European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances

Seat belt use and cardiac arrest immediately after motor vehicle collision: Nationwide observational study

Objective

Motor vehicle collisions (MVCs) are known to cause traumatic cardiac arrest; it is unclear whether seat belts prevent this. This study aimed to evaluate the association between seat belt use and immediate cardiac arrest in cases of MVCs.

Method

This cross-sectional observational study used data from a nationwide EMS-based severe trauma registry in South Korea. The sample comprised adult patients with EMS-assessed severe trauma due to MVCs between 2018 and 2019. The primary, secondary, and tertiary outcomes were immediate cardiac arrest, in-hospital mortality, and death or severe disability, respectively. We calculated the adjusted odds ratios (AORs) of immediate cardiac arrest with seat belt use after adjusting for potential confounders.

Results

Among the 8178 eligible patients, 6314 (77.2 %) and 1864 (29.5 %) were wearing and not wearing seat belts, respectively. Immediate cardiac arrest, mortality, and death/severe disability rates were higher in the "no seat belt use" group than in the "seat belt use" group (9.4 % vs. 4.0 %, 12.4 % vs. 6.2 %, 17.7 % vs. 9.9 %, respectively; p < 0.001). The former group was more likely to experience immediate cardiac arrest (AOR [95 %CI]: 3.29 [2.65-4.08]), in-hospital mortality (AOR [95 %CI]: 2.72 [2.26-3.27]), and death or severe disability (AOR [95 %CI]: 2.40 [2.05-2.80]).

Conclusion

There was an association between wearing seat belts during MVCs and a reduced risk of immediate cardiac arrest.

Intravenous lipid emulsion for local anaesthetic systemic toxicity in pregnant women: a scoping review

BACKGROUND

Local anaesthetic systemic toxicity (LAST) is a rare but life-threatening complication that can occur after local anaesthetic administration. Various clinical guidelines recommend an intravenous lipid emulsion as a treatment for local anaesthetic-induced cardiac arrest. However, its therapeutic application in pregnant patients has not yet been established. This scoping review aims to systematically identify and map the evidence on the efficacy and safety of intravenous lipid emulsion for treating LAST during pregnancy.

METHOD

We searched electronic databases (Medline, Embase and Cochrane Central Register Controlled Trials) and a clinical registry (lipidrescue.org) from inception to Sep 30, 2022. No restriction was placed on the year of publication or the language. We included any study design containing primary data on obstetric patients with signs and symptoms of LAST.

RESULTS

After eliminating duplicates, we screened 8,370 titles and abstracts, retrieving 41 full-text articles. We identified 22 women who developed LAST during pregnancy and childbirth, all presented as case reports or series. The most frequent causes of LAST were drug overdose and intravascular migration of the epidural catheter followed by wrong-route drug errors (i.e. intravenous anaesthetic administration). Of the 15 women who received lipid emulsions, all survived and none sustained lasting neurological or cardiovascular damage related to LAST. No adverse events or side effects following intravenous lipid emulsion administration were reported in mothers or neonates. Five of the seven women who did not receive lipid emulsions survived; however, the other two died.

CONCLUSION

Studies on the efficacy and safety of lipids in pregnancy are scarce. Further studies with appropriate comparison groups are needed to provide more robust evidence. It will also be necessary to accumulate data-including adverse events-to enable clinicians to conduct risk-benefit analyses of lipids and to facilitate evidence-based decision-making for clinical practice.

Preparedness for severe maternal morbidity in European hospitals: The MaCriCare study

PURPOSE

To evaluate obstetric units (OUs) and intensive care units (ICUs) preparedness for severe maternal morbidity (SMM).

METHODS

From September 2021 to January 2022, an international multicentre cross-sectional study surveyed OUs in 26 WHO Europe Region countries. We assessed modified early obstetric warning score usage (MEOWS), approaches to four SMM clinical scenarios, invasive monitoring availability in OUs, and access to high-dependency units (HDUs) and onsite ICUs. Within ICUs, we examined the availability of trained staff, response to obstetric emergencies, leadership, and data collection.

RESULTS

1133 responses were evaluated. MEOWS use was 34.5%. Non-obstetric early warning scores were being used. 21.4% (242) of OUs provided invasive monitoring in the OU. A quarter lacked access to onsite HDU beds. In cases of SMM, up to 13.8% of all OUs indicated the need for transfer to another hospital. The transfer rate was highest (74.0%) in small units. 81.9% of centers provided onsite ICU facilities to obstetric patients. Over 90% of the onsite ICUs provided daily specialist obstetric reviews but lacked immediate access to key resources: 3.4% - uterotonic drugs, 7.5% - neonatal resuscitation equipment, 9.2% - neonatal resuscitation team, 11.4% - perimortem cesarean section equipment. 41.2% reported obstetric data to a national database.

CONCLUSION

Gaps in provision exist for obstetric patients with SMM in Europe, potentially compromising patient safety and experience. MEOWS use in OUs was low, while access to invasive monitoring and onsite HDU and ICU facilities was variable. ICUs frequently lacked resources and did not universally collect obstetric data for quality control.

Prolonged critical avalanche burial for nearly 23 h with severe hypothermia and severe frostbite with good recovery: a case report

BACKGROUND

Accidental hypothermia with severe frostbite is a rare combination of injuries with a high risk for long-term sequelae. There are widely accepted recommendations for the management of avalanche victims and for frostbite treatment, but no recommendation exists for the treatment of frostbite in severe hypothermic patients, specifically for the management of hypothermic avalanche victims presenting with frostbite.

