitation Practices for Patients with Out-of-Hospital Cardiac Arrest

OBJECTIVES

There are well-described racial, ethnic, and gender-based inequities following out-of-hospital cardiac arrest (OHCA). Few studies have analyzed disparities in emergency medical services (EMS) termination of resuscitation (TOR) practices. This purpose of this study was to identify inequities in duration of prehospital resuscitation prior to TOR.

METHODS

A retrospective cohort of adult (≥18 years-old), non-traumatic OHCA events in a single metropolitan, fire-based EMS system was evaluated. Duration of resuscitation prior to prehospital TOR was separately evaluated among racial/ethnic (Black, Hispanic, and White) and gender (female and male) groups using a multivariable linear regression model. Variables in the model included bystander cardiopulmonary resuscitation (CPR) provision, arrest witnessed status, initial rhythm (shockable versus non-shockable), and patient age. Multiple imputation was used to account for missing data entries where duration of resuscitation was not documented. Incidence of hospital transport between racial/ethnic and gender groups was also assessed.

RESULTS

Between February 1, 2020 and February 28, 2023, 3700 patients met inclusion criteria, of which 1,895 (51.2%) had field TOR and 1,328/1,895 had a documented time of TOR. When controlling for arrest witnessed status, bystander CPR provision, initial shockable rhythm, and subject age, Black race [24.1 min (95% confidence interval 21.2-27.0, p < 0.001)] and Hispanic ethnicity [23.7 min (95% CI 20.0-27.5, p = 0.03)] were associated with shorter duration of resuscitation compared to White race [25.8 min (95% CI 23.9-27.7)]. These racial inequities persisted when using multiple imputation modeling. There was no difference in duration of resuscitation between female [24.3 min (95% CI 22.4-26.2)] and male gender [24.7 min (95% CI 21.8-27.5), p = 0.46]. There were no differences in incidence of hospital transport.

CONCLUSIONS

This study identified inequities in prehospital termination of resuscitation practices following OHCA. Black and Hispanic patients, as compared to White patients, received approximately 2-min-shorter prehospital resuscitative efforts prior to TOR despite controlling for bystander CPR, witnessed status, initial rhythm, and patient age. There were no gender-based differences in prehospital duration of resuscitation.

[Connaissances, attitudes et pratiques des medecins camerounais sur la réanimation cardio-pulmonaire]

BACKGROUND

Identification of cardiopulmonary arrest and its immediate and effective management are decisive factors in survival.

OBJECTIVE

To evaluate the knowledge, attitudes, and practices of Cameroonian physicians concerning cardiopulmonary resuscitation METHODS: We conducted a cross-sectional study among doctors in Douala, Bafoussam, Garoua, and Yaoundé in Cameroon over three months from March 2024 to May 2024. We included specialists, residents/interns, and general practitioners practising in these cities who agreed to participate in the study. Were not included physicians who had been in practice for less than six months in Cameroon. Answers were validated by referring to the European Resuscitation Council 2015 recommendations and the American Heart Association 2020. Means were compared using the ANOVA and Kruskal-Wallis test. The association between different variables was assessed using a χ2 test or an exact Fisher test. A p-value < 0.05 was considered significant.

RESULTS

Of the 95 participants recruited, the median age was 31 (IQR 28- 33), with extremes between 25 and 56. Residents/interns represented the largest group in our population, with 66 (69.5%) participants. We had 56 (58.9%) participants who had already attended a cardiopulmonary resuscitation training course. Participants who had never attended a previous cardiopulmonary resuscitation training course had a significantly lower mean than those who had (9.90 ± 1.93 vs. 11.61 ± 2.80, P = 0.002). Participants whose last training was more than a year ago had a significantly lower mean score than participants whose previous training was less than a year ago (11.05 ± 2.97 vs. 12.78 ± 2.02, P = 0.016). There was a significant difference between participants' means according to the city of exercise (P=0.037). The doctors practising in Yaoundé had more inadequate practices than those practising outside of Yaoundé (OR: 7.607; 95% CI 1.897-30.509; p = 0.005).

CONCLUSION

Most of our participants' knowledge and practices regarding cardiopulmonary resuscitation were incomplete and inadequate. However, our study noted a positive attitude toward physicians. Therefore, it is essential to emphasise the training of health care providers on cardiopulmonary resuscitation.

Optimizing Pediatric Chest Compressions: A Randomized Crossover Simulation Trial of Over-the-Head vs. Lateral Techniques

BACKGROUND/OBJECTIVES

Pediatric cardiac arrest poses considerable obstacles, with survival rates markedly inferior to those of adults. Effective chest compressions are essential for enhancing outcomes; nevertheless, the ideal rescuer attitude is still ambiguous. This study sought to compare the efficacy of lateral (LAT) and over-the-head (OTH) chest compression techniques in pediatric cardiopulmonary resuscitation (CPR) and to ascertain whether OTH presents a viable alternative to the conventional LAT method by assessing compression quality, rescuer fatigue, and ergonomics.

METHODS

A randomized crossover simulation study was conducted in a high-fidelity medical simulation facility. Thirty-five medical students executed 2 min cycles of chest compressions with both LAT and OTH techniques, interspersed with a 15 min rest period between sessions.

RESULTS

OTH showed a tendency for enhanced overall performance (72.94 vs. 64.46; p = 0.08), while the differences lacked statistical significance. The compression rate was somewhat elevated with OTH (116.94 compared to 114.57; p = 0.31). We assessed LAT as somewhat less challenging (4.37 vs. 3.91; p = 0.17) and found less fatigue (4.83 vs. 4.40; p = 0.24). Male rescuers and individuals with elevated BMI attained larger compression depths. Age was negatively connected with the ease and efficiency of compressions.

CONCLUSIONS

Although no statistically significant differences were detected, OTH demonstrated potential for enhanced performance. The anthropometrics of rescuers affected the quality of CPR, highlighting the necessity for tailored training methods. Future investigations should examine the long-term viability of OTH in clinical and pre-hospital environments.

Rapid Cycle Deliberate Practice Simulation for a Maternal Cardiac Arrest With Obstetrics and Gynecology Residents

Introduction

Maternal cardiac arrest is rare; therefore, simulation serves as an opportunity to better prepare obstetrics and gynecology residents for these emergencies.

Methods

We conducted a 2-hour educational activity for 16 obstetrics and gynecology residents at an academic medical center, utilizing rapid cycle deliberate practice to teach them the recognition and management of a maternal cardiac arrest. The case centered on a patient admitted to the labor and delivery floor who was in her third trimester. She developed chest pain and had a subsequent cardiac arrest. The case used up to seven rounds of rapid cycles with debriefing after each. Learners were expected to recognize the cardiac arrest, initiate initial management, consider the differential diagnosis, and prepare for a resuscitative hysterotomy.

Results

After the simulation case, learners' average comfort level for managing cardiac arrest improved from 1.8 to 3.6 (on a 5-point Likert scale: 1 = extremely uncomfortable, 5 = extremely comfortable). Comfort performing supportive airway management went from 1.9 to 4.1. Residents found the knowledge gained during the session useful to future practice, and the average course rating was 5.8 on a 6-point scale (with 6 = excellent).

Discussion

Rapid cycle deliberate practice simulation for a maternal cardiac arrest improves obstetrics and gynecology residents' comfort and readiness for obstetrics emergencies.

The Neurochemical Signature of Cardiac Arrest: A Multianalyte Online Microdialysis Study

This work describes the use of high resolution online microdialysis coupled with a wireless microfluidic electrochemical sensing platform for continuous monitoring of the effect of cardiac arrest and resuscitation methods on brain glucose and other key neurochemicals in a porcine model. The integrated portable device incorporates low-volume three-dimensional (3D) printed microfluidic flow cells containing enzyme-based biosensors for glucose, lactate and glutamate measurement and a complementary metal-oxide semiconductor (CMOS)-based ion-sensitive field effect transistor (ISFET) for potassium measurement. Both analysis systems incorporate wireless electronics forming a complete compact system that is ideal for use in a crowded clinical environment. Using this integrated system we were able to build a signature of the neurochemical impact of cardiac arrest and resuscitation. Our results demonstrate the almost complete depletion of brain glucose following cardiac arrest and the subsequent increase in lactate, highlighting the vulnerability of the brain while the blood flow is compromised. Following a return of spontaneous circulation, glucose levels increased again and remained higher than baseline levels. These trends were correlated with simultaneous blood measurements to provide further explanation of the metabolic changes occurring in the brain. In addition, the onset of cardiac arrest corresponded to a transient increase in potassium. In most cases glutamate levels remained unchanged after cardiac arrest, while in some cases a transient increase was detected. We were also able to validate the trends seen using online microdialysis with traditional discontinuous methods; the two methods showed good agreement although online microdialysis was able to capture dynamic changes that were not seen in the discontinuous data.

