Optimizing Outcomes After Out-of-Hospital Cardiac Arrest With Innovative Approaches to Public-Access Defibrillation: A Scientific Statement From the International Liaison Committee on Resuscitation

Mortality risk and burden of sudden cardiac arrest associated with hot nights, heatwaves, cold spells, and non-optimum temperatures in 0.88 million patients: An individual-level case-crossover study

Sudden cardiac arrest (SCA) is a global health concern, imposing a substantial mortality burden. However, the understanding of the impact of various extreme temperature events, when accounting for the effect of daily average temperature on SCA, remains incomplete. Additionally, the assessment of SCA mortality burden associated with temperatures from an individual-level design is limited. This nationwide case-crossover study collected individual SCA death records across all (2844) county-level administrative units in the Chinese Mainland from 2013 to 2019. Four definitions for hot nights and ten for both cold spells and heatwaves were established using various temperature thresholds and durations. Conditional logistic regression models combined with distributed lag nonlinear models were employed to estimate the cumulative exposure-response relationships. Based on 887,662 SCA decedents, this analysis found that both hot nights [odds ratio (OR): 1.28; attributable fraction (AF): 1.32 %] and heatwaves (OR: 1.40; AF: 1.29 %) exhibited significant added effects on SCA mortality independent of daily average temperatures, while cold spells were not associated with an elevated SCA risk after accounting for effects of temperatures. Cold temperatures [below the minimum mortality temperature (MMT)] accounted for a larger mortality burden than high temperatures (above the MMT) [AF: 12.2 % vs. 1.5 %]. Higher temperature-related mortality risks and burdens were observed in patients who experienced out-of-hospital cardiac arrest compared to those with in-hospital cardiac arrest. This nationwide study presents the most compelling and comprehensive evidence of the elevated mortality risk and burden of SCA associated with extreme temperature events and ambient temperatures amid global warming.

Bystanders' willingness to assist using automated external defibrillators during cardiac arrest

The "bystander effect," in which the presence of others inhibits rescue actions, has not been specifically examined in the context of cardiac arrest; understanding this effect in relation to rescue with automated external defibrillators (AEDs) is important. This study aims to identify the presence of others as a factor inhibiting rescue actions using an AED, from a social psychology perspective. We collected data through a web-based questionnaire involving registered residents in all 47 prefectures of Japan. The participants were presented with hypothetical scenarios of witnessing cardiac arrest events at train stations, under sparse or crowded conditions, and with or without the presence of competent parties (e.g., station staff or security guards). Their willingness to intervene was assessed across three levels of rescue behavior: (1) running and calling for help, (2) retrieving an AED, and (3) using an AED. This study found evidence of the bystander effect, indicating that the presence of competent others reduced behavioral interventions by bystanders during out-of-hospital cardiac arrest (OHCA) events. Moreover, the perceived presence of competent parties at the scene of a cardiac arrest reduced bystanders' willingness to initiate rescue under certain circumstances. While many bystanders were willing to initiate rescue efforts in response to calls for help, they resisted rescues involving an AED. This study observes that a bystander effect occurs among bystanders witnessing OHCA, explores the inhibiting effects of identifying competent parties on the initiation of rescue efforts, and suggests that there are significant invisible barriers to using AEDs in rescuing patients with OHCA.

Walking time to nearest public automated external defibrillator for out-of-hospital cardiac arrest in a major U.S. city

Background

How frequently out-of-hospital cardiac arrest (OHCA) occurs within a reasonable walking distance to the nearest public automated external defibrillator (AED) has not been well studied.

Methods

As Kansas City, Missouri has a comprehensive city-wide public AED registry, we identified adults with an OHCA in Kansas City during 2019-2022 in the Cardiac Arrest Registry to Enhance Survival. Using AED location data from the registry, we computed walking times between OHCAs and the nearest registered AED using the Haversine formula, a mapping algorithm to calculate walking distance in miles from one location to another. Results were stratified by OHCA location (home vs. public) and by whether the patient received bystander cardiopulmonary resuscitation (CPR).

Results

Of 1,522 OHCAs, 1,291 (84.8%) occurred at home and 231 (15.2%) in public. Among at-home OHCAs, 634 (49.1%) received bystander CPR and no patients had an AED applied even as 297 (23.0%) were within a 4-minute walk to the closest public AED. Among OHCAs in public, 108 (46.8%) were within a 4-minute walk to the closest public AED. For public OHCAs within a 4-minute walk, bystanders applied an AED in 13 (12.0%) of these cases and in 24.5% (13/53) of those who received bystander CPR.

Conclusion

In one U.S. city with a publicly available AED registry, there were no instances in which a bystander accessed a public AED for an OHCA at home. For OHCAs in public, nearly half occurred within a 4-minute walk to the closest AED but bystander use of an AED was low.

Impact of anthropometric factors on chest compression depth during CPR provided by children aged 11-14 in a community-wide study

Objective

To assess the depth of chest compressions (CC) provided by schoolchildren and their relation with providers's anthropometric characteristics.

Methods

We organized 1-hour hands-on training sessions for 11-14y.o. in volunteering schools. After training, willing subjects performed 2 min of recorded continuous CCs by means of Laerdal Resusci Anne® with CPRMeter2®, with visual feedback. Compression pace was given by metronome; instructors supervised the correct body position. Collected data included age, sex, as well as measured body weight and height.