CASE PRESENTATION

We present a case of a previously healthy, 53-year-old male skier who was critically buried by an avalanche at 2300 m of altitude at an ambient temperature of - 8 °C for nearly 23 h. The victim was found with the right hand out of the snow and an air connection to outside. He was somnolent with Glasgow Coma Scale 11 (Eye 4, Verbal 2, Motor 5) and spontaneously breathing, in a severely hypothermic state with an initial core temperature of 23.1 °C and signs of cold injuries in all four extremities. After rescue and active external forced air rewarming in the intensive care unit, the clinical signs of first-degree frostbite on both feet and the left hand vanished, while third- to fourth-degree frostbite injuries became apparent on all fingers of the right hand. After reaching a core body temperature of approximately 36 °C, aggressive frostbite treatment was started with peripheral arterial catheter-directed thrombolysis with alteplase, intravenous iloprost, ibuprofen, dexamethasone and regional sympathicolysis with a right-sided continuous axillary block. After ten months, the patient had no tissue loss but needed neuropathic pain treatment with pregabalin.

CONCLUSION

The combination of severe accidental hypothermia and severe frostbite is rare and challenging, as drug metabolism is unpredictable in a hypothermic patient and no recommendations for combined treatment exist. There is general agreement to give hypothermia treatment the priority and to begin frostbite treatment as early as possible after full rewarming of the patient. More evidence is needed to identify the optimal dosage and time point to initiate treatment of frostbite in severely hypothermic patients. This should be taken into consideration by future treatment recommendations.

Implementation of Extracorporeal CPR Programs for Out-of-Hospital Cardiac Arrest: Another Tale of Two County Hospitals

Extracorporeal cardiopulmonary resuscitation (ECPR) is a form of intensive life support that has seen increasing use globally to improve outcomes for patients who experience out-of-hospital cardiac arrest (OHCA). Hospitals with advanced critical care capabilities may be interested in launching an ECPR program to offer this support to the patients they serve; however, to do so, they must first consider the significant investment of resources necessary to start and sustain the program. The existing literature describes many single-center ECPR programs and often focuses on inpatient care and patient outcomes in hospitals with cardiac surgery capabilities. However, building a successful ECPR program and using this technology to support an individual patient experiencing refractory cardiac arrest secondary to a shockable rhythm depends on efficient out-of-hospital and emergency department (ED) management. This article describes the process of implementing 2 intensivist-led ECPR programs with limited cardiac surgery capability. We focus on emergency medical services and ED clinician roles in identifying patients, mobilizing resources, initiation and management of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in the ED, and ongoing efforts to improve ECPR program quality. Each center experienced a significant learning curve to reach goals of arrest-to-flow times of cannulation for ECPR. Building consensus from multidisciplinary stakeholders, including out-of-hospital stakeholders; establishing shared expectations of ECPR outcomes; and ensuring adequate resource support for ECPR activation were all key lessons in improving our ECPR programs.

Sodium Bicarbonate and Calcium Chloride for the Treatment of Hyperkalemia-Induced Cardiac Arrest: A Randomized, Blinded, Placebo-Controlled Animal Study

OBJECTIVES

Current international guidelines recommend administrating calcium chloride and sodium bicarbonate to patients with hyperkalemia-induced cardiac arrest, despite limited evidence. The aim of this study was to evaluate the efficacy of calcium chloride and sodium bicarbonate on return of spontaneous circulation (ROSC) in a pig model of hyperkalemia-induced cardiac arrest.

DESIGN

A randomized, blinded, placebo-controlled experimental pig study. Hyperkalemia was induced by continuous infusion of potassium chloride over 45 minutes followed by a bolus. After a no flow period of 7 minutes, pigs first received 2 minutes of basic cardiopulmonary resuscitation and subsequently advanced life support. The first intervention dose was administered after the fifth rhythm analysis, followed by a defibrillation attempt at the sixth rhythm analysis. A second dose of the intervention was administered after the seventh rhythm analysis if ROSC was not achieved. In case of successful resuscitation, pigs received intensive care for 1 hour before termination of the study.

SETTING

University hospital laboratory.

SUBJECTS

Fifty-four female Landrace/Yorkshire/Duroc pigs (38-42 kg).

INTERVENTIONS

The study used a 2 × 2 factorial design, with calcium chloride (0.1 mmol/kg) and sodium bicarbonate (1 mmol/kg) as the interventions.

MEASUREMENTS AND MAIN RESULTS

Fifty-two pigs were included in the study. Sodium bicarbonate significantly increased the number of animals achieving ROSC (24/26 [92%] vs. 13/26 [50%]; odds ratio [OR], 12.0; 95% CI, 2.3-61.5; p = 0.003) and reduced time to ROSC (hazard ratio [HR] 3.6; 95% CI, 1.8-7.5; p < 0.001). There was no effect of calcium chloride on the number of animals achieving ROSC (19/26 [73%] vs. 18/26 [69%]; OR, 1.2; 95% CI, 0.4-4.0; p = 0.76) or time to ROSC (HR, 1.5; 95% CI, 0.8-2.9; p = 0.23).

CONCLUSIONS

Administration of sodium bicarbonate significantly increased the number of animals achieving ROSC and decreased time to ROSC. There was no effect of calcium chloride on the number of animals achieving ROSC or time to ROSC.

Monitoring of Brain Tissue Oxygen Tension in Cardiac Arrest: a Translational Systematic Review from Experimental to Clinical Evidence

BACKGROUND

Cardiac arrest (CA) is a sudden event that is often characterized by hypoxic-ischemic brain injury (HIBI), leading to significant mortality and long-term disability. Brain tissue oxygenation (PbtO2) is an invasive tool for monitoring brain oxygen tension, but it is not routinely used in patients with CA because of the invasiveness and the absence of high-quality data on its effect on outcome. We conducted a systematic review of experimental and clinical evidence to understand the role of PbtO2 in monitoring brain oxygenation in HIBI after CA and the effect of targeted PbtO2 therapy on outcomes.