National early warning score 2 plus non-invasive capnography and perfusion index to estimate poor outcomes in emergency departments

BACKGROUND

The study of the inclusion of new variables in already existing early warning scores is a growing field. The aim of this work was to determine how capnometry measurements, in the form of end-tidal CO2 (ETCO2) and the perfusion index (PI), could improve the National Early Warning Score (NEWS2).

METHODS

A secondary, prospective, multicenter, cohort study was undertaken in adult patients with unselected acute diseases who needed continuous monitoring in the emergency department (ED), involving two tertiary hospitals in Spain from October 1, 2022, to June 30, 2023. The primary outcome was 30-day all-cause in-hospital mortality. Demographics and vital signs necessary for NEWS2, ETCO2 and PI were collected.

RESULTS

A total of 687 patients were included in the study. The median age was 79 years (IQR: 69-86), and 36.7 % were females, with an in-hospital mortality rate of 6.7 %. The NEWS2 score was 7 points for nonsurvivors and 4 points for survivors (p < 0.001). The EtCO2 levels were 30 mmHg (26-35) and 23  mmHg (16-30), and the PI levels were 4.7% (2.2-8.1) and 2.5 % (0.98-4.4) for survivors and nonsurvivors, respectively (both p < 0.001). The discrimination capacity of NEWS2 was AUC = 0.769 (95 % CI: 0.707-0.831), that of EtCO2 + PI was AUC = 0.737 (95 % CI: 0.66-0.814), and that of NEWS2 + ETCO2 + PI was AUC = 0.804 (95 % CI: 0.745-0.863).

CONCLUSIONS

The present study findings indicate that the PI and ETCO2 improved the ability of the NEWS2 to predict 30-day in-hospital mortality. The novel association of the NEWS2 with the PI and ETCO2 should be considered since it could improve the identification of patients at risk of clinical worsening.

Survival rates with favorable neurological outcomes after in-hospital and out-of-hospital cardiac arrest: A prospective cohort study

OBJECTIVES

To evaluate the survival rates with favorable neurological outcomes among patients who experienced in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA).

DESIGN

This prospective cohort study assessed 554 adult patients with IHCA or OHCA referred to Hamad General Hospital, Qatar, between February 2015 and November 2021. Neurologic outcomes were measured using the Cerebral Performance Category (CPC) score. Survival rate and neurologic status were re-evaluated at 28 days, hospital discharge, and one year after cardiac arrest (CA).

FINDINGS

For all participants, the hospital discharge and one-year survival rates with a favorable neurological outcome (CPC ≤ 2) were 18.5 % and 19.5 %, respectively. Specifically, among patients with IHCA, the rates were 20.5 % and 19 %, while in patients with OHCA, the rates were 16.4 % and 19.9 %, respectively. Multivariate regression analysis indicated that factors male sex (OR: 2.129, 95 % CI: 1.168-3.881, P = 0.014), initial shockable rhythm (OR: 1.691, 95 % CI: 1.024-2.788, P = 0.041), and the use of ECPR (OR: 1.944, 95 % CI: 1.178-3.209, P = 0.009) were associated with increased likelihood of survival with favorable neurological outcomes at 28 days. Conversely, older age, presence of comorbidities, infection, higher APACHE II score, longer hospital stays, and undergoing tracheostomy were linked to decreased chances of survival with favorable neurological outcomes at different time points.

CONCLUSION

Survival with good neurological outcomes after OHCA was 20.3 %, 16.4 %, and 19.9 % at 28 days, hospital discharge, and one year, respectively. Among patients with IHCA, survival with good neurological outcomes was 20.5 %, 20.5 %, and 19 % at 28 days, hospital discharge, and one year, respectively.

IMPLICATIONS FOR CLINICAL PRACTICE

Care of CA patients in a cardiac arrest center is associated with improved long-term survival with favorable neurological outcomes. Prioritizing early intervention for shockable rhythms and utilizing ECPR where appropriate could enhance patient prognosis.

Emergency medicine updates: Managing the patient with return of spontaneous circulation

INTRODUCTION

Patients with return of spontaneous circulation (ROSC) following cardiac arrest are a critically important population requiring close monitoring and targeted interventions in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the management of this condition.

OBJECTIVE

This paper provides evidence-based updates concerning the management of the post-ROSC patient.

DISCUSSION

The patient with ROSC following cardiac arrest is critically ill, including a post-cardiac arrest syndrome which may include hypoxic brain injury, myocardial dysfunction, systemic ischemia and reperfusion injury, and persistent precipitating pathophysiology. Initial priorities in the ED setting in the post-ROSC patient include supporting cardiopulmonary function, addressing and managing the underlying cause of arrest, minimizing secondary cerebral injury, and correcting physiologic derangements. Testing including laboratory assessment, electrocardiogram (ECG), and imaging are necessary, aiming to evaluate for the precipitating cause and assess end-organ injury. Computed tomography head-to-pelvis may be helpful in the post-ROSC patient, particularly when the etiology of arrest is unclear. There are several important components of management, including targeting a mean arterial pressure of at least 65 mmHg, preferably >80 mmHg, to improve end-organ and cerebral perfusion pressure. An oxygenation target of 92-98 % is recommended using ARDSnet protocol, along with carbon dioxide partial pressure values of 35-55 mmHg. Antibiotics should be reserved for those with evidence of infection but may be considered if the patient is comatose, intubated, and undergoing hypothermic targeted temperature management (TTM). Corticosteroids should not be routinely administered. While the majority of cardiac arrests in adults are associated with cardiovascular disease, not all post-ROSC patients require emergent coronary angiography. However, if the patient has ST-segment elevation on ECG following ROSC, emergent angiography and catheterization is recommended. This should also be considered if the patient had an initial history concerning for acute coronary syndrome or a presenting arrhythmia of ventricular fibrillation or pulseless ventricular tachycardia. TTM at 32-34° C does not appear to demonstrate improved outcomes compared with targeted normothermia, but fever should be avoided.

CONCLUSIONS

An understanding of literature updates can improve the ED care of patients post-ROSC.

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.

Prehospital Trauma Compendium: Management of Injured Pregnant Patients- A Position Statement and Resource Document of NAEMSP

The assessment and management of critically injured pregnant trauma patients represents a high-risk, low-frequency event. One in every 12 pregnant patients experience physical trauma during their pregnancy, but only 0.1% experience major trauma with an injury severity score (ISS) greater than fifteen. It is crucial that emergency medical services (EMS) clinicians understand the anatomic and pathophysiologic changes that impact morbidity and mortality for pregnant trauma patients so they can effectively provide life-saving interventions and resuscitation for this patient population.

Prehospital Management of Adults With Traumatic Out-of-Hospital Circulatory Arrest-A Joint Position Statement

The National Association of Emergency Medical Services Physicians (NAEMSP), American College of Surgeons Committee on Trauma (ACS-COT), and American College of Emergency Physicians (ACEP) believe that evidence-based, pragmatic, and collaborative protocols addressing the care of patients with traumatic out-of-hospital circulatory arrest (TOHCA) are needed to optimize patient outcomes and clinician safety. When the etiology of arrest is unclear, particularly without clear signs of life-threatening trauma, standard basic and advanced cardiac life support (BCLS/ACLS) treatments for medical cardiac arrest are appropriate. Traumatic circulatory arrest may result from massive hemorrhage, airway obstruction, obstructive shock, respiratory disturbances, cardiogenic causes, or massive head trauma. While resuscitation and/or transport is appropriate for some populations, it is appropriate to withhold or discontinue resuscitation attempts for TOHCA patients for whom these efforts are nonbeneficial. This position statement and resource document were written as an update to the 2013 joint position statements. NAEMSP, ACEP, and ACS-COT recommend.

Sudden cardiac arrest prediction via deep learning electrocardiogram analysis

Aims

Sudden cardiac arrest (SCA) is a commonly fatal event that often occurs without prior indications. To improve outcomes and enable preventative strategies, the electrocardiogram (ECG) in conjunction with deep learning was explored as a potential screening tool.

Methods and results

A publicly available data set containing 10 s of 12-lead ECGs from individuals who did and did not have an SCA, information about time from ECG to arrest, and age and sex was utilized for analysis to individually predict SCA or not using deep convolution neural network models. The base model that included age and sex, ECGs within 1 day prior to arrest, and data sampled from windows of 720 ms around the R-waves from 221 individuals with SCA and 1046 controls had an area under the receiver operating characteristic curve of 0.77. With sensitivity set at 95%, base model specificity was 31%, which is not clinically applicable. Gradient-weighted class activation mapping showed that the model mostly relied on the QRS complex to make predictions. However, models with ECGs recorded between 1 day to 1 month and 1 month to 1 year prior to arrest demonstrated predictive capabilities.

Conclusion

Deep learning models processing ECG data are a promising means of screening for SCA, and this method explains differences in SCAs due to age and sex. Model performance improved when ECGs were nearer in time to SCAs, although ECG data up to a year prior had predictive value. Sudden cardiac arrest prediction was more dependent upon QRS complex data compared to other ECG segments.