Results

We analyzed records from N = 702 children (mean age: 12.76 ± 1.02 years, 379 (51.63%) boys) out of 761 participating in the study. Their mean median compression depth (MCD) was 46.70 ± 7.74 mm, which was below minimal effective CC depth advised by current guidelines (50 mm). This corresponded to low mean fraction of CCs ≥ 50 mm (CCF ≥ 50 mm, 42.86 ± 33.67%), and only 42.88% of children achieving at least 50% of compressions ≥ 50 mm. Boys had significantly higher mean MCD and CCF ≥ 50 mm than girls (MCD: 49.34 ± 7.05 mm vs 45.97 ± 8.07 mm, p < 0.0001; CCF ≥ 50 mm: 50.23 ± 32.90% vs 40.40 ± 34.97%, p < 0.0001). Age differentiated children who achieved at least 50% of compressions ≥50 mm from those who did not with AUC of 0.69 (for cut-off of 12.1 years: 85% sensitivity, 41% specificity), whereas weight offered an improved prediction (AUC 0.74; for cut-off 44.8 kg: 77.4% sensitivity, 61.1% specificity).

Conclusions

Sex, age and anthropometric factors are significant CC quality factors. Children with higher body weight are more likely to deliver CCF50%≥50 mm. Among the studied population, children ≥12 years old provided more effective chest compressions.

Knowledge and barriers of out of hospital cardiac arrest bystander intervention and public access automated external defibrillator use in the Northeast of England: a cross-sectional survey study

Intervention by members of the public during an out of hospital cardiac arrest (OHAC) including resuscitation attempts and accessible automated external defibrillator (AED) has been shown to improve survival. This study aimed to investigate the OHCA and AED knowledge and confidence, and barriers to intervention, of the public of North East England, UK. This study used a face-to-face cross-sectional survey on a public high street in Newcastle, UK. Participants were asked unprompted to explain what they would do when faced with an OHCA collapse. Chi-Square analysis was used to test the association of the independent variables sex and first aid trained on the participants' responses. Of the 421 participants recruited to our study, 82.9% (n = 349) reported that they would know what to do during an OHCA collapse. The most frequent OHCA action mentioned was call 999 (64.1%, n = 270/421) and 58.2% (n = 245/421) of participants reported that they would commence CPR. However, only 14.3% (n = 60/421) of participants spontaneously mentioned that they would locate an AED, while only 4.5% (n = 19/421) recounted that they would apply the AED. Just over half of participants (50.8%, n = 214/421) were first aid trained, with statistically more females (57.3%, n = 126/220) than males (43.9%,  n = 87/198) being first aiders (p = 0.01 χ2 = 7.41). Most participants (80.3%, n = 338/421) knew what an AED was, and 34.7% (n = 326/421) reported that they knew how to use one, however, only 11.9% (n = 50/421) mentioned that they would actually shock a patient. Being first aid trained increased the likelihood of freely recounting actions for OHCA and AED intervention. The most common barrier to helping during an OHCA was lack of knowledge (29.9%, n = 126/421). Although most participants reported they would know what to do during an OHCA and had knowledge of an AED, low numbers of participants spontaneously mentioned specific OHCA and AED actions. Improving public knowledge would help improve the public's confidence of intervening during an OHCA and may improve OHCA survival.

Cardiac Arrest and Cardiopulmonary Resuscitation Outcome Reports: 2024 Update of the Utstein Out-of-Hospital Cardiac Arrest Registry Template

The Utstein Out-of-Hospital Cardiac Arrest Resuscitation Registry Template, introduced in 1991 and updated in 2004 and 2015, standardizes data collection to enable research, evaluation, and comparisons of systems of care. The impetus for the current update stemmed from significant advances in the field and insights from registry development and regional comparisons. This 2024 update involved representatives of the International Liaison Committee on Resuscitation and used a modified Delphi process. Every 2015 Utstein data element was reviewed for relevance, priority (core or supplemental), and improvement. New variables were proposed and refined. All changes were voted on for inclusion. The 2015 domains-system, dispatch, patient, process, and outcomes-were retained. Further clarity is provided for the definitions of out-of-hospital cardiac arrest attended resuscitation and attempted resuscitation. Changes reflect advancements in dispatch, early response systems, and resuscitation care, as well as the importance of prehospital outcomes. Time intervals such as emergency medical service response time now emphasize precise reporting of the times used. New flowcharts aid the reporting of system effectiveness for patients with an attempted resuscitation and system efficacy for the Utstein comparator group. Recognizing the varying capacities of emergency systems globally, the writing group provided a minimal dataset for settings with developing emergency medical systems. Supplementary variables are considered useful for research purposes. These revisions aim to elevate data collection and reporting transparency by registries and researchers and to advance international comparisons and collaborations. The overarching objective remains the improvement of outcomes for patients with out-of-hospital cardiac arrest.

Cardiac arrest and cardiopulmonary resuscitation outcome reports: 2024 update of the Utstein Out-of-Hospital Cardiac Arrest Registry template

The Utstein Out-of-Hospital Cardiac Arrest Resuscitation Registry Template, introduced in 1991 and updated in 2004 and 2015, standardizes data collection to enable research, evaluation, and comparisons of systems of care. The impetus for the current update stemmed from significant advances in the field and insights from registry development and regional comparisons. This 2024 update involved representatives of the International Liaison Committee on Resuscitation and used a modified Delphi process. Every 2015 Utstein data element was reviewed for relevance, priority (core or supplemental), and improvement. New variables were proposed and refined. All changes were voted on for inclusion. The 2015 domains-system, dispatch, patient, process, and outcomes-were retained. Further clarity is provided for the definitions of out-of-hospital cardiac arrest attended resuscitation and attempted resuscitation. Changes reflect advancements in dispatch, early response systems, and resuscitation care, as well as the importance of prehospital outcomes. Time intervals such as emergency medical service response time now emphasize precise reporting of the times used. New flowcharts aid the reporting of system effectiveness for patients with an attempted resuscitation and system efficacy for the Utstein comparator group. Recognizing the varying capacities of emergency systems globally, the writing group provided a minimal dataset for settings with developing emergency medical systems. Supplementary variables are considered useful for research purposes. These revisions aim to elevate data collection and reporting transparency by registries and researchers and to advance international comparisons and collaborations. The overarching objective remains the improvement of outcomes for patients with out-of-hospital cardiac arrest.