METHODS

The search was conducted using four search engines (PubMed, Scopus, Embase, and Cochrane), using the Boolean operator to combine mesh terms such as PbtO2, CA, and HIBI.

RESULTS

Among 1,077 records, 22 studies were included (16 experimental studies and six clinical studies). In experimental studies, PbtO2 was mainly adopted to assess the impact of gas exchanges, drugs, or systemic maneuvers on brain oxygenation. In human studies, PbtO2 was rarely used to monitor the brain oxygen tension in patients with CA and HIBI. PbtO2 values had no clear association with patients' outcomes, but in the experimental studies, brain tissue hypoxia was associated with increased inflammation and neuronal damage.

CONCLUSIONS

Further studies are needed to validate the effect and the threshold of PbtO2 associated with outcome in patients with CA, as well as to understand the physiological mechanisms influencing PbtO2 induced by gas exchanges, drug administration, and changes in body positioning after CA.

Is the Over-the-Head Technique an Alternative for Infant CPR Performed by a Single Rescuer? A Randomized Simulation Study with Lifeguards

(1) Objective: The objective was to evaluate the quality of cardiopulmonary resuscitation (CPR, chest compressions and ventilations) when performed by a lone first responder on an infant victim via the over-the-head technique (OTH) with bag-mask ventilation in comparison with the standard lateral technique (LAT) position. (2) Methods: A randomized simulation crossover study in a baby manikin was conducted. A total of 28 first responders performed each of the techniques in two separate CPR tests (15:2 chest compressions:ventilations ratio), each lasting 5 min with a 15 min resting period. Quality CPR parameters were assessed using an app connected to the manikin. Those variables were related to chest compressions (CC: depth, rate, and correct CC point) and ventilation (number of effective ventilations). Additional variables included perceptions of the ease of execution of CPR. (3) Results: The median global CPR quality (integrated CC + V) was 82% with OTH and 79% with LAT (p = 0.94), whilst the CC quality was 88% with OTH and 80% with LAT (p = 0.67), and ventilation quality was 85% with OTH and 85% with LAT (p = 0.98). Correct chest release was significantly better with OTH (OTH: 92% vs. LAT: 62%, p < 0.001). There were no statistically significant differences in the remaining variables. Ease of execution perceptions favored the use of LAT over OTH. (4) Conclusions: Chest compressions and ventilations can be performed with similar quality in an infant manikin by lifeguards both with the standard recommended position (LAT) and the alternative OTH. This option could give some advantages in terms of optimal chest release between compressions. Our results should encourage the assessment of OTH in some selected cases and situations as when a lone rescuer is present and/or there are physical conditions that could impede the lateral rescue position.

Severe trauma associated cardiac failure

Although significant efforts have been made to enhance trauma care, the mortality rate for traumatic cardiac arrest (TCA) remains exceedingly high. Therefore, our institution has implemented special measures to optimize the treatment of major trauma patients. These measures include a prehospital Medical Intervention Car (MIC) and a 'code red' protocol in the trauma resuscitation room for patients with TCA or shock. These measures enable the early treatment of reversible causes of TCA and have resulted in a significant number of patients achieving adequate ROSC. However, a significant proportion of these patients still die due to circulatory failure shortly after. Our observations from patients who underwent clamshell thoracotomy or received echocardiographic evaluation in conjunction with current scientific findings led us to conclude that dysfunction of the heart itself may be the cause. Therefore, we propose discussing severe trauma-associated cardiac failure (STAC) as a new entity to facilitate scientific research and the development of specific treatment strategies, with the aim of improving the outcome of severe trauma.

Outcomes with intracoronary vs. intravenous epinephrine in cardiac arrest

BACKGROUND

Advanced Cardiovascular Life Support (ACLS) guidelines recommend intravenous (IV) and intraosseous (IO) epinephrine as a basic cornerstone in the resuscitation process. Data about the efficacy and safety of intracoronary (IC) epinephrine during cardiac arrest in the catheterization laboratory are lacking.

OBJECTIVE

To examine the efficacy and safety of IC vs. IV epinephrine for resuscitation during cardiac arrest in the catheterization laboratory.

METHODS AND RESULTS

This is a prospective observational study that included all patients who experienced cardiac arrest in the cath lab at two tertiary centres in Egypt from January 2015 to July 2022. Patients were divided into two groups according to the route of epinephrine given; IC vs. IV. The primary outcome was survival to hospital discharge. Secondary outcomes included rate of return of spontaneous circulation (ROSC), time-to-ROSC, and favourable neurological outcome at discharge defined as modified Rankin Scale (MRS) <3. A total of 162 patients met our inclusion criteria, mean age (60.69 ± 9.61), 34.6% women. Of them, 52 patients received IC epinephrine, and 110 patients received IV epinephrine as part of the resuscitation. Survival to hospital discharge was significantly higher in the IC epinephrine group (84.62% vs. 53.64%, P < 0.001) compared with the IV epinephrine group. The rate of ROSC was higher in the IC epinephrine group (94.23% vs. 70%, P < 0.001) and achieved in a shorter time (2.6 ± 1.97 min vs. 6.8 ± 2.11 min, P < 0.0001) compared with the IV group. Similarly, favourable neurological outcomes were more common in the IC epinephrine group (76.92% vs. 47.27%, P < 0.001) compared with the IV epinephrine group.

CONCLUSION

In this observational study, IC epinephrine during cardiac arrest in the cath lab appeared to be safe and may be associated with improved outcomes compared with the IV route. Larger randomized studies are encouraged to confirm these results.

Traumatic Cardiac Arrest-A Narrative Review

A paradigm shift in traumatic cardiac arrest (TCA) perception switched the traditional belief of futility of TCA resuscitation to a more optimistic perspective, at least in selected cases. The goal of TCA resuscitation is to rapidly and aggressively treat the common potentially reversible causes of TCA. Advances in diagnostics and therapy in TCA are ongoing; however, they are not always translating into improved outcomes. Further research is needed to improve outcome in this often young and previously healthy patient population.