Association between bystander cardiopulmonary resuscitation initiation and patient's sex: a systematic review and meta-analysis

Background and aim

The chain of survival, including cardiopulmonary resuscitation (CPR) and automated external defibrillation (AED), improves patients' outcomes in case of cardiac arrest. Socioeconomic status, race, and gender appear to be associated with the likelihood of receiving resuscitation. The aim of this systematic review and meta-analysis was to evaluate the association between female sex and the odds of bystander CPR initiation and AED application in patients with cardiac arrest, compared with male individuals.

Methods

The protocol of this systematic review was prospectively registered in PROSPERO (CRD42024512024). PubMed, Scopus, and Cochrane were searched for studies describing the association between patient sex and the initiation of bystander CPR or the application of AED pads.

Results

Fifteen observational cohort studies were included, for a total of 499,854 patients. The analysis from adjusted estimates of the primary outcome showed substantial heterogeneity (I 2 = 89%, very low certainty evidence) and was narratively summarised. Female sex was associated with reduced odds of AED pad application compared with males (OR 0.79; 95% CI 0.66-0.94; P = 0.008; I 2 = 45%; moderate certainty evidence).

Conclusions

The evidence regarding the association between bystander CPR initiation and patient's sex is characterised by substantial heterogeneity. Female sex appears to be associated with a lower probability of AED pad application compared with males.

Comparative effectiveness of self-learning and instructor-assisted pediatric cardiopulmonary resuscitation training: A prospective randomized study

BACKGROUND

Unlike that for adults, training for cardiopulmonary resuscitation of infant and child is scarce, and warrants efforts for greater accessibility. Effective self-learning could expand training accessibility and facilitate the development of effective infant and child cardiopulmonary resuscitation training methods.

AIM

This study was conducted to develop a pediatric cardiopulmonary resuscitation self-learning training program, implement nurse training, and evaluate training effectiveness by comparing trainees' achievement of self-efficacy in pediatric cardiopulmonary resuscitation, with or without instructor assistance.

DESIGN

Prospective randomized controlled study.

SETTINGS

General hospital.

PARTICIPANTS

Nurses working in a general hospital.

METHODS

Participants were randomly and sequentially assigned to either an instructor-assisted or a self-learning group and completed a pre-training survey, pediatric cardiopulmonary resuscitation training, post-training survey and test, and a 1-year follow-up test. Pediatric cardiopulmonary resuscitation training was divided into infant and child cardiopulmonary resuscitation training.

RESULTS

Among the 97 participants, instructor-assisted and self-learning groups trained in pediatric cardiopulmonary resuscitation showed no significant difference in correct chest compressions, ventilation performance, and self-efficacy at the post-training assessment. However compared to the pre-training assessment, these parameters increased significantly in both groups at the post-training assessment (self-efficacy: infant cardiopulmonary resuscitation: pre-training 15.48, post-training: 17.25 vs pre-training 19.74, post-training 20.05; child cardiopulmonary resuscitation: pre-training 15.78, post-training 17.90 vs pre-training 19.48, post-training 20.55; both p < 0.001), respectively. In the self-learning group, at the 1-year follow-up, the rate of correct infant resuscitation compression decreased significantly from 89 (immediate post-training score) to 76 (p = 0.07), without significant intergroup difference. Regarding the time of measurement, although the main effect was significant (p < 0.001), the interaction effect of instructor-assisted training and time of measurement on pediatric cardiopulmonary resuscitation self-efficacy was not.

CONCLUSION

Pediatric cardiopulmonary resuscitation training did not differ significantly with training modality and improved self-efficacy, which changed significantly over time. These results aid the design of effective self-learning training programs for pediatric cardiopulmonary resuscitation training.

Factors related to the decision to perform synchronized cardioversion for supraventricular tachyarrhythmias by prehospital emergency medical services workers

BACKGROUND

While clinical indicators for synchronized cardioversion in regular supraventricular tachycardias are well-established, their application by prehospital emergency medical services (EMS) still needs to be explored.

OBJECTIVE

The purpose of this study was to evaluate the factors influencing the decision-making process of prehospital EMS personnel to perform synchronized cardioversion in adults with narrow QRS regular tachyarrhythmias.

METHODS

This descriptive study included 598 paramedics actively engaged in prehospital EMS. Data were collected using a form that included questions about their experiences with synchronized cardioversion and presented three cases involving narrow QRS regular tachyarrhythmias. Since the data did not exhibit a normal distribution, the Mann-Whitney U test was employed to evaluate the significance of differences between the variables "number of previous SC applications" and "not performing SC despite recognizing unstable findings".

RESULTS

The participants comprised 320 males (53.5 %) and 278 females (46.5 %). A majority (93.8 %, n = 561) had attended postgraduate training on synchronized cardioversion (SC) for adult patients, and 220 participants (36.8 %) reported prior experience performing synchronized cardioversion, with an average of three applications each. Despite recognizing sufficient clinical findings of unstable status for synchronized cardioversion in narrow QRS regular tachyarrhythmias, 177 participants (29.6 %) reported instances where they chose not to perform the procedure. Immediate synchronized cardioversion was preferred by 319 participants (53.3 %) in cases of altered mental status; however, this rate decreased to 16.9 % (n = 101) for ischemic chest discomfort and 30.4 % (n = 182) for acute heart failure cases.

CONCLUSIONS

Previous experience with synchronized cardioversion and the proximity to the receiving hospital are key factors in the decision-making process. Additionally, the type of unstable finding is critical in making the decision for synchronized cardioversion.

Epidemiology and outcomes of patients with cardiac arrest in the emergency department of a lower middle-income country

BACKGROUND

Advanced cardiovascular life support (ACLS) for cardiac arrest is a cornerstone of emergency care and yet remains poorly studied in low- and middle-income countries. We characterised the clinical epidemiology and outcomes of cardiac arrest and ACLS in an ED in central Haiti, a lower middle-income country with a nascent emergency care system.

METHODS

We conducted a prospective observational study of adult and paediatric patients who suffered cardiac arrest in an academic hospital ED in central Haiti from January 2019 to August 2020. Patients were identified prospectively at the time of clinical care. Data on demographics, comorbidities, clinical presentation, management with or without ACLS and outcomes were extracted from patient charts using a standardised form and analysed in SAS V.9.4. The primary outcome was survival to 24 hours after arrest.

RESULTS

We identified 161 patients who suffered cardiac arrest in the ED. The mean age was 45 years; 55.9% were female, and 82.6% were aged >18. Common presenting diagnoses were pneumonia (16.1%), sepsis (14.9%), congestive heart failure/cardiogenic shock (11.2%) and cerebrovascular accident (10.6%). Few patients were on cardiac or oxygen saturation monitors (23.1%; 63.5%) prior to arrest. 43 (27%) patients received ACLS (two patients missing data). Among these, 58.1% had initial rhythm assessed, and 2/25 (8%) patients had shockable rhythms. The median time to arrest was 23.6 hours. Sustained return of spontaneous circulation was achieved in two patients (4.7%). Among patients for whom ACLS was not initiated, the majority were due to poor prognosis (66.4%) or irreversible cause (22.4%) in the setting of available resources. One patient survived to 24 hours; none survived to hospital discharge.

CONCLUSION

In this lower middle-income setting, cardiac arrest in the ED was associated with poor survival despite ACLS. Survival may be impacted by limited resources for prearrest monitoring as well as for ongoing critical care.

Out-of-hospital cardiac arrest event after cancer diagnosis: a korean metropolitan cohort study

BACKGROUND

The importance of assessing out-of-hospital cardiac arrest (OHCA) risk in cancer patients is increasing as cancer incidence rises in aging populations.

OBJECTIVE

This study aimed to investigate the association between newly diagnosed cancer and OHCA risk using a metropolitan cohort from South Korea.

METHODS

A population-based retrospective cohort study was conducted, linking the nationwide OHCA registry with the National Health Information Database. The study included adults aged 40 years or older, residing in Seoul between 2015 and 2018, with no history of cancer or OHCA. The main exposure was cancer development. The primary outcome was the occurrence of OHCA with medical cause. Adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) were calculated using a cause-specific hazard model considering death as a competing risk. Analyses stratified by age group and cancer type were also conducted.

RESULTS

During a follow-up period of up to 4 years for 5,450,438 individuals, 174,785 participants developed cancer. The incidence rates of OHCA per 100,000 person-years were 54.0 in non-cancer and 145.0 in cancer groups, respectively. The aHR (95% CI) for OHCA associated with cancer development was 3.18 (2.97-3.41). The aHR (95% CI) for OHCA was highest in the 40-49 years of age group (7.52 [5.52-10.25]), followed by 50-59 years old (6.66 [5.56-7.97]) compared to older age groups. By cancer type, pancreatic, lung, biliary tract, and liver cancer were associated with a significantly increased risk of OHCA.