Insights from coronial recommendations for preventing natural deaths in sport and recreation in Québec, Canada

Introduction

This descriptive retrospective study analyzed coronial recommendations for natural deaths in sport and recreation from January 2006 to December 2019 using data from the Bureau du coroner du Québec.

Methods

Reports with recommendations were analyzed by sex, age group, cause of death, context, and activity. The nature of recommendations was assessed using a public health-based model. Thematic analysis was conducted following a four-phase approach in which themes developed were emphasized and further connected with existing literature.

Results

Reports involving individuals aged 18-24 and reports related to ice hockey were significantly more likely to contain recommendations. Reports related to individuals ≥45 years old, or related to cycling or hunting had higher death frequencies, but relatively low recommendation rates. Most recommendations aligned with the public health-based model but specifying implementation time frames was rare (11.7%). Nearly 60% of coroner's recommendations focused on automated external defibrillator implementation, delivery and training.

Discussion

Mitigation of sudden cardiac arrest risk for individuals ≥45 years old, timely treatment of life-threatening arrhythmias especially for activity practiced in remote regions and specifying implementation time frames were identified as improvement areas. The multi-faceted approach to enhancing public access defibrillation developed by the International Liaison Committee on Resuscitation in 2022 addresses recurrent themes covered by coroners and holds the potential to inform evidence-based decision making.

Incidence and Survival of Out-of-Hospital Cardiac Arrest in Public Housing Areas in 3 European Capitals

BACKGROUND

Strategies to reach out-of-hospital cardiac arrests (called cardiac arrest) in residential areas and reduce disparities in care and outcomes are warranted. This study investigated incidences of cardiac arrests in public housing areas.

METHODS

This register-based cohort study included cardiac arrest patients from Amsterdam (the Netherlands) from 2016 to 2021, Copenhagen (Denmark) from 2016 to 2021, and Vienna (Austria) from 2018 to 2021. Using Poisson regression adjusted for spatial correlation and city, we compared cardiac arrest incidence rates (number per square kilometer per year and number per 100 000 inhabitants per year) in public housing and other residential areas and examined the proportion of cardiac arrests within public housing and adjacent areas (100-m radius).

RESULTS

Overall, 9152 patients were included of which 3038 (33.2%) cardiac arrests occurred in public housing areas and 2685 (29.3%) in adjacent areas. In Amsterdam, 635/1801 (35.3%) cardiac arrests occurred in public housing areas; in Copenhagen, 1036/3077 (33.7%); and in Vienna, 1367/4274 (32.0%). Public housing areas covered 42.4 (12.6%) of 336.7 km2 and 1 024 470 (24.6%) of 4 164 700 inhabitants. Across the capitals, we observed a lower probability of 30-day survival in public housing versus other residential areas (244/2803 [8.7%] versus 783/5532 [14.2%]). The incidence rates and rate ratio of cardiac arrest in public housing versus other residential areas were incidence rate, 16.5 versus 4.1 n/km2 per year; rate ratio, 3.46 (95% CI, 3.31-3.62) and incidence rate, 56.1 versus 36.8 n/100 000 inhabitants per year; rate ratio, 1.48 (95% CI, 1.42-1.55). The incidence rates and rate ratios in public housing versus other residential areas were consistent across the 3 capitals.

CONCLUSIONS

Across 3 European capitals, one-third of cardiac arrests occurred in public housing areas, with an additional third in adjacent areas. Public housing areas exhibited consistently higher cardiac arrest incidences per square kilometer and 100 000 inhabitants and lower survival than other residential areas. Public housing areas could be a key target to improve cardiac arrest survival in countries with a public housing sector.

Reducing the Likelihood of Opioid Overdose Fatalities on College and University Campuses: An Action Plan and Model

For more than two decades there has been a continuous rise in opioid overdose related deaths. The majority of the deaths include the age range when, traditionally, individuals are likely to attend college or university. As a result, Vassar College has taken the important initiative and created and implemented a new opioid overdose intervention strategy and action plan called AED+. AED+ expands on the Model of Greater Awareness, Training and Increased Availability of and Accessibility to Life Saving Intervention Devices; a model that was created based on AED devices improving outcomes of out-of-hospital cardiac arrest emergencies. Similar to AED's improving out-of-hospital cardiac arrest outcomes, the + component of the AED+ initiative increases awareness and provides basic, targeted education about naloxone and its use. Furthermore, the education includes information about naloxone's greater availability and its more immediate access across the campus by students, staff, faculty, administrators, and visitors in the event of a suspected opioid overdose. Starting in May 2023, members of the school's Health Service and senior administrative leaders identified it necessary to be proactive and not reactive to managing an opioid overdose in the campus community. Although Vassar College has not recently experienced an opioid overdose, it is confidently projected that these targeted actions will proactively and positively reduce the likelihood of opioid-related fatalities on campus. Furthermore, it is the purpose of this article to share the AED+ model so other colleges and universities can modify it to best fit their unique setting in order to improve opioid overdose outcomes.

Association of coronary angiography with ST-elevation and no ST-elevation in patients with refractory ventricular fibrillation - A substudy of the DOuble SEquential External Defibrillation for Refractory Ventricular Fibrillation (DOSE-VF randomized control trial)

BACKGROUND

Refractory ventricular fibrillation or pulseless ventricular tachycardia (rVF/pVT) during out-of-hospital cardiac arrest (OHCA) is associated with poor survival. Double sequential defibrillation (DSED) and vector change (VC) improved survival for rVF/pVT in the DOSE-VF RCT. However, the role of angiography and percutaneous coronary intervention (angiography/PCI) during the trial is unknown.