Approach to traumatic cardiac arrest in the emergency department: a narrative literature review for emergency providers

BACKGROUND

Traumatic cardiac arrest (TCA) is a major contributor to mortality and morbidity in all age groups and poses a significant burden on the healthcare system. Although there have been advances in treatment modalities, survival rates for TCA patients remain low. This narrative literature review critically examines the indications and effectiveness of current therapeutic approaches in treating TCA.

METHODS

We performed a literature search in the PubMed and Scopus databases for studies published before December 31, 2022. The search was refined by combining search terms, examining relevant study references, and restricting publications to the English language. Following the search, 943 articles were retrieved, and two independent reviewers conducted a screening process.

RESULTS

A review of various studies on pre- and intra-arrest prognostic factors showed that survival rates were higher when patients had an initial shockable rhythm. There were conflicting results regarding other prognostic factors, such as witnessed arrest, bystander cardiopulmonary resuscitation (CPR), and the use of prehospital or in-hospital epinephrine. Emergency thoracotomy was found to result in more favorable outcomes in cases of penetrating trauma than in those with blunt trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides an advantage to emergency thoracotomy in terms of occupational safety for the operator as an alternative in managing hemorrhagic shock. When implemented in the setting of aortic occlusion, emergency thoracotomy and REBOA resulted in comparable mortality rates. Veno-venous extracorporeal life support (V-V ECLS) and veno-arterial extracorporeal life support (V-A ECLS) are viable options for treating respiratory failure and cardiogenic shock, respectively. In the context of traumatic injuries, V-V ECLS has been associated with higher rates of survival to discharge than V-A ECLS.

CONCLUSION

TCA remains a significant challenge for emergency medical services due to its high morbidity and mortality rates. Pre- and intra-arrest prognostic factors can help identify patients who are likely to benefit from aggressive and resource-intensive resuscitation measures. Further research is needed to enhance guidelines for the clinical use of established and emerging therapeutic approaches that can help optimize treatment efficacy and ameliorate survival outcomes.

Outcomes and potential for improvement in the prehospital treatment of penetrating chest injuries in a European metropolitan area: A retrospective analysis of 2009 - 2017

BACKGROUND

Trauma is the leading cause of death in patients <45 years living in high-resource settings. However, penetrating chest injuries are still relatively rare in Europe - with an upwards trend. These cases are of particular interest to emergency medical services (EMS) due to available invasive treatment options like chest tube placement or resuscitative thoracotomy. To date, there is no sufficient data from Austria regarding penetrating chest trauma in a metropolitan area, and no reliable source to base decisions regarding further skill proficiency training on.

METHODS

For this retrospective observational study, we screened all trauma emergency responses of the Viennese EMS between 01/2009 and 12/2017 and included all those with a National Advisory Committee for Aeronautics (NACA) score ≥ IV (= potentially life-threatening). Data were derived from EMS mission documentations and hospital files, and for those cases with the injuries leading to cardiopulmonary resuscitation (CPR), we assessed the EMS cardiac arrest registry and consulted a forensic physician.

RESULTS

We included 480 cases of penetrating chest injuries of NACA IV-VII (83% male, 64% > 30 years old, 74% stab wounds, 16% cuts, 8% gunshot wounds, 56% inflicted by another party, 26% self-inflicted, 18% unknown). In the study period, the incidence rose from 1.4/100,000 to 3.5/100,000 capita, and overall, about one case was treated per week. In the cases with especially severe injury patterns (= NACA V-VII, 43% of total), (tension-)pneumothorax was the most common injury (29%). The highest mortality was seen in injuries to pulmonary vessels (100%) or the heart (94%). Fifty-eight patients (12% of total) deceased, whereas in 15 cases, the forensic physician stated survival could theoretically have been possible. However, only five of these CPR patients received at least unilateral thoracostomy. Regarding all penetrating chest injuries, thoracostomy had only been performed in eight patients.

CONCLUSIONS

Severe cases of penetrating chest trauma are rare in Vienna and happened about once a week between 2009 and 2017. Both incidence and case load increased over the years, and potentially life-saving invasive procedures were only reluctantly applied. Therefore, a structured educational and skill retention approach aimed at both paramedics and emergency physicians should be implemented.

TRIAL REGISTRATION

Retrospective analysis without intervention.

Peri-operative cardiac arrest: management and outcomes of patients analysed in the 7th National Audit Project of the Royal College of Anaesthetists

The 7th National Audit Project of the Royal College of Anaesthetists studied peri-operative cardiac arrest in the UK, a topic of importance to patients, anaesthetists and surgeons. We report the results of the 12-month registry phase, from 16 June 2021 to 15 June 2022, focusing on management and outcomes. Among 881 cases of peri-operative cardiac arrest, the initial rhythm was non-shockable in 723 (82%) cases, most commonly pulseless electrical activity. There were 665 (75%) patients who survived the initial event and 384 (52%) who survived to hospital discharge. A favourable functional outcome (based on modified Rankin Scale score) was reported for 249 (88%) survivors. Outcomes varied according to arrest rhythm. The highest rates of survival were seen for bradycardic cardiac arrests with 111 (86%) patients surviving the initial event and 77 (60%) patients surviving the hospital episode. The lowest survival rates were seen for patients with pulseless electrical activity, with 312 (68%) surviving the initial episode and 156 (34%) surviving to hospital discharge. Survival to hospital discharge was worse in patients at the extremes of age with 76 (40%) patients aged > 75 y and 9 (45%) neonates surviving. Hospital survival was also associated with surgical priority, with 175 (88%) elective patients and 176 (37%) non-elective patients surviving to discharge. Outcomes varied with the cause of cardiac arrest, with lower initial survival rates for pulmonary embolism (5, 31%) and bone cement implantation syndrome (9, 45%), and hospital survival of < 25% for pulmonary embolism (0), septic shock (13, 24%) and significant hyperkalaemia (1, 20%). Overall care was rated good in 464 (53%) cases, and 18 (2%) cases had overall care rated as poor. Poor care elements were present in a further 245 (28%) cases. Care before cardiac arrest was the phase most frequently rated as poor (92, 11%) with elements of poor care identified in another 186 (21%) cases. These results describe the management and outcomes of peri-operative cardiac arrest in UK practice for the first time.