CONCLUSION

We found an association between newly diagnosed cancer and the occurrence of OHCA. Our findings underscore the importance of tailored risk assessments and proactive care planning for patients with cancer.

Are Saudi Radiological Sciences Students Prepared for Emergencies? Exploring Knowledge, and Attitudes Towards Basic Life Support and Cardiopulmonary Resuscitation

Purpose

This study aims to evaluate the preparedness of Saudi radiological sciences students for emergencies by assessing their awareness of cardiac arrest evaluation criteria, knowledge of Cardiopulmonary Resuscitation (CPR) and defibrillators, and attitudes towards performing CPR.

Methods

A cross-sectional descriptive study was conducted among students from the radiological sciences program at three Saudi universities. Using a well-established questionnaire, the study employed non-probability convenient sampling. Descriptive statistics were generated, and chi-square test examined associations between categorical variables and Basic Life Support (BLS) training status.

Results

Out of 367 students contacted, 261 participated (71.1% response rate). BLS training markedly enhances knowledge of the correct chest compression rate, with 50.9% of trained students demonstrating accurate understanding compared to 27.5% of untrained students (P < 0.0001). A significant correlation was found between BLS training and the ability to perform cardiac massage during cardiac arrest and respiratory standstill, with 44.1% of students demonstrating this knowledge (P < 0.0001). Notably, 80.8% of students without BLS training lacked knowledge of cardiac massage, compared to only 30.4% of those with training. Additionally, 30.6% of students were familiar with defibrillators, and 44.1% knew AED locations (P = 0.0007). Hesitation to perform CPR was mainly due to fear of mistakes (53.6%) and harm concerns (31.1%).

Conclusion

Our findings reveal significant gaps in knowledge, confidence, and preparedness for cardiac emergencies among Saudi radiological sciences students, with only 41.4% having completed BLS training. These results highlight the urgent need for comprehensive BLS education to.

Guidelines for Performing Ultrasound-Guided Vascular Cannulation: Recommendations of the American Society of Echocardiography

Vascular access is a commonly performed procedure to facilitate patient care. This document provides expert consensus from diverse specialists on best practices and techniques for incorporating ultrasound (US) into vascular access procedures. This update replaces the 2011 American Society of Echocardiography guidelines for US-guided vascular cannulation. It includes recommendations for US-guided access to central and peripheral veins and arteries in adult and pediatric patients based on the strength of the scientific evidence present in the literature. The major roles of US during vascular access include (1) precannulation vessel assessment, (2) dynamic US guidance during cannulation, and (3) identification of local complications. This document discusses the general aspects of anatomic and US imaging of vessels, US-guided vascular cannulation techniques, and the identification of local vascular cannulation complications. Proper training should impart the cognitive knowledge and technical skills necessary to perform US-guided cannulation. There is an increasing body of literature indicating that US-guided vascular access improves success rates and reduces complications, although the quality of the evidence to date remains weak. A gap remains between the existing evidence and guidelines for the use of US in clinical practice. The availability of US equipment and clinical proficiency will more likely influence the role of US-guided vascular access as a standard of care than will future research studies.

Comparison of Macintosh Direct Laryngoscope with the C-MAC and Tuoren Videolaryngoscopes in Facilitating Endotracheal Intubation during Uninterrupted Manual Chest Compression: A Randomized Crossover Manikin Study

Background

Videolaryngoscopes (VLS) frequently provide superior views of the glottis compared with traditional direct laryngoscopy (DL), especially during unexpected difficult airways. Chest compressions during attempts to intubate the trachea make it a difficult situation. Although VLS have been compared with DL for intubation during resuscitation, there is a paucity of literature comparing VLS with integrated screen and distant screen with DL during continued manual chest compressions.

Materials and methods

This was a prospective, randomized, crossover observational manikin study. A total of 20 participants performed intubation, while manual chest compression was continuing, with each of the three devices on six occasions, but in different, randomized order. The primary outcome parameter was the total time taken for successful intubation. The secondary outcome criteria included the number of attempts, ease of intubation, and the device preference.

Results

Time taken for successful intubation and ease of intubation were significantly better with C-MAC VLS and DL as compared with Tuoren VLS (C-Mac vs Tuoren p < 0.000 for both; DL vs Tuoren p < 0.001 for time and p = 0.021 for ease). There was no significant difference between C-MAC and DL (p = 1.0 for time and p = 0.69 for ease). There was no significant difference with regard to the number of attempts for successful intubation with any of these devices (p = 0.310). C-Mac was the most and Tuoren was the least preferred device.

Conclusion

C-MAC VLS and Macintosh DL are significantly easier to use and require significantly less time to achieve successful intubation as compared with the Tuoren VLS during continued manual chest compression. Among the devices tested, C-MAC VLS was the most preferred for endotracheal intubation during uninterrupted manual chest compressions.

How to cite this article

Kumar R, Kumar R, Kumar N. Comparison of Macintosh Direct Laryngoscope with the C-MAC and Tuoren Videolaryngoscopes in Facilitating Endotracheal Intubation during Uninterrupted Manual Chest Compression: A Randomized Crossover Manikin Study. Indian J Crit Care Med 2025;29(2):113-116.

Development and Implementation of a Multicenter Registry for Resuscitation-Focused Transesophageal Echocardiography

STUDY OBJECTIVE

To evaluate the clinical effect, safety, and clinical outcomes of focused transesophageal echocardiography (TEE) in the evaluation of critically ill patients in the emergency department (ED) and ICUs.

METHODS

We established a prospective, multicenter, observational registry involving adult critically ill patients in whom focused TEE was performed for evaluation of out-of-hospital cardiac arrest (OHCA), inhospital cardiac arrest, evaluation of undifferentiated shock, hemodynamic monitoring, and/or procedural guidance in the ED, ICU, or operating room setting. The primary objective of the current investigation was to evaluate the clinical influence and safety of focused, point-of-care TEE in critically ill patients. Data elements included patient and procedure characteristics, laboratory values, timing of interventions, clinical outcomes, and TEE video images.

RESULTS

A total of 1,045 focused TEE studies were collected among 916 patients from 28 hospitals, including 585 (64%) intraarrest and postarrest OHCA and inhospital cardiac arrest, 267 (29%) initial evaluation of undifferentiated shock, 101 (11%) procedural guidance, and 92 (10%) hemodynamic monitoring. TEE changed management in 85% of patients with undifferentiated shock, 71% of patients with inhospital cardiac arrest, and 62% of patients with OHCA. There were no reported esophageal perforations or oropharyngeal injuries, and other procedural complications were rare.

CONCLUSIONS

A prospective, multicenter, and multidisciplinary TEE registry was successfully implemented, and demonstrated that focused TEE is safe and clinically impactful across multiple critical care applications. Further studies from this research network will accelerate the development of outcome-oriented research and knowledge translation on the use of TEE in emergency and critical care settings.

Advancing healthcare practice and education via data sharing: demonstrating the utility of open data by training an artificial intelligence model to assess cardiopulmonary resuscitation skills

Health professional education stands to gain substantially from collective efforts toward building video databases of skill performances in both real and simulated settings. An accessible resource of videos that demonstrate an array of performances - both good and bad-provides an opportunity for interdisciplinary research collaborations that can advance our understanding of movement that reflects technical expertise, support educational tool development, and facilitate assessment practices. In this paper we raise important ethical and legal considerations when building and sharing health professions education data. Collective data sharing may produce new knowledge and tools to support healthcare professional education. We demonstrate the utility of a data-sharing culture by providing and leveraging a database of cardio-pulmonary resuscitation (CPR) performances that vary in quality. The CPR skills performance database (collected for the purpose of this research, hosted at UK Data Service's ReShare Repository) contains videos from 40 participants recorded from 6 different angles, allowing for 3D reconstruction for movement analysis. The video footage is accompanied by quality ratings from 2 experts, participants' self-reported confidence and frequency of performing CPR, and the demographics of the participants. From this data, we present an Automatic Clinical Assessment tool for Basic Life Support that uses pose estimation to determine the spatial location of the participant's movements during CPR and a deep learning network that assesses the performance quality.

Evaluating the Impact of Point-of-Care Electroencephalography on Length of Stay in the Intensive Care Unit: Subanalysis of the SAFER-EEG Trial

BACKGROUND

Electroencephalography (EEG) is needed to diagnose nonconvulsive seizures. Prolonged nonconvulsive seizures are associated with neuronal injuries and deleterious clinical outcomes. However, it is uncertain whether the rapid identification of these seizures using point-of-care EEG (POC-EEG) can have a positive impact on clinical outcomes.

METHODS

In a retrospective subanalysis of the recently completed multicenter Seizure Assessment and Forecasting with Efficient Rapid-EEG (SAFER-EEG) trial, we compared intensive care unit (ICU) length of stay (LOS), unfavorable functional outcome (modified Rankin Scale score ≥ 4), and time to EEG between adult patients receiving a US Food and Drug Administration-cleared POC-EEG (Ceribell, Inc.) and those receiving conventional EEG (conv-EEG). Patient records from January 2018 to June 2022 at three different academic centers were reviewed, focusing on EEG timing and clinical outcomes. Propensity score matching was applied using key clinical covariates to control for confounders. Medians and interquartile ranges (IQRs) were calculated for descriptive statistics. Nonparametric tests (Mann-Whitney U-test) were used for the continuous variables, and the χ2 test was used for the proportions.