OBJECTIVES

To determine the incidence of ST-elevation (STE) and no ST-elevation (NO-STE) on post-arrest ECG and the use of angiography/PCI in patients with rVF/pVT during the DOSE-VF RCT.

METHOD

Adults (≥18-years) with rVF/pVT OHCA randomized in the DOSE-VF RCT who survived to hospital admission were included. The primary analysis compared the proportion of angiography in STE and NO-STE. We performed regression modelling to examine association between STE, the interaction with defibrillation strategy, and survival to discharge controlling for known covariates.

RESULTS

We included 151 patients, 74 (49%) with STE and 77 (51%) with NO-STE. The proportion of angiography was higher in the STE cohort than NO-STE (87.8% vs 44.2%, p < 0.001); similarly the proportion of PCI was also higher (75.7% vs 9.1%, p < 0.001). Survival to discharge was similar between STE and NO-STE (63.5% vs 51.9%, p = 0.15). Use of angiography/PCI did not differ between defibrillation strategies. Decreased age (OR 0.95, 95% CI 0.92-0.98; p = 0.001) and angiography (OR 9.33, 95% CI 3.60-26.94; p < 0.001) were predictors of survival; however, STE was not.

CONCLUSION

We found high rates of angiography/PCI in patients with STE compared to NO-STE, however similar rates of survival. Angiography was an independent predictor of survival. Improved rates of survival employing DSED and VC were independent of angiography/PCI.

Metabolically Glycoengineered Neural Stem Cells Boost Neural Repair After Cardiac Arrest

Cardiac arrest (CA)-induced cerebral ischemia remains challenging with high mortality and disability. Neural stem cell (NSC) engrafting is an emerging therapeutic strategy with considerable promise that, unfortunately, is severely compromised by limited cell functionality after in vivo transplantation. This groundbreaking report demonstrates that metabolic glycoengineering (MGE) using the "Ac5ManNTProp (TProp)" monosaccharide analog stimulates the Wnt/β-catenin pathway, improves cell adhesion, and enhances neuronal differentiation in human NSCs in vitro thereby substantially increasing the therapeutic potential of these cells. For the first time, MGE significantly enhances NSC efficacy for treating ischemic brain injury after asphyxia CA in rats. In particular, neurological deficit scores and neurobehavioral tests experience greater improvements when the therapeutic cells are pretreated with TProp than with "stand-alone" NSC therapy. Notably, the TProp-NSC group exhibits significantly stronger neuroprotective functions including enhanced differentiation, synaptic plasticity, and reduced microglia recruitment; furthermore, Wnt pathway agonists and inhibitors demonstrate a pivotal role for Wnt signaling in the process. These findings help establish MGE as a promising avenue for addressing current limitations associated with NSC transplantation via beneficially influencing neural regeneration and synaptic plasticity, thereby offering enhanced therapeutic options to boost brain recovery following global ischemia.

Spatiotemporal Analysis of Out-of-Hospital Cardiac Arrest Incidence and Survival Outcomes in Korea (2009-2021)

BACKGROUND

Out-of-hospital cardiac arrest is a major public health concern in Korea. Identifying spatiotemporal patterns of out-of-hospital cardiac arrest incidence and survival outcomes is crucial for effective resource allocation and targeted interventions. Thus, this study aimed to investigate the spatiotemporal epidemiology of out-of-hospital cardiac arrest in Korea, with a focus on identifying high-risk areas and populations and examining factors associated with prehospital outcomes.

METHODS

We conducted this population-based observational study using data from the Korean out-of-hospital cardiac arrest registry from January 2009 to December 2021. Using a Bayesian spatiotemporal model based on the Integrated Nested Laplace Approximation, we calculated the standardized incidence ratio and assessed the relative risk to compare the spatial and temporal distributions over time. The primary outcome was out-of-hospital cardiac arrest incidence, and the secondary outcomes included prehospital return of spontaneous circulation, survival to hospital admission and discharge, and good neurological outcomes.

RESULTS

Although the number of cases increased over time, the spatiotemporal analysis exhibited a discernible temporal pattern in the standardized incidence ratio of out-of-hospital cardiac arrest with a gradual decline over time (1.07; 95% credible interval [CrI], 1.04-1.09 in 2009 vs. 1.00; 95% CrI, 0.98-1.03 in 2021). The district-specific risk ratios of survival outcomes were more favorable in the metropolitan and major metropolitan areas. In particular, the neurological outcomes were significantly improved from relative risk 0.35 (0.31-0.39) in 2009 to 1.75 (1.65-1.86) in 2021.

CONCLUSION

This study emphasized the significance of small-area analyses in identifying high-risk regions and populations using spatiotemporal analyses. These findings have implications for public health planning efforts to alleviate the burden of out-of-hospital cardiac arrest in Korea.

Wolf creek XVII part 4: Amplifying lay-rescuer response

Introduction

Amplifying lay-rescuer response is a key priority to increase survival from out-of-hospital cardiac arrest (OHCA). We describe the current state of lay-rescuer response, how we envision the future, and the gaps, barriers, and research priorities that will amplify response to OHCA.

Methods

'Amplifying Lay-Rescuer Response' was one of six focus topics for the Wolf Creek XVII Conference held on June 14-17, 2023, in Ann Arbor, Michigan, USA. Conference invitees included international thought leaders and scientists in the field of cardiac arrest resuscitation from academia and industry. Participants submitted via online survey knowledge gaps, barriers to translation and research priorities for each focus topic. Expert panels used the survey results and their own perspectives and insights to create and present a preliminary unranked list for each category that was debated, revised and ranked by all attendees to identify the top 5 for each category.