Prehospital interventions and outcomes in traumatic cardiac arrest: a population-based cohort study using the Danish Helicopter Emergency Medical Services data

BACKGROUND AND IMPORTANCE

Traumatic cardiac arrest is associated with poor prognosis, and timely evidence-based treatment is paramount for increasing survival rates. Physician-staffed helicopter emergency medical service use in major trauma has demonstrated improved outcomes. However, the sparsity of data highlights the necessity for a comprehensive understanding of the epidemiology of traumatic cardiac arrest.

OBJECTIVES

The primary objective of the present study was to evaluate survival and return of spontaneous circulation (ROSC) and to investigate the characteristics of patients with traumatic cardiac arrest assessed by the Danish HEMS.

DESIGN

This was a population-based cohort study based on data from the Danish helicopter emergency medical service database.

SETTINGS AND PARTICIPANTS

The study included all patients assessed by the Danish helicopter emergency medical services between 2016 and 2021.

OUTCOME MEASURES AND ANALYSIS

Data were analysed using descriptive statistics, non-parametric testing and logistic regression analyses. Descriptive analysis of prehospital interventions included cardiopulmonary resuscitation, defibrillation, airway management, administration of blood products, and thoracic decompression. The primary outcome was 30-day survival, and the key secondary outcome was prehospital ROSC.

MAIN RESULTS

A total of 223 patients with TCA were included. The median age was 54 years (IQR 34-68), and the majority were males. Overall, 23% of patients achieved prehospital ROSC, and the 30-day survival rate was 4%. Factors associated with an increased likelihood of ROSC were an initial shockable cardiac rhythm, odds ratio (OR) of 3.78 (95% CI 1.33-11.00) and endotracheal intubation, OR 7.10 (95% CI 2.55-22.85).

CONCLUSION

This study highlights the low survival rates observed among patients with traumatic cardiac arrest assessed by helicopter emergency medical services. The findings support the positive impact of an initial shockable cardiac rhythm and endotracheal intubation in improving the likelihood of ROSC. The study contributes to the limited literature on traumatic cardiac arrests assessed by physician-staffed helicopter emergency services. Finally, the findings emphasise the need for further research to understand and improve outcomes in this subgroup of cardiac arrest.

Suspension syndrome: a scoping review and recommendations from the International Commission for Mountain Emergency Medicine (ICAR MEDCOM)

BACKGROUND

Suspension syndrome describes a multifactorial cardio-circulatory collapse during passive hanging on a rope or in a harness system in a vertical or near-vertical position. The pathophysiology is still debated controversially.

AIMS

The International Commission for Mountain Emergency Medicine (ICAR MedCom) performed a scoping review to identify all articles with original epidemiological and medical data to understand the pathophysiology of suspension syndrome and develop updated recommendations for the definition, prevention, and management of suspension syndrome.

METHODS

A literature search was performed in PubMed, Embase, Web of Science and the Cochrane library. The bibliographies of the eligible articles for this review were additionally screened.

RESULTS

The online literature search yielded 210 articles, scanning of the references yielded another 30 articles. Finally, 23 articles were included into this work.

CONCLUSIONS

Suspension Syndrome is a rare entity. A neurocardiogenic reflex may lead to bradycardia, arterial hypotension, loss of consciousness and cardiac arrest. Concomitant causes, such as pain from being suspended, traumatic injuries and accidental hypothermia may contribute to the development of the Suspension Syndrome. Preventive factors include using a well-fitting sit harness, which does not cause discomfort while being suspended, and activating the muscle pump of the legs. Expediting help to extricate the suspended person is key. In a peri-arrest situation, the person should be positioned supine and standard advanced life support should be initiated immediately. Reversible causes of cardiac arrest caused or aggravated by suspension syndrome, e.g., hyperkalaemia, pulmonary embolism, hypoxia, and hypothermia, should be considered. In the hospital, blood and further exams should assess organ injuries caused by suspension syndrome.

Hypothermia: Beyond the Narrative Review-The Point of View of Emergency Physicians and Medico-Legal Considerations

Hypothermia is a widespread condition all over the world, with a high risk of mortality in pre-hospital and in-hospital settings when it is not promptly and adequately treated. In this review, we aim to describe the main specificities of the diagnosis and treatment of hypothermia through consideration of the physiological changes that occur in hypothermic patients. Hypothermia can occur due to unfavorable environmental conditions as well as internal causes, such as pathological states that result in reduced heat production, increased heat loss or ineffectiveness of the thermal regulation system. The consequences of hypothermia affect several systems in the body-the cardiovascular system, the central and peripheral nervous systems, the respiratory system, the endocrine system and the gastrointestinal system-but also kidney function, electrolyte balance and coagulation. Once hypothermia is recognized, prompt treatment, focused on restoring body temperature and supporting vital functions, is fundamental in order to avert preventable death. It is important to also denote the fact that CPR has specificities related to the unique profile of hypothermic patients.