RESULTS

A total of 283 ICU patients (62 conv-EEG, 221 POC-EEG) were included. The two populations were matched using demographic and clinical characteristics. We found that the ICU LOS was significantly shorter in the POC-EEG cohort compared to the conv-EEG cohort (3.9 [IQR 1.9-8.8] vs. 8.0 [IQR 3.0-16.0] days, p = 0.003). Moreover, modified Rankin Scale functional outcomes were also different between the two EEG cohorts (p = 0.047).

CONCLUSIONS

This study reveals a significant association between early POC-EEG detection of nonconvulsive seizures and decreased ICU LOS. The POC-EEG differed from conv-EEG, demonstrating better functional outcomes compared with the latter in a matched analysis. These findings corroborate previous research advocating the benefit of early diagnosis of nonconvulsive seizure. The causal relationship between the type of EEG and metrics of interest, such as ICU LOS and functional/clinical outcomes, needs to be confirmed in future prospective randomized studies.

Cardiac Critical Care of the Cardio-Obstetric Patient

Cardiovascular disease (CVD) is the leading cause of pregnancy-related mortality in the United States, with an incidence that has increased from 7.2 to 32.9 fatalities per 100,000 live births in the last 3 decades. This trend underscores the potential for an increase in the volume of admissions to cardiac intensive care units (CICUs) in the peripartum period. While congestive heart failure remains at the forefront of maternal morbidity, other life-threatening conditions include myocardial infarction (MI), hypertensive emergencies, fatal arrhythmias such as ventricular fibrillation, venous thromboembolism, aortopathies, valvular dysfunction, cardiac arrest, and cardiogenic shock. The lack of standardized guidelines to facilitate management of these conditions highlights the significant gap in medical knowledge while caring for acutely ill pregnant women. Through this comprehensive review, we highlight the most common cardiac pathologies encountered in the obstetric population and their diagnosis and contemporary management in the cardiac intensive care unit.

Emergency response planning for sudden cardiac arrest in amateur football clubs in Germany (federal state Saarland)

ABSTRACT

Objective

While emergency care for sudden cardiac arrest (SCA) is strictly regulated in professional football, the situation in amateur football is unclear. This study investigated the emergency readiness for SCA in German amateur football clubs.

Methods

A cross-sectional survey of 253 German amateur football clubs (fifth division and lower) was conducted between January and August 2023. Club representatives participated in a 30-point questionnaire on automated external defibrillator (AED) availability, visibility, purchase, usage, frequency of staff trained in cardiopulmonary resuscitation (CPR) and AED usage, regular CPR and AED training, and the existence of an emergency action plan (EAP).

Results

161 of 253 eligible clubs (64% response rate) participated. An AED was available in 48/161 (30%) clubs. 46 of 161 clubs (29%) had no CPR-trained staff. A high availability of CPR- and AED-trained staff (>75% likelihood of being present at the pitch) was more likely during a match (61% and 84%) than training (40% and 51%), respectively. Retrospectively, over 7 years, five clubs reported that CPR-trained staff used an AED, resulting in a survival rate of 80%. 16 clubs (10%) had an EAP in the event of an SCA.

Conclusion

German amateur football clubs show low emergency readiness for SCA despite a promising survival rate when an AED is used by CPR-trained staff on-site. Regular CPR and AED training for club members, increased availability of AEDs, and the development of EAPs might be beneficial in responding adequately to an SCA during football training and matches.

Prehospital critical care beyond advanced life support for out-of-hospital cardiac arrest: A systematic review

Aim

To assess the clinical outcomes of patients with out-of-hospital cardiac arrest attended by prehospital critical care teams compared to non-critical care teams.

Methods

This review was prospectively registered with PROSPERO and the eligibility criteria followed a PICOST framework for ILCOR systematic reviews. Prehospital critical care was defined as any provider with enhanced clinical competencies beyond standard advanced life support algorithms and dedicated dispatch to critically ill patients. MEDLINE, Embase and CINAHL databases were searched from inception to 20 April 2024. Risk of bias was assessed using the ROBINS-I tool and the certainty of evidence by the GRADE approach. Meta-analyses of pooled data from studies at moderate risk of bias were performed using a generic inverse-variance with random-effects.

Results

The search returned 6,444 results and 17 articles were included, reporting 1,192,158 patients. Three studies reported traumatic patients and one reported paediatric patients. All studies were non-randomised and 15 were at moderate risk of bias. Most studies included prehospital physicians (n = 16). For adult non-traumatic patients, the certainty of evidence was low and prehospital critical care was associated with improved survival to hospital admission (OR 1.95, 95% CI 1.35-2.82), survival to hospital discharge (OR 1.34, 95% CI 1.10-1.63), survival at 30 days (OR 1.56, 95% CI 1.38-1.75), and favourable neurological outcome at 30 days (OR 1.48, 95% CI 1.19-1.84). Prehospital critical care was also associated with improved outcomes for traumatic and paediatric patients and the certainty of evidence was very low.

Conclusion

Attendance of prehospital critical care teams to patients with out-of-hospital cardiac arrest is associated with improved outcomes.

Breaking down barriers: Call-taker strategies to address caller perception of inappropriateness of cardiopulmonary resuscitation during the emergency ambulance call

BACKGROUND

Ambulance call-takers perform the critical role of prompting callers to initiate and continue cardiopulmonary resuscitation (CPR) for patients with suspected out-of-hospital cardiac arrest (OHCA). This study aimed to identify call-taker strategies to address callers' perceptions of CPR 'inappropriateness' (perceiving the patient as dead and beyond help, or as showing signs of life).

METHODS

Using a linguistic approach, we analysed 31 calls previously identified as having an inappropriateness barrier to CPR initiation or continuation. In Phase 1, we listened to call recordings and studied call transcripts to identify the strategies and linguistic features used by call-takers. Phase 2 was a discourse analysis of transcript extracts to describe how certain strategies, identified in Phase 1, were used in the caller-call-taker interactions.

RESULTS

Call-takers used various strategies when responding to callers who considered CPR inappropriate. Call-takers rarely used a single strategy or linguistic feature in isolation, tending to use combinations of minimal tokens of alignment (e.g. caller name or encouragements statements), with deontics (including directives/commands and statements of obligation e.g. "do this for me") and provision of either context (e.g. "the ambulance is on its way") or a rationale ("he's not breathing effectively so we need to perform CPR to help him"). Most call-taker attempts were successful, with callers overcoming 71% of initiation barriers and 88% of continuation barriers.

CONCLUSIONS

Call-takers used a combination of linguistic features (minimal/symbolic tokens, deontics) and strategies (providing unscripted statements about the context or a rationale for CPR) to overcome barriers of perceived inappropriateness to CPR.

Advancements in Public First Responder Programs for Out-of-Hospital Cardiac Arrest: An Updated Literature Review

Out-of-hospital cardiac arrest (OHCA) is a leading cause of death worldwide, with a low survival rate of around 7% globally. Key factors for improving survival include witnessed arrest, bystander cardiopulmonary resuscitation (CPR), and early defibrillation. Despite guidelines advocating for the "chain of survival", bystander CPR and defibrillation rates remain suboptimal. Innovative approaches, such as dispatcher-assisted CPR (DA-CPR) and smartphone-based alerts, have emerged to address these challenges. DA-CPR effectively transforms emergency callers into lay rescuers, and smartphone apps are increasingly being used to alert volunteer first responders to OHCA incidents, enhancing response times and increasing survival rates. Smartphone-based systems offer advantages over traditional text messaging by providing real-time guidance and automated external defibrillator (AED) locations. Studies show improved outcomes with app-based alerts, including higher rates of early CPR, increased survival rates and improved neurological outcomes. Additionally, the potential of unmanned aerial vehicles (drones) to deliver AEDs rapidly to OHCA sites has been demonstrated, particularly in rural areas with extended emergency medical services response times. Despite technological advancements, challenges such as ensuring responder training, effective dispatching, and maintaining responder well-being, particularly during the coronavirus disease 19 (COVID-19) pandemic, remain. During the pandemic, some community first responder programs were suspended or modified due to shortages of personal protective equipment (PPE) and increased risks of infection. However, systems that adapted by using PPE and revising protocols generally maintained responder participation and effectiveness. Moving forward, integrating new technology within robust responder systems and support mechanisms will be essential to improving OHCA outcomes and sustaining effective response networks.