Results

The top five knowledge gaps as ranked by the panel, reflected a recognition of the need to better understand the psycho-social aspects of lay response. The top five barriers to translation reflected issues at the individual, community, societal, structural, and governmental levels. The top five research priorities were focused on understanding the social/psychological and emotional barriers to action, finding the most effective/cost-effective strategies to educate lay persons and implement community life-saving interventions, evaluation of new technological solutions and how to enhance the role of dispatch working with lay-rescuers.

Conclusion

Future research in lay rescuer response should incorporate technology innovations, understand the "humanity" of the situation, leverage implementation science and systems thinking to save lives. This will require the field of resuscitation to engage with scholars outside our traditional ranks and to be open to new ways of thinking about old problems.

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

Importance

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

Objective

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

Evidence review

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

Findings

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

Conclusions and relevance

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

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

Sudden Cardiac Death at Home: Potential Lives Saved With Fully Automated External Defibrillators

Sudden cardiac death from ventricular arrhythmia kills about 350,000 people annually in the United States. This number has not improved since the widespread public availability of semi-automated external defibrillators (AEDs) and the teaching of nonbreathing cardiopulmonary resuscitation (CPR) procedures. When an out-of-hospital cardiac arrest occurs in a public space, lay witnesses do CPR in 40% of the cases and use AEDs on only 7.4% of the victims before emergency medical services (EMS) arrive. About 70% of sudden cardiac death occurs at home, where an AED is usually unavailable until EMS appears. The time from a 911 call to shock averages approximately 7 minutes in urban areas and is more than 14.5 minutes in rural environments. Because arrest onset is often not observed, arrest onset to shock times maybe even longer. Survival from cardiac arrest decreases by approximately 7 to 10% per minute of ventricular arrhythmia. A prearrest protocol is proposed for the at-home use of fully automated external defibrillators in select cardiac patients, which should reduce the arrest-to-shock interval to under 1 minute and may eliminate the need for CPR in some cases.

Action Plan and Model to Reduce Potential Opioid Overdose Deaths on K-12 Campuses

School communities are not immune to the alarming increase in opioid-related deaths occurring in the United States during the past decade. The purpose of this article is to share how a middle school in New York State, beginning in the late fall of 2022, successfully implemented a program to reduce the likelihood of opioid overdose deaths in their building through expansion of the accessibility of and education and training in use of naloxone, an opioid antagonist. The program is applicable for all K-12 campuses and follows the Model of Greater Awareness, Improved Training, and Increased Availability of and Accessibility to Intervention Devices, based on the steps successfully used for out-of-hospital cardiac arrest emergencies. Because opioid addiction does not discriminate, it is confidently projected that these targeted actions will proactively and positively reduce the likelihood of opioid overdose deaths in our school setting, including for students, faculty, staff, administrators, and visitors, when and should they occur.

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

Prompt-enhanced hierarchical transformer elevating cardiopulmonary resuscitation instruction via temporal action segmentation

The vast majority of people who suffer unexpected cardiac arrest are performed cardiopulmonary resuscitation (CPR) by passersby in a desperate attempt to restore life, but endeavors turn out to be fruitless on account of disqualification. Fortunately, many pieces of research manifest that disciplined training will help to elevate the success rate of resuscitation, which constantly desires a seamless combination of novel techniques to yield further advancement. To this end, we collect a specialized CPR video dataset in which trainees make efforts to behave resuscitation on mannequins independently in adherence to approved guidelines, promoting an auxiliary toolbox to assist supervision and rectification of intermediate potential issues via modern deep learning methodologies. Our research empirically views this problem as a temporal action segmentation (TAS) task in computer vision, which aims to segment an untrimmed video at a frame-wise level. Here, we propose a Prompt-enhanced hierarchical Transformer (PhiTrans) that integrates three indispensable modules, including a textual prompt-based Video Features Extractor (VFE), a transformer-based Action Segmentation Executor (ASE), and a regression-based Prediction Refinement Calibrator (PRC). The backbone preferentially derives from applications in three approved public datasets (GTEA, 50Salads, and Breakfast) collected for TAS tasks, which experimentally facilitates the model excavation on the CPR dataset. In general, we probe into a feasible pipeline that elevates the CPR instruction qualification via action segmentation equipped with novel deep learning techniques. Associated experiments on the CPR dataset advocate our resolution with surpassing 91.0% on Accuracy, Edit score, and F1 score.

Artificial intelligence in emergency medicine. A systematic literature review

Motivation and objective: Emergency medicine is becoming a popular application area for artificial intelligence methods but remains less investigated than other healthcare branches. The need for time-sensitive decision-making on the basis of high data volumes makes the use of quantitative technologies inevitable. However, the specifics of healthcare regulations impose strict requirements for such applications. Published contributions cover separate parts of emergency medicine and use disparate data and algorithms. This study aims to systematize the relevant contributions, investigate the main obstacles to artificial intelligence applications in emergency medicine, and propose directions for further studies.

METHODS

The contributions selection process was conducted with systematic electronic databases querying and filtering with respect to established exclusion criteria. Among the 380 papers gathered from IEEE Xplore, ACM Digital Library, Springer Library, ScienceDirect, and Nature databases 116 were considered to be a part of the survey. The main features of the selected papers are the focus on emergency medicine and the use of machine learning or deep learning algorithms.