Termination of Cardiopulmonary Resuscitation in Mountain Rescue: A Scoping Review and ICAR MedCom 2023 Recommendations

Lugnet, Viktor, Miles McDonough, Les Gordon, Mercedes Galindez, Nicolas Mena Reyes, Alison Sheets, Ken Zafren, and Peter Paal. Termination of cardiopulmonary resuscitation in mountain rescue: a scoping review and ICAR MedCom 2023 recommendations. High Alt Med Biol. 24:274-286, 2023. Background: In 2012, the International Commission for Mountain Emergency Medicine (ICAR MedCom) published recommendations for termination of cardiopulmonary resuscitation (CPR) in mountain rescue. New developments have necessitated an update. This is the 2023 update for termination of CPR in mountain rescue. Methods: For this scoping review, we searched the PubMed and Cochrane libraries, updated the recommendations, and obtained consensus approval within the writing group and the ICAR MedCom. Results: We screened a total of 9,102 articles, of which 120 articles met the inclusion criteria. We developed 17 recommendations graded according to the strength of recommendation and level of evidence. Conclusions: Most of the recommendations from 2012 are still valid. We made minor changes regarding the safety of rescuers and responses to primary or traumatic cardiac arrest. The criteria for termination of CPR remain unchanged. The principal changes include updated recommendations for mechanical chest compression, point of care ultrasound (POCUS), extracorporeal life support (ECLS) for hypothermia, the effects of water temperature in drowning, and the use of burial times in avalanche rescue.

Prediction Models for Return of Spontaneous Circulation in Patients with Cardiac Arrest: A Systematic Review and Critical Appraisal

Objectives

Prediction models for the return of spontaneous circulation (ROSC) in patients with cardiac arrest play an important role in helping physicians evaluate the survival probability and providing medical decision-making reference. Although relevant models have been developed, their methodological rigor and model applicability are still unclear. Therefore, this study aims to summarize the evidence for ROSC prediction models and provide a reference for the development, validation, and application of ROSC prediction models.

Methods

PubMed, Cochrane Library, Embase, Elsevier, Web of Science, SpringerLink, Ovid, CNKI, Wanfang, and SinoMed were systematically searched for studies on ROSC prediction models. The search time limit was from the establishment of the database to August 30, 2022. Two reviewers independently screened the literature and extracted the data. The PROBAST was used to evaluate the quality of the included literature.

Results

A total of 8 relevant prediction models were included, and 6 models reported the AUC of 0.662-0.830 in the modeling population, which showed good overall applicability but high risk of bias. The main reasons were improper handling of missing values and variable screening, lack of external validation of the model, and insufficient information of overfitting. Age, gender, etiology, initial heart rhythm, EMS arrival time/BLS intervention time, location, bystander CPR, witnessed during sudden arrest, and ACLS duration/compression duration were the most commonly included predictors. Obvious chest injury, body temperature below 33°C, and possible etiologies were predictive factors for ROSC failure in patients with TOHCA. Age, gender, initial heart rhythm, reason for the hospital visit, length of hospital stay, and the location of occurrence in hospital were the predictors of ROSC in IHCA patients.

Conclusion

The performance of current ROSC prediction models varies greatly and has a high risk of bias, which should be selected with caution. Future studies can further optimize and externally validate the existing models.

A simulation-based randomized trial of ABCDE style cognitive aid for emergency medical services CHecklist In Prehospital Settings: the CHIPS-study

BACKGROUND

Checklists are a powerful tool for reduction of mortality and morbidity. Checklists structure complex processes in a reproducible manner, optimize team interaction, and prevent errors related to human factors. Despite wide dissemination of the checklist, effects of checklist use in the prehospital emergency medicine are currently unclear. The aim of the study was to demonstrate that participants achieve higher adherence to guideline-recommended actions, manage the scenario more time-efficient, and thirdly demonstrate better adherence to the ABCDE-compliant workflow in a simulated ROSC situation.

METHODS

CHIPS was a prospective randomized case-control study. Professional emergency medical service teams were asked to perform cardiopulmonary resuscitation on an adult high-fidelity patient simulator achieving ROSC. The intervention group used a checklist which transferred the ERC guideline statements of ROSC into the structure of the 'ABCDE' mnemonic. Guideline adherence (performance score, PS), utilization of process time (items/minute) and workflow were measured by analyzing continuous A/V recordings of the simulation. Pre- and post-questionnaires addressing demographics and relevance of the checklist were recorded. Effect sizes were determined by calculating Cohen's d. The level of significance was defined at p < 0.05.

RESULTS

Twenty scenarios in the intervention group (INT) and twenty-one in the control group (CON) were evaluated. The average time of use of the checklist (CU) in the INT was 6.32 min (2.39-9.18 min; SD = 2.08 min). Mean PS of INT was significantly higher than CON, with a strong effect size (p = 0.001, d = 0.935). In the INT, significantly more items were completed per minute of scenario duration (INT, 1.48 items/min; CON, 1.15 items/min, difference: 0.33/min (25%), p = 0.001), showing a large effect size (d = 1.11). The workflow did not significantly differ between the groups (p = 0.079), although a medium effect size was shown (d = 0.563) with the tendency of the CON group deviating stronger from the ABCDE than the INT.

CONCLUSION

Checklists can have positive effects on outcome in the prehospital setting by significantly facilitates adherence to guidelines. Checklist use may be time-effective in the prehospital setting. Checklists based on the 'ABCDE' mnemonic can be used according to the 'do verify' approach. Team Time Outs are recommended to start and finish checklists.

Out-of-Hospital Arterial to End-Tidal Carbon Dioxide Gradient in Patients With Return of Spontaneous Circulation After Out-of-Hospital Cardiac Arrest: A Retrospective Study

STUDY OBJECTIVE

End-tidal carbon dioxide (etCO2) is used to guide ventilation after achieving return of spontaneous circulation (ROSC) in certain out-of-hospital systems, despite an unknown difference between arterial and end-tidal CO2 (partial pressure of carbon dioxide [paCO2]-etCO2 difference) levels in this population. The primary aim of this study was to evaluate and quantify the paCO2-etCO2 difference in out-of-hospital patients with ROSC after nontraumatic cardiac arrest.