Eighteen-year trends in the rates of intra-operative cardiac arrest and associated mortality at a public university hospital in Brazil

BACKGROUND

Intra-operative cardiac arrest is a rare but life-threatening event. Over the past two decades, various initiatives have improved the care of patients undergoing surgery at our quaternary teaching hospital in Brazil. We aimed to evaluate the epidemiology of intra-operative cardiac arrest and associated 30-day mortality over an 18-year period. A secondary aim was to identify associated risk factors.

METHODS

We conducted a retrospective observational study using data collected from 1 January 2005 to 31 December 2022. Factors associated with cardiac arrest and mortality were identified using multivariable logistic regression analysis.

RESULTS

Among the 154,178 cases, the overall rates of intra-operative cardiac arrest (n = 297) and associated 30-day mortality (n = 248) were 19.3 (95%CI (16.6-21.9)) and 16.1 (95% CI 13.9-18.3) per 10,000 anaesthetics, respectively. These decreased over time (2005-2010 vs. 2017-2022) from 26.3 (95%CI 21.0-31.6) to 15.4 (95%CI 12.0-18.7) per 10,000 anaesthetics, and from 23.4 (95%CI 18.8-28.1) to 13.7 (95%CI 10.8-16.7) per 10,000 anaesthetics, respectively. Factors associated with intra-operative cardiac arrest included children aged < 1 year (adjusted OR (95%CI) 3.51 (1.87-6.57)); ASA physical status 3-5 (adjusted OR (95%CI) 13.85 (8.86-21.65)); emergency surgery (adjusted OR (95%CI) 10.06 (7.85-12.89)); general anaesthesia (adjusted OR (95%CI) 8.79 (4.60-19.64)); surgical procedure involving multiple specialities (adjusted OR (95%CI) 9.13 (4.24-19.64)); cardiac surgery (adjusted OR (95%CI) 7.69 (5.05-11.71)); vascular surgery (adjusted OR (95%CI) 6.21 (4.05-9.51)); and gastrointestinal surgery (adjusted OR (95%CI) 2.98 (1.91-4.65)).

DISCUSSION

We have shown an important reduction in intra-operative cardiac arrest and associated 30-day mortality over an 18-year period. Identification of relative risk factors associated with intra-operative cardiac arrest can be used to improve the safety and quality of patient care, especially in a resource-limited setting.

Rationale and development of a prehospital goal-directed bundle of care to prevent rearrest after return of spontaneous circulation

In patients with out-of-hospital cardiac arrest (OHCA) who attain return of spontaneous circulation (ROSC), rearrest while in the prehospital setting represents a significant barrier to survival. To date, there are limited data to guide prehospital emergency medical services (EMS) management immediately following successful resuscitation resulting in ROSC and prior to handoff in the emergency department. Post-ROSC care encompasses a multifaceted approach including hemodynamic optimization, airway management, oxygenation, and ventilation. We sought to develop an evidenced-based, goal-directed bundle of care targeting specified vital parameters in the immediate post-ROSC period, with the goal of decreasing the incidence of rearrest and improving survival outcomes. Here, we describe the rationale and development of this goal-directed bundle of care, which will be adopted by several EMS agencies within California. We convened a group of EMS experts, including EMS Medical Directors, quality improvement officers, data managers, educators, EMS clinicians, emergency medicine clinicians, and resuscitation researchers to develop a goal-directed bundle of care to be applied in the field during the period immediately following ROSC. This care bundle includes guidance for prehospital personnel on recognition of impending rearrest, hemodynamic optimization, ventilatory strategies, airway management, and diagnosis of underlying causes prior to the initiation of transport.

Evaluating video-supported layperson CPR compared to a standard training course: A randomized controlled trial

Background

While just-in-time (JIT) training is associated with time and cost savings, limited evidence directly compares layperson CPR performance using JIT videos to in-person CPR courses. We measured layperson CPR performance using a JIT video compared to an in-person course or no training.

Methods

Adult employees at a professional sports stadium were randomized to perform CPR in a simulated scenario a) after completing an AHA HeartSaver® course, b) using a JIT training video, or c) neither (control). CPR performance was assessed by trained evaluators and QCPR-enabled simulators. The primary outcome was the performance of pre-defined critical actions. Participants were blinded to study objectives and trained evaluators used standardized checklists.

Results

Of 230 eligible subjects, 221 were included in analysis, without significant differences in group characteristics. Correct CPR performance was low, though significantly higher in the AHA group (AHA: 40%, 95%CI 28-51; JIT: 15%, 95%CI 8-26; control 10%, 95%CI 4-19). Compression fraction was significantly greater in the AHA group (90%, IQR 69-98) compared to JIT (61%, IQR 29-89) or control (65%, IQR 33-93). An AED was requested more frequently in the AHA group (47%) than in the JIT (15%) or control (10%) groups.

Conclusions

While overall performance of correct CPR skills was best following a traditional CPR course, laypersons using real-time video training performed as well as those taking an AHA HeartSaver® course on several key measures including time to chest compressions and compression rate.Trial Registration.NCT05983640.

In-hospital cardiac arrest in middle-income settings: A comprehensive analysis of clinical profiles and outcomes of both adults and pediatrics

Background

In hospital cardiac arrest is associated with poor survival despite basic and advanced life support measures. This study aimed to identify the clinical characteristics and outcomes of cardiac arrests occurring during in-hospital admission to the tertiary care center in Pakistan.

Method

A retrospective, cross-sectional study at Aga Khan University Hospital from 2021 to 2023 analyzed 230 cardiac arrest cases. Data included demographics, arrest type, timing, initial rhythm, resuscitation duration, and arrest location. American Heart Association guidelines were adhered to for life support. The main outcomes focused on the return of spontaneous circulation survival to hospital discharge.

Results

During the study, 230 cardiac arrests were observed: 152 in adults (mean age 57.8, 142 shockable cases, ROSC 52.6 %, alive at discharge 28.3 %) and 78 in pediatric patients (mean age 4.99, non-shockable rhythm 85.9 %, ROSC 51.3 %, alive at discharge 17.9 %). Adult Charles comorbidity index: 2.88 (SD±2.08), pediatric index: 0.610 (SD±0.88). Survival rates were lower with a high comorbidity index and code duration > 20 min.

Conclusion

The study provides valuable observational data that challenges global survival rates for in-hospital cardiac arrest. It highlights how factors like being in monitored units and the presence of rapid response teams can lead to higher survival rates. The research underscores the influence of comorbidities, initial rhythms, and the duration of resuscitation efforts on patient outcomes, emphasizing the need for more research, especially in settings with limited resources.

Influence of rescuer position and arm angle on chest compression quality: An international multicentric randomized crossover simulation trial

Background

Success in resuscitation depends not only on the timeliness of the maneuvers but also on the quality of chest compressions. Factors such as the rescuer position and arm angle can significantly impact compression quality.

Aim

This study explores the influence of rescuer positioning and arm angle on the quality of chest compressions among healthcare professionals experienced in cardiopulmonary resuscitation.

Methods

In this international, multicentric, randomized crossover simulation trial with independent groups, healthcare professionals were assigned to one of four positions: kneeling on the floor, standing, standing on a step stool, and kneeling on the bed. Participants performed two 3-minute trials of uninterrupted chest compressions at arm angles of 90° and 105°. Compression quality was assessed, using manikin derived data.

Results

A total of 76 participants entered the study. Those using a 90° arm angle exhibited higher compression scores than those at a 105° angle. Rescuers standing on a step stool maintained higher scores over time when compared to other groups. In contrast, rescuers kneeling on the bed consistently scored below 75% throughout the trial, with particularly low scores at the 105° angle.

Conclusion

Rescuer position and arm angle significantly influence CPR quality, with a 90° arm angle and elevated positioning optimizing compression depth and effectiveness. The results recommend against kneeling on the bed due to its negative impact on chest compression quality.

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.

The association between early hypotension and neurologic outcome after pediatric cardiac ECPR in children with cardiac disease

Objective

Explore the relationship between early hypotension after ECPR and survival to hospital discharge (SHD) with favorable neurologic outcome (FNO) in children with cardiac disease.

Methods

Retrospective cohort study of patients undergoing ECPR at a single center pediatric cardiac intensive care unit. Hypotension was defined as MAP < 5th percentile for age. Primary and secondary exposure variables were presence and burden of hypotension respectively, during the first 6 h after ECPR. Our primary outcome was SHD with FNO defined by Pediatric Cerebral Performance Category score of 1-3 or no change from baseline. Secondary outcomes included acute central nervous system (CNS) injury via neuroimaging and EEG. Univariate and multivariable logistic regression analyses were performed.

Results

We analyzed 82 index ECPR events from 2010 to 2022. Hypotension was observed for at least one MAP value in 36/82 (43.9%) of the cohort. The median [IQR] burden of hypotension was 0 [0,14.3]%. Patients with SHD with FNO had shorter CPR duration, lower number of epinephrine and calcium doses, and lower maximum lactate levels when compared to patients who died or had SHD without FNO. After controlling for potential confounders, there was no association between presence of hypotension or burden of hypotension and SHD, SHD with FNO, or acute CNS injury via neuroimaging and EEG.