FINDINGS AND DISCUSSION

The selected papers were classified into two branches: diagnostics-specific and triage-specific. The former ones are focused on either diagnosis prediction or decision support. The latter covers such applications as mortality, outcome, admission prediction, condition severity estimation, and urgent care prediction. The observed contributions are highly specialized within a single disease or medical operation and often use privately collected retrospective data, making them incomparable. These and other issues can be addressed by creating an end-to-end solution based on human-machine interaction.

CONCLUSION

Artificial intelligence applications are finding their place in emergency medicine, while most of the corresponding studies remain isolated and lack higher generalization and more sophisticated methodology, which can be a matter of forthcoming improvements.

Artificial Intelligence and Machine Learning Applications in Sudden Cardiac Arrest Prediction and Management: A Comprehensive Review

PURPOSE OF REVIEW

This literature review aims to provide a comprehensive overview of the recent advances in prediction models and the deployment of AI and ML in the prediction of cardiopulmonary resuscitation (CPR) success. The objectives are to understand the role of AI and ML in healthcare, specifically in medical diagnosis, statistics, and precision medicine, and to explore their applications in predicting and managing sudden cardiac arrest outcomes, especially in the context of prehospital emergency care.

RECENT FINDINGS

The role of AI and ML in healthcare is expanding, with applications evident in medical diagnosis, statistics, and precision medicine. Deep learning is gaining prominence in radiomics and population health for disease risk prediction. There's a significant focus on the integration of AI and ML in prehospital emergency care, particularly in using ML algorithms for predicting outcomes in COVID-19 patients and enhancing the recognition of out-of-hospital cardiac arrest (OHCA). Furthermore, the combination of AI with automated external defibrillators (AEDs) shows potential in better detecting shockable rhythms during cardiac arrest incidents. AI and ML hold immense promise in revolutionizing the prediction and management of sudden cardiac arrest, hinting at improved survival rates and more efficient healthcare interventions in the future. Sudden cardiac arrest (SCA) continues to be a major global cause of death, with survival rates remaining low despite advanced first responder systems. The ongoing challenge is the prediction and prevention of SCA. However, with the rise in the adoption of AI and ML tools in clinical electrophysiology in recent times, there is optimism about addressing these challenges more effectively.

Community intervention to improve defibrillation before ambulance arrival in residential neighbourhoods with a high risk of out-of-hospital cardiac arrest: study protocol of a cluster-randomised trial (the CARAMBA trial)

INTRODUCTION

In Denmark, multiple national initiatives have been associated with improved bystander defibrillation and survival following out-of-hospital cardiac arrest (OHCA) in public places. However, OHCAs in residential neighbourhoods continue to have poor outcomes. The Cardiac Arrest in Residential Areas with MoBile volunteer responder Activation trial aims to improve bystander defibrillation and survival following OHCA in residential neighbourhoods with a high risk of OHCA. The intervention consists of: (1) strategically deployed automated external defibrillators accessible at all hours, (2) cardiopulmonary resuscitation (CPR) training of residents and (3) recruitment of residents for a volunteer responder programme.

METHODS AND ANALYSIS

This is a prospective, pair-matched, cluster-randomised, superiority trial with clusters of 26 residential neighbourhoods, testing the effectiveness of the intervention in a real-world setting. The areas are randomised for intervention or control. Intervention and control areas will receive the standard OHCA emergency response, including volunteer responder activation. However, targeted automated external defibrillator deployment, CPR training and volunteer responder recruitment will only be provided in the intervention areas. The primary outcome is bystander defibrillation, and the secondary outcome is 30-day survival. Data on patients who had an OHCA will be collected through the Danish Cardiac Arrest Registry.

ETHICS AND DISSEMINATION

Approval to store OHCA data has been granted from the Legal Office, Capital Region of Denmark (j.nr: 2012-58-0004, VD-2018-28, I-Suite no: 6222, and P-2021-670). In Denmark, formal approval from the ethics committee is only obtainable when the study regards testing medicine or medical equipment on humans or using genome or diagnostic imagine as data source. The Ethics Committee of the Capital Region of Denmark has evaluated the trial and waived formal approval unnecessary (H-19037170). Results will be published in peer-reviewed papers and shared with funders, stakeholders, and housing organisations through summaries and presentations.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT04446585).

Clinical Features and Outcomes Among Patients With Refractory Out-of-Hospital Cardiac Arrest and an Initial Shockable Rhythm

BACKGROUND

Clinical features among patients with refractory out-of-hospital cardiac arrest (OHCA) and initial shockable rhythms of ventricular fibrillation/pulseless ventricular tachycardia are not well-characterized.

METHODS

We compared clinical characteristics and coronary angiographic findings between patients with refractory OHCA (incessant ventricular fibrillation/pulseless ventricular tachycardia after ≥3 direct-current shocks) and those without refractory OHCA.

RESULTS

Between 2014 and 2018, a total of 204 patients with ventricular fibrillation/pulseless ventricular tachycardia OHCA (median age 62; males 78%) were divided into groups with (36%, 74/204) and without refractory arrest (64%, 130/204). Refractory OHCA patients had longer cardiopulmonary resuscitation (23 versus 15 minutes), more frequently required ≥450 mg amiodarone (34% versus 3.8%), and had cardiogenic shock (80% versus 55%) necessitating higher adrenaline dose (4.0 versus 1.0 mg) and higher rates of mechanical ventilation (92% versus 74%; all P<0.01). Of 167 patients (82%) selected for coronary angiography, 33% (n=55) had refractory OHCA (P=0.035). Significant coronary artery disease (≥1 major vessel with >70% stenosis) was present in >70% of patients. Refractory OHCA patients frequently had acute coronary occlusion (64% versus 47%), especially left circumflex (20% versus 6.4%) and graft vessel (7.3% versus 0.9%; all P<0.05) compared with those without refractory OHCA. Refractory OHCA group had higher in-hospital mortality (45% versus 30%, P=0.036) and greater new requirement for dialysis (18% versus 6.3%, P=0.011). After adjustment, refractory OHCA was associated with over 2-fold higher odds of in-hospital mortality (odds ratio, 2.28 [95% CI, 1.06-4.89]; P=0.034).