METHODS

This retrospective single-center study included patients aged 18 years and older with sustained ROSC after nontraumatic out-of-hospital cardiac arrest. In patients with an existing out-of-hospital arterial blood gas analysis within 30 minutes after achieving ROSC, matching etCO2 values were evaluated. Linear regression and Bland-Altman plot analysis were performed to ascertain the primary endpoint of interest.

RESULTS

We included data of 60 patients in the final analysis. The mean paCO2-etCO2 difference was 32 (±18) mmHg. Only a moderate correlation (R2=0.453) between paCO2 and etCO2 was found. Bland-Altman analysis showed a bias of 32 mmHg (95% confidence interval [CI], 27 to 36) [the upper limit of agreement of 67 mmHg (95% CI, 59 to 74) and the lower limit of agreement of -3 mmHg (95% CI, -11 to 5)].

CONCLUSION

The paCO2-etCO2 difference in patients with ROSC after out-of-hospital cardiac arrest is far from physiologic ranges, and the between-patient variability is high. Therefore, etCO2-guided adaption of ventilation might not provide adequate accuracy in this setting.

Danish Drowning Formula for identification of out-of-hospital cardiac arrest from drowning

BACKGROUND

Accurate, reliable, and sufficient data is required to reduce the burden of drowning by targeting preventive measures and improving treatment. Today's drowning statistics are informed by various methods sometimes based on data sources with questionable reliability. These methods are likely responsible for a systematic and significant underreporting of drowning. This study's aim was to assess the 30-day survival of patients with out-of-hospital cardiac arrest (OHCA) identified in the Danish Cardiac Arrest Registry (DCAR) after applying the Danish Drowning Formula.

METHODS

This nationwide, cohort, registry-based study with 30-day follow-up used the Danish Drowning Formula to identify drowning-related OHCA with a resuscitation attempt from the DCAR from January 1st, 2016, through December 31st, 2021. The Danish Drowning Formula is a text-search algorithm constructed for this study based on trigger-words identified from the prehospital medical records of validated drowning cases. The primary outcome was 30-day survival from OHCA. Data were analyzed using multiple logistic regression.

RESULTS

Drowning-related OHCA occurred in 374 (1%) patients registered in the DCAR compared to 29,882 patients with OHCA from other causes. Drowning-related OHCA more frequently occurred at a public location (87% vs 25%, p < 0.001) and were more frequently witnessed by bystanders (80% vs 55%, p < 0.001). Both 30-day and 1-year survival for patients with drowning-related OHCA were significantly higher compared to OHCA from other causes (33% vs 14% and 32% vs 13%, respectively, p < 0.001). The adjusted odds ratio for 30-day survival for drowning-related OHCA and other causes of OHCA was 2.3 [1.7-3.2], p < 0.001. Increased 30-day survival was observed for drowning-related OHCA occurring at swimming pools compared to public location OHCA from other causes with an OR of 11.6 [6.0-22.6], p < 0.001.

CONCLUSIONS

This study found higher 30-day survival among drowning-related OHCA compared to OHCA from other causes. This study proposed that a text-search algorithm (Danish Drowning Formula) could explore unstructured text fields to identify drowning persons. This method may present a low-resource solution to inform the drowning statistics in the future.

REGISTRATION

This study was registered at ClinicalTrials.gov before analyses (NCT05323097).

Rewarming from unwitnessed hypothermic cardiac arrest with good neurological recovery using extracorporeal membrane oxygenation

A 26-year-old man, who was training in bad weather for a mountain ultramarathon, became hypothermic after running for 4 h. He deteriorated and was unable to continue. His running partner went for help. The man suffered an unwitnessed hypothermic cardiac arrest. The on-site management and evacuation are described and included the use of intermittent cardiopulmonary resuscitation and a mechanical device during transport. The patient was successfully resuscitated and rewarmed by Extracorporeal Membrane Oxygenation (ECMO) after more than 2 h of cardiopulmonary resuscitation. After 14 h of ECMO support and five days of ventilation, the patient subsequently made a good neurological recovery. At hospital discharge, he had normal cerebral function, and an improving peripheral polyneuropathy affecting distal limbs, with paraesthesia in both feet and reduced coordination and fine motor skills in both hands.

Efficacy of in-bed chest compressions depending on provider position during in-hospital cardiac arrest: a controlled manikin study

BACKGROUND

In contrast to the pre-hospital environment, patients with in-hospital cardiac arrest are usually lying in a hospital bed. Interestingly, there are no current recommendations for optimal provider positioning. The present study evaluates in bed chest compression quality in different provider positions during in-hospital-cardiac-arrest.

METHODS

Paramedics conducted four resuscitation scenarios: manikin lying on the floor with provider position kneeling next to the manikin (control group), manikin lying in a hospital bed with the provider kneeling astride, kneeling beside or standing next to the manikin. A resuscitation board was not used according to the current guideline recommendations. Quality of resuscitation, compression depth, compression rate and percentage of compressions with complete chest rebound were recorded. Afterwards, the paramedics were asked about subjective efficiency and fatigue. Data were analyzed using Generalized-Linear-Mixed-Models and, in addition, by non-parametric Friedman test.

RESULTS

A total of 60 participants were recruited. The total quality of chest compressions was significantly higher in floor-based control position compared to the standing (P<.001) and both kneeling positions (P<.05). Also, the compression depth was significantly more guideline compliant in the control (P<.001) and the kneeling position (P<.05) compared to the standing position. The compression frequency as well as the complete chest wall recoil did not differ significantly. The standing position was rated as more fatiguing than the other positions (p≤0.001), kneeling beside as subjectively more efficient than the standing position (P<0.001).