Conclusion

In children with cardiac disease, there was no association between early hypotension after ECPR and SHD with FNO. Multicenter studies are needed to better understand how early hypotension after ECPR affects neurologic outcomes in children with cardiac disease.

Vasopressor or advanced airway first in cardiac arrest?

BACKGROUND

While resuscitation guidelines emphasize early vasopressor administration and advanced airway management, their optimal sequence remains unclear. We sought to determine the associations between vasopressor-airway resuscitation sequence and out-of-hospital cardiac arrest (OHCA) outcomes in the Pragmatic Airway Resuscitation Trial (PART).

METHODS

We analyzed data from the PART trial. For each patient we determined times of first vasopressor administration (epinephrine or vasopressin), and successful advanced airway insertion (laryngeal tube or endotracheal tube). We classified each case as vasopressor-first or advanced airway-first. We used Generalized Estimating Equations to determine associations between vasopressor-airway sequence and outcomes (72-hour survival, return of spontaneous circulation (ROSC) on emergency department arrival, survival to hospital discharge, hospital survival with favorable neurologic status) and CPR outside of recommended parameters (chest compression fraction <0.8, chest compression rate <100 or >120 per min, or ventilation rate <8 or >12 breaths/min), adjusting for confounders.

RESULTS

Of 3,004 patients in the parent trial, we analyzed 2,404, including 1,821 vasopressor-first and 583 advanced airway-first. Median intervention times: ALS arrival-to-vasopressor 8 min (IQR 6-11) and ALS arrival-to-airway 11 min (8-15). Compared with airway-first, vasopressor-first sequence was not associated with 72-hour survival (adjusted OR 0.96; 95% CI: 0.71-1.31), ROSC (0.83; 0.66-1.06), hospital survival (1.09; 0.68-1.73), or hospital survival with favorable neurologic status (0.97; 0.53-1.78). Vasopressor-first sequence was not associated with non-compliance with recommended CPR performance parameters.

CONCLUSIONS

Vasopressor-airway resuscitation sequence was not associated with OHCA outcomes or CPR quality.

Why physicians use sodium bicarbonate during cardiac arrest: A cross-sectional survey study of adult and pediatric clinicians

Background

Despite recommendations against routine use, sodium bicarbonate (SB) is administered in approximately 50% of adult and pediatric in-hospital cardiac arrest (IHCA).

Methods

Cross-sectional electronic survey of adult and pediatric attending physicians at two academic hospitals in Boston, Massachusetts. The survey included two IHCA vignettes. Additional open- and closed-ended items explored clinician beliefs surrounding intra-arrest SB and perspectives on a hypothetical clinical trial comparing SB with placebo.

Results

Of the 356 physicians invited, 224 (63 %) responded. Of these, 54 (24 %) said they would "probably" or "definitely give" SB in Scenario 1 (10-minute asystolic arrest) compared to 110 (49 %) for Scenario 2 (20-minute asystolic arrest; p < 0.001). The most frequently reported indications for SB were: hyperkalemia (78 %); metabolic acidosis (76 %); tricyclic anti-depressant overdose (71 %); and prolonged arrest duration (64 %). Of the 207 (92 %) respondents who reported using intra-arrest SB in at least some circumstances, the most common reasons for use were: "last ditch effort" in a prolonged arrest (75 %) and belief that there were physiologic benefits (63 %). When asked of the importance of a clinical trial to guide intra-arrest SB use, 188 (84 %) respondents felt it was at least of average importance, and 140 (63 %) said they would be "somewhat" or "very comfortable" enrolling patients in a trial comparing SB and placebo in IHCA.

Conclusions

Physicians reported practice variations surrounding cardiac arrest management with SB. Respondents commonly cited metabolic acidosis and prolonged arrest duration as indications for intra-arrest SB, despite not being supported by the American Heart Association's advanced life support guidelines.

Enhancing Nurse Practitioners' Emergency Care Competency and Self-Efficacy Through Experiential Learning: A Single-Group Repeated Measures Study

BACKGROUND/OBJECTIVE

Nurse practitioners serve a vital role as first responders in emergencies. This study investigated the effectiveness of experiential learning in enhancing emergency care competency and self-efficacy among nurse practitioners.

METHODS

A single-group repeated measures design was implemented from June to August 2023 at a regional teaching hospital in southern Taiwan, involving 95 nurse practitioners and NP trainees. Participants completed a baseline (T0) three-minute emergency simulation test, followed by one-on-one guidance, an immediate post-test (T1), and a follow-up test one month later (T2). The "Emergency Care Capability Checklist" (ECCC) was used to assess performance after each test, and the "General Self-Efficacy Scale" at T1 and T2.

RESULTS

The mean age of the participants was 42.1 years (SD = 6.7), with 91 out of 95 participants (95.8%) being female. ECCC scores increased significantly from a baseline mean of 34.6 (standard deviation [SD] = 8.8 at T0 to 46.4 (SD = 4.3) at T1 (p < 0.001). Scores remained elevated at T2, with a mean of 44.7 (SD = 4.9), which was significantly higher than T0 (p < 0.001). However, scores at T2 were slightly lower than at T1 (p = 0.018). GSES scores also increased significantly from T1 (mean = 26.2, SD = 0.6) to T2 (mean = 28.0, SD = 0.6) (p = 0.009).

CONCLUSIONS

This study found that experiential learning was able to significantly improve nurse practitioners' emergency care competencies and self-efficacy. Future research should explore the application of experiential learning in diverse clinical settings to further advance emergency preparedness and self-efficacy among nurse practitioners.

The Association of Time to Key Prehospital Interventions Recorded by EMT-Worn video Devices and Sustained Return of Spontaneous Circulation in Out-of-Hospital Cardiac Arrest

OBJECTIVES

The quality of prehospital resuscitation provided by emergency medical technicians (EMTs) is essential to ensure better outcomes following out-of-hospital cardiac arrests (OHCA). We assessed the quality of prehospital resuscitation by recording time to key prehospital interventions using EMT-worn video devices and investigated its association with outcomes of patients with OHCA.

METHODS

This retrospective, cross-sectional study included cases of non-traumatic OHCA in adults treated by emergency medical services (EMS) in Hsinchu City, Taiwan, during 2022 and 2023. We used data from high-resolution, chest-mounted wearable cameras to define and measure six quality indices (QIs) for prehospital resuscitation interventions (i.e., time spent recognizing OHCA). To evaluate the association between QI performance and sustained return of spontaneous circulation (ROSC), we used multivariable logistic regression.

RESULTS

Of 745 patients eligible for this study, 187 (25.1%) achieved sustained ROSC. Six core QIs were analyzed: recognition of OHCA (median time: 9.0 s), time from recognizing OHCA to initiating cardiopulmonary resuscitation (cardiopulmonary resuscitation [CPR]; 9.0 s), automated external defibrillator setup (34.0 s), time from recognizing OHCA to beginning ventilation (160.0 s), advanced airway management (300 s), and deploying a mechanical CPR device (50 s). The performance of the six QIs were not associated with sustained ROSC (Adjusted odds ratio [95% confidence interval]: 1.00 [0.99-1.00], 0.99 [0.98-1.00], 1.00 [1.00-1.01], 1.00 [1.00-1.00], 1.00 [1.00-1.00], and 0.99 [0.99-1.00], respectively).

CONCLUSIONS

This study describes the rate of sustained ROSC and time to key interventions captured by EMT-worn video devices in non-traumatic OHCA patients. Although we found no direct link between QI performance and improved OHCA outcomes, this study highlights the potential of video-assisted QIs to enhance the documentation and understanding of prehospital resuscitation processes. These findings suggest that further refinement and application of these QIs could support more effective resuscitation strategies and training programs.

YouTube as a source of information in cardiopulmonary resuscitation for 2020 AHA Resuscitation Guidelines

Background

The Internet has transformed global information access, particularly through platforms like YouTube, which launched in 1995 and has since become the second largest search engine worldwide with over two billion monthly users. While YouTube offers extensive educational content, including health topics like cardiopulmonary resuscitation (CPR) and basic life support (BLS), it also poses risks due to potential misinformation. Our study focuses on evaluating the accuracy of CPR and BLS videos on YouTube according to the latest 2020 American Heart Association (AHA) guidelines. This research aims to highlight inconsistencies and provide insights into improving YouTube as a reliable educational resource for both lay rescuers and healthcare professionals.

Methods

In this cross-sectional observational study, English YouTube videos uploaded between October 21, 2020, and May 1, 2023, were searched using keywords related to CPR and basic life support. Videos were assessed for their source, duration, views, use of human or mannequin models, and mean assessment scores by two emergency medicine physicians. A third physician's opinion was sought in cases of disagreement. The first assessment evaluated video validity based on specified information criteria, while the second assessed their ability to convey advanced medical information aligned with the 2020 AHA guidelines.