CONCLUSIONS

Refractory ventricular fibrillation/pulseless ventricular tachycardia OHCA was associated with more intensive resuscitation, higher rates of acute coronary occlusion, and poorer in-hospital outcomes, underscoring the need for future studies in this extreme-risk subgroup.

Effectiveness of rescue Me CPR! smartphone app providing real-time guidance to untrained bystanders performing CPR

Background

Out-of-hospital cardiac arrest (OHCA) is a persistent global health challenge, owing, in part, to low rates of population CPR training. Smartphone applications have the potential to widely disseminate CPR basic training to a populace, but other studies have found multiple limitations in previously developed CPR guidance applications (CPR-GA). This study aims to use medical simulation to assess the relative CPR performance of novices using the 'Rescue Me CPR!' (RMC) app, a custom CPR-GA designed by this research team, to novices using 'PG-CPR!' (PGC), the most downloaded CPR-GA available in the USA, and to CPR certified medical personnel.

Methods

In a prospective randomized experimental trial of 60 individuals, subjects were either given the RMC app, the PGC app, or had active CPR certification. They were presented a cardio-pulmonary arrest scenario and were observed while performing CPR on a high-fidelity manikin. Data was collected through four cycles of CPR, during which time 24 pertinent performance metrics and CPR steps were timed and recorded. These metrics were assessed on their own and used to calculate average time to compressions, average chest compression fraction, and rate of high-quality CPR for each study group.

Results

CPR certified subjects called 911 in 100 % of simulation cases, started compressions 34 ± 10 s after first seeing the simulated patient, had an average chest compression fraction of 0.52, and performed high-quality CPR in 25 % of aggregate compression cycles. PGC app users called 911 in 70 % of simulation cases, started compressions 86 ± 17 s after first seeing the simulated patient, had an average chest compression fraction that could not be assessed due to inconsistent pauses during CPR, and performed high-quality CPR in 2.5 % of aggregate compression cycles. RMC app users called 911 in 100 % of simulation cases, started compressions 55 ± 6 s after first seeing the simulated patient, had an average chest compression fraction of 0.48, and performed high-quality CPR in 50 % of aggregate compression cycles.

Conclusion

The results of this study demonstrate that in all studied metrics, except time-to-first-compression, CPR provided by individuals using the RMC app is statistically equivalent or superior to CPR performed by a CPR certified individual and, in almost every metric, superior to CPR performed by users of the most downloaded android CPR guidance application, PG-CPR.

Follow-up on volunteer responders dispatched for out-of-hospital cardiac arrests: Addressing the psychological and physical impact

Introduction

Smartphone technology is increasingly used to engage lay people as volunteer responders in resuscitation attempts. Attention has recently been drawn to how resuscitation attempts may impact bystanders. Attempting resuscitation in out-of-hospital cardiac arrests (OHCA) may be an overwhelming experience and, in some cases, difficult to cope with. We developed a volunteer responder follow-up program to systematically measure the psychological and physical impact on volunteer responders dispatched for OHCAs.

Methods and Results

The nationwide Danish volunteer responder program dispatches volunteer responders for presumed cardiac arrests. 90 min after notification of a potential nearby cardiac arrest, all volunteer responders receive a survey, and are asked to self-report their mental state of mind after the event. The volunteer responders are also asked to disclose any physical injury they sustained in relation to the event. Volunteer responders who report severe mental effects are offered a defusing conversation by a trained nurse. Between 1 September 2017 and 31 December 2022, the Danish volunteer responder program has alerted 177,866 volunteer responders for 10,819 presumed cardiac arrest alerts. Of 177,866 alerted volunteers responders, 62,711 accepted the alarm. In the same period, 7,317 cancelled their registration. From January 2019 to 31 December 31 2022, a total of 535 volunteer responders were offered a defusing consultation.

Conclusion

The Danish volunteer responder follow-up program is carried out to assess the psychological and physical risks of responding to a suspected OHCA. We suggest a survey-based method for systematic screening of volunteer responders that allow volunteer responders to report any physical injury or need of psychological follow-up. The person providing defusing should be a trained and experienced healthcare professional.

Public access defibrillation: challenges and new solutions

PURPOSE OF REVIEW

The purpose of this article is to review the current status of public access defibrillation and the various utility modalities of early defibrillation.

RECENT FINDINGS

Defibrillation with on-site automated external defibrillators (AEDs) has been the conventional approach for public access defibrillation. This strategy is highly effective in cardiac arrests occurring in close proximity to on-site AEDs; however, only a few cardiac arrests will be covered by this strategy. During the last decades, additional strategies for public access defibrillation have developed, including volunteer responder programmes and drone assisted AED-delivery. These programs have increased chances of early defibrillation within a greater radius, which remains an important factor for survival after out-of-hospital cardiac arrest.

SUMMARY

Recent advances in the use of public access defibrillation show great potential for optimizing early defibrillation. With new technological solutions, AEDs can be transported to the cardiac arrest location reaching OHCAs in both public and private locations. Furthermore, new technological innovations could potentially identify and automatically alert the emergency medical services in nonwitnessed OHCA previously left untreated.

Volunteer responder provision of support to relatives of out-of-hospital cardiac arrest patients: a qualitative study

OBJECTIVES

Smartphone dispatch of volunteer responders for out-of-hospital cardiac arrest (OHCA) is implemented worldwide. While basic life support courses prepare participants to provide CPR, the courses rarely address the possibility of meeting a family member or relative in crisis. This study aimed to examine volunteer responders' provision of support to relatives of cardiac arrest patients and how relatives experienced the interaction with volunteer responders.

DESIGN

In this qualitative study, we conducted 16 semistructured interviews with volunteer responders and relatives of cardiac arrest patients.

SETTING

Interviews were conducted face to face and by video and recorded and transcribed verbatim.

PARTICIPANTS

Volunteer responders dispatched to cardiac arrests and relatives of cardiac arrest patients were included in the study. Participants were included from all five regions of Denmark.

RESULTS

A thematic analysis was performed with inspiration from Braun and Clarke. We identified three themes: (1) relatives' experiences of immediate relief at arrival of assistance, (2) volunteer responders' assessment of relatives' needs and (3) the advantage of being healthcare educated.

CONCLUSIONS

Relatives to out-of-hospital cardiac arrest patients benefited from volunteer responders' presence and support and experienced the mere presence of volunteer responders as supportive. Healthcare-educated volunteer responders felt confident and skilled to provide care for relatives, while some non-healthcare-educated volunteer responders felt they lacked the proper training and knowledge to provide emotional support for relatives. Future basic life support courses should include a lesson on how to provide emotional support to relatives of cardiac arrest patients.

Impact of COVID-19 on out-of-hospital cardiac arrest care processes

Early bystander cardiopulmonary resuscitation, use of defibrillators (including automated external defibrillators) and timely treatment by emergency medical services are known to increase the chances of survival for a patient experiencing an out-of-hospital cardiac arrest (OHCA); however, the impact of the COVID-19 pandemic on this is unclear from examining previous literature. This commentary critically appraises a recent systematic review and meta-analysis which assesses the effect of the COVID-19 pandemic on pre-hospital care for OHCA.

Factors affecting public access defibrillator placement decisions in the United Kingdom: A survey study

Aim

This study aimed to understand current community PAD placement strategies and identify factors which influence PAD placement decision-making in the United Kingdom (UK).

Methods

Individuals, groups and organisations involved in PAD placement in the UK were invited to participate in an online survey collecting demographic information, facilitators and barriers to community PAD placement and information used to decide where a PAD is installed in their experiences. Survey responses were analysed through descriptive statistical analysis and thematic analysis.

Results

There were 106 included responses. Distance from another PAD (66%) and availability of a power source (63%) were most frequently used when respondents are deciding where best to install a PAD and historical occurrence of cardiac arrest (29%) was used the least. Three main themes were identified influencing PAD placement: (i) the relationship between the community and PADs emphasising community engagement to create buy-in; (ii) practical barriers and facilitators to PAD placement including securing consent, powering the cabinet, accessibility, security, funding, and guardianship; and (iii) 'risk assessment' methods to estimate the need for PADs including areas of high footfall, population density and type, areas experiencing health inequalities, areas with delayed ambulance response and current PAD provision.

Conclusion

Decision-makers want to install PADs in locations that maximise impact and benefit to the community, but this can be constrained by numerous social and infrastructural factors. The best location to install a PAD depends on local context; work is required to determine how to overcome barriers to optimal community PAD placement.

Compression-Only Cardiopulmonary Resuscitation and Automated External Defibrillator Course for Primary School Students: A Malaysian Pilot Study

The Malaysian national school curriculum currently lacks resources and tools to enforce CPR education. The aim of this study was to investigate the efficacy of a compression-only cardiopulmonary resuscitation and automated external defibrillator course among primary school students to increase their knowledge and technical skills and improve their attitudes. A quasi-experimental study was conducted using a pre−post non-equivalent design involving 38 students aged 10−12. Cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) knowledge, technical skills, and attitude towards CPR were assessed in a post test with three-month follow-up. Results of the MANOVA analysis showed significant differences in the level of knowledge (F = 10.29, p < 0.001) and attitude (F = 13.87, p < 0.001) based on the students’ age group at the time of the post test. The proportion of students who passed the technical skills component differed significantly by age (χ2 = 12.12; p = 0.002) and BMI (χ2 = 6.34; p = 0.041). No significant decay was reported in the total mean scores for knowledge, technical skills, and attitude (F = 0.727, p = 0.54) at 3-month follow-up. The course helped students perform CPR and utilize AED effectively while promoting a positive attitude with up to 3 months of retention, demonstrating the feasibility of extending the course within the Malaysian primary school curriculum.

[AED drones on the rise? : Use of drones to improve public access defibrillation]

BACKGROUND

The poor availability of automatic external defibrillators (AED) and the modest knowledge of lay persons in handling these devices has led to an insufficient spread of public access defibrillation in Germany.

OBJECTIVE

This article examines whether the automated deployment of AED drones to out-of-hospital cardiac arrest can help to remedy this situation.

METHODS

Narrative literature review, evaluation of statistics, analysis of relevant media reports, and discussion of key research.

RESULTS

The present investigations are mainly located in the experimental field and demonstrate the feasibility and safety of drone use, as well as shorter times to first defibrillation, which is confirmed by initial clinical studies. Mathematical models also indicate cost-effectiveness of airborne AED delivery compared to ground dispatch. Integration into the chain of survival appears to be possible but adaptations to existing emergency medical service structures and close cooperation with regional first responder and AED schemes as well as local authorities is required to optimise patient benefit and efficiency.

CONCLUSION

The use of AED drones could probably contribute to improving public access defibrillation in Germany. This applies to both rural and urban regions. The technological requirements are met but flight regulations still have to be amended. In order to explore the full potential of this novel technology, further field trials are required to achieve smooth integration into existing emergency medical services.