Results

In this study, 201 English YouTube videos uploaded between October 21, 2020, and May 1, 2023, were evaluated based on search terms related to CPR and BLS, resulting in 95 videos meeting inclusion criteria after excluding 106 due to various reasons. Most included videos were from healthcare professionals (49.5%), followed by anonymous sources (29.5%) and official medical organizations (21.1%). Video durations ranged widely from 43 to 6,019 seconds, with an average of 692 seconds. Videos featuring mannequins predominated (91.6%), followed by those using human subjects (5.3%) or both (3.2%). Healthcare professional and official medical organization videos scoring significantly higher than those of unknown origin (p = 0.001). Video length did not correlate significantly with view counts, although shorter videos under 5 minutes tended to have higher average views.

Discussion

The results presented in this study demonstrated that English-language videos on YouTube related to BLS and CPR, throughout the study period, did not conform to the 2020 AHA guidelines in terms of providing basic information for lay rescuers. Furthermore, healthcare professionals cannot obtain advanced medical knowledge through these videos. We recommend a professional oversight mechanism in health-related videos that does not tolerate such misinformation.

2024 Systematic Review of Evidence-Based Guidelines for Prehospital Care

OBJECTIVES

Evidence-based guidelines (EBGs) are widely recognized as valuable tools to aggregate and translate scientific knowledge into clinical care. High-quality EBGs can also serve as important components of dissemination and implementation efforts focused on educating emergency medical services (EMS) clinicians about current evidence-based prehospital clinical care practices and operations. We aimed to perform the third biennial systematic review of prehospital EBGs to identify and assess the quality of prehospital EBGs published since 2021.

METHODS

We systematically searched Ovid Medline and EMBASE from January 1, 2021, to June 6, 2023, for publications relevant to prehospital care, based on an organized review of the literature, and focused on providing recommendations for clinical care or operations. Included guidelines were appraised using the National Academy of Medicine (NAM) criteria for high-quality guidelines and scored using the Appraisal of Guidelines for Research and Evaluation (AGREE) II Tool.

RESULTS

We identified 33 new guidelines addressing clinical and operational topics of EMS medicine. The most addressed EMS core content areas were time-life critical conditions (n = 17, 51.5%), special clinical considerations (n = 15, 45%), and injury (n = 12, 36%). Seven (21%) guidelines included all elements of the National Academy of Medicine (NAM) criteria for high-quality guidelines, including the full reporting of a systematic review of the evidence. Guideline appraisals by the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool demonstrated modest compliance to reporting recommendations and similar overall quality compared to previously identified guidelines (mean overall domain score 67%, SD 12%), with Domain 5 ("Applicability") scoring the lowest of the six AGREE II domains (mean score of 53%, SD 13%).

CONCLUSIONS

This updated systematic review identified and appraised recent guidelines addressing prehospital care and identifies important targets for education of EMS personnel. Continued opportunities exist for prehospital guideline developers to include comprehensive evidence-based reporting into guideline development to facilitate widespread implementation of high-quality EBGs in EMS systems and incorporate the best available scientific evidence into initial education and continued competency activities.

Implementing an intelligent diagnosis and treatment system for in-hospital cardiac arrest in the Utstein style: a multi-center case study

BACKGROUND

Cardiac arrest presents a variety of causes and complexities, making it challenging to develop targeted treatment plans. Often, the original data are either inadequate or lack essential patient information. In this study, we introduce an intelligent system for diagnosing and treating in-hospital cardiac arrest (IHCA), aimed at improving the success rate of cardiopulmonary resuscitation and restoring spontaneous circulation.

METHODS

To compensate for insufficient or incomplete data, a hybrid mega trend diffusion method was used to generate virtual samples, enhancing system performance. The core of the system is a modified episodic deep reinforcement learning module, which facilitates the diagnosis and treatment process while improving sample efficiency. Uncertainty analysis was performed using Monte Carlo simulations, and dependencies between different parameters were assessed using regular vine copula. The system's effectiveness was evaluated using ten years of data from Utstein-style IHCA registries across seven hospitals in China's Hebei Province.

RESULTS

The system demonstrated improved performance compared to other models, particularly in scenarios with inadequate data or missing patient information. The average reward scores in two key stages increased by 2.3-9 and 9.9-23, respectively.

CONCLUSIONS

The intelligent diagnosis and treatment effectively addresses IHCA, providing reliable diagnosis and treatment plans in IHCA scenarios. Moreover, it can effectively induce cardiopulmonary resuscitation and restoration of spontaneous circulation processes even when original data are insufficient or basic patient information is missing.

Benefits of Virtual Reality Training for Cardiopulmonary Resuscitation Skill Acquisition and Maintenance

OBJECTIVES

To investigate the benefits of virtual reality (VR) first-aid training in acquiring cardiopulmonary resuscitation (CPR) skills.

METHODS

A total of 100 non-medical professional volunteers from Nanchang were selected in March 2021 using the convenience sampling method. They were randomly divided into two groups: the VR training group (VR group) and the traditional simulation scenario training group (traditional group). The VR Group underwent immersive virtual reality CPR training with interactive feedback, while the Traditional Group received standard simulation-based CPR training using mannequins and instructor guidance. After training, relevant data were collected for comparative analysis.

RESULTS

The study revealed that the VR group consistently outperforming the traditional group in theoretical knowledge test (cardiac arrest recognition, chest compressions, airway management, and artificial respiration) scores at 1, 3, 6, and 12 months post-training (p < 0.05). Similarly, the VR group showed superior performance in overall skills test scores and individual CPR quality metrics at all post-training assessments. The VR group scored higher in total skills, assessment, post-resuscitation assessment, chest compressions (at 1, 3, and 6 months), airway opening, and artificial respiration compared to the traditional group (p < 0.05). Despite these findings, both groups exhibited a gradual decrease in skills test scores over time.

CONCLUSIONS

Virtual reality training can significantly improve non-medical professional volunteers' CPR knowledge and skill levels, helping them master and maintain these competencies. However, a decrease in CPR knowledge and skills among the participants over time was observed after VR training, suggesting the need for further retraining sessions.

High-dose intranasal insulin in an adaptive dose-escalation study in healthy human participants

Intranasal insulin is a putative neuroprotective therapy after cardiac arrest, but safety in humans at doses extrapolated from animal models is unknown. This phase I, open-label adaptive dose-escalation study explores the maximum tolerated dose of intranasal insulin in healthy human participants. Placebo or insulin at doses from 0 to 1000 units was given to healthy participants intranasally on repeated weekly visits. Serum glucose, insulin, and C-peptide levels were measured serially at 0, 15, 30, 60, 120, 180, and 240 min after administration. Twenty-four participants (12 female, median age 53, IQR 35-61) were enrolled. There was minimal change in average serum glucose after administration of intranasal insulin. Average serum insulin increased slightly in a dose-dependent manner, reaching maximum concentrations at 15 min. C-peptide decreased over time from administration in all groups. One participant had severe hypoglycemia (24 mg/dL at 45 min) and a different participant had mild hypoglycemia (51 mg/dL at 30 min), both after receiving 600 U intranasal insulin. Hypoglycemic episodes were associated with increases in serum insulin. Both participants continued in the study without hypoglycemia after additional doses. High-dose intranasal insulin up to 1000 U was generally well tolerated, with minimal measurable systemic absorption and without significant aggregate changes in mean glucose. Idiosyncratic episodic systemic absorption and hypoglycemia require further study and additional caution in potential clinical application. Further study of its target engagement and efficacy as a neuroprotective therapy after cardiac arrest at these doses is warranted.

A validated NICU database: recounting 50 years of clinical growth, quality improvement and research

The importance of a Neonatal Intensive Care Unit (NICU) database lies in its critical role in improving the quality of care for very preterm neonates and other high-risk newborns. These databases contain extensive information regarding maternal exposures, pregnancy complications, and neonatal care. They support quality improvement (QI) initiatives, facilitate clinical research, and track health outcomes in order to identify best practices and improve clinical guidelines. The Parkland Memorial Hospital NICU database was originally part of the Maternal and Neonatal Data Acquisition, Transmission and Evaluation project funded by the Robert Wood Johnson Foundation to assess perinatal-neonatal care in Dallas County Texas, 1977-1982. Clinical data points were defined, transcribed and validated in 1977; revalidation has occurred multiple times. Data are prospectively extracted from health records of high-risk neonates among >11,000 births annually. The database contains clinical information on >50,000 neonates, including all initially admitted to the NICU regardless of gestational age or birthweight and since 10/03/2011, all neonates admitted for observation and transferred to the term newborn nursery. The database has provided the basis for QI studies and research designed to assess and improve neonatal care. We discuss the history, evolution, administration, impact on neonatal outcomes, and future directions of our database. IMPACT: A single neonatal intensive care unit (NICU) database was designed for prospective data collection, validated and maintained for 46yrs. This database has supported quality improvement assessment, original clinical research, education and administrative requirements and impacted clinical neonatal care.