CONCLUSIONS

In case of an in-bed resuscitation, high quality chest compressions are possible. Kneeling astride or beside the patient should be preferred because these positions demonstrated a good chest compression quality and were more efficient and less exhausting.

Extracorporeal Life Support for Recurrent Hypothermic Cardiac Arrest: A Case Report

Hypothermia-associated cardiac arrest (HACA) is a challenge for emergency physicians. Standard cardiopulmonary resuscitation (CPR) remains the primary intervention for the treatment of HACA, but extracorporeal life support (ECLS) may be needed as an adjunct to CPR. In this report, we present the case of an adult Asian patient who experienced two episodes of HACA at a two-year interval. In both episodes, the patient was treated with ECLS in addition to standard CPR. We discuss the fundamentals of HACA and how to safely and effectively incorporate ECLS into its management. No-flow time, age, comorbidities, and the cause of the cardiac arrest are criteria to consider when deciding on the duration of CPR and the intensity of the resources deployed. Hypothermia is a reversible cause of cardiac arrest, justifying prolonged CPR. According to the Hypothermia Outcome Prediction after ECLS (HOPE) score, active rewarming through ECLS is recommended. However, a history of cardiac arrest is rare and might be considered a severe comorbidity contraindicating ECLS use. Nevertheless, the indication is determined on a case-by-case basis.

Implications of differences between point-of-care blood gas analyser and laboratory analyser potassium results on hyperkalaemia diagnosis & treatment

BACKGROUND

Hyperkalaemia is managed in the emergency department (ED) following measurement of potassium results by blood gas analysers (BGA) or laboratory analysers (LAB).

AIMS

To determine the prevalence of clinically significant differences between BGA and LAB potassium results and the impact on ED hyperkalaemia management.

METHODS

Retrospective analysis of time-matched ED BGA and LAB potassium samples from 2019 to 2020 (taken within 15 min, one or both results ≥6.0 mmol/L). Mean differences and 95% limits of agreement (LoA) were determined for pairs with one or both results ≥6.0 mmol/L and a separate 500 consecutive sample pairs.

RESULTS

Four hundred eighty-eight matched BGA and LAB samples met the inclusion criteria. Of these, 201 (41.2%) differed by ≤0.5 mmol/L, 169 (34.6%) included a haemolysed LAB sample, and 12 (2.5%) had an unreportable BGA sample. One hundred six (21.7%) pairs differed by >0.5 mmol/L, and 60/106 (57%) had normal LAB potassium results, but BGA indicated moderate/severe hyperkalaemia (two of these pairs received hyperkalaemia treatment). Of patients with a haemolysed LAB sample, or where pairs differed by >0.5 mmol, 48 were treated with insulin and five (10.4%) experienced hypoglycaemia. Mean differences and LoA for pairs with LAB results <6.0 mmol/L but BGA ≥6.0 mmol/L demonstrated unacceptable agreement, with 18 (25.7%) BGA results exceeding 8.0 mmol/L.

CONCLUSIONS

Potentially significant discordance may occur between BGA and LAB potassium results. Clinicians need to be aware of factors impacting both analytical methods' accuracy (such as poor venepuncture or sample handling, (K) EDTA interference) and undetectable haemolysis with BGA measurements. We recommend BGA hyperkalaemia be confirmed with LAB results using a non-haemolysed sample where time permits.

Hospital-administered ECPR for out-of-hospital cardiac arrest: an observational cohort study

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) is a treatment method for refractory out-of-hospital cardiac arrest (OHCA) requiring a complex chain of care.

METHODS

All cases of OHCA between 1 January 2016 and 31 December 2021 in the Helsinki University Hospital catchment area in which the ECPR protocol was activated were included in the study. The protocol involved patient transport from the emergency site with ongoing mechanical cardiopulmonary resuscitation (CPR) directly to the cardiac catheterisation laboratory where the implementation of extracorporeal membrane oxygenation (ECMO) was considered. Cases of hypothermic cardiac arrest were excluded. The main outcomes were the number of ECPR protocol activations, duration of prehospital and in-hospital time intervals, and whether the ECPR candidates were treated using ECMO or not.

RESULTS

The prehospital ECPR protocol was activated in 73 cases of normothermic OHCA. The mean patient age (SD) was 54 (±11) years and 67 (91.8%) of them were male. The arrest was witnessed in 67 (91.8%) and initial rhythm was shockable in 61 (83.6%) cases. The median ambulance response time (IQR) was 9 (7-11) min. All patients received mechanical CPR, epinephrine and/or amiodarone. Seventy (95.9%) patients were endotracheally intubated. The median (IQR) highest prehospital end-tidal CO2 was 5.5 (4.0-6.9) kPa.A total of 37 (50.7%) patients were treated with venoarterial ECMO within a median (IQR) of 84 (71-105) min after the arrest. Thirteen (35.1%) of them survived to discharge and 11 (29.7%) with a cerebral performance category (CPC) 1-2. In those ECPR candidates who did not receive ECMO, 8 (22.2%) received permanent return of spontaneuous circulation during transport or immediately after hospital arrival and 6 (16.7%) survived to discharge with a CPC 1-2.

CONCLUSIONS

Half of the ECPR protocol activations did not lead to ECMO treatment. However, every fourth ECPR candidate and every third patient who received ECMO-facilitated resuscitation at the hospital survived with a good neurological outcome.

The first hour of trauma reception is critical for patients with major thoracic trauma: A retrospective analysis from the TraumaRegister DGU

BACKGROUND

Up to 25% of trauma deaths are related to thoracic injuries.

OBJECTIVE

The primary goal was to analyse the incidence and time distribution of death in adult patients with major thoracic injuries. The secondary goal was to determine if potentially preventable deaths occurred within this time distribution and, if so, identify an associated therapeutic window.

DESIGN

Retrospective observational analysis.

SETTING

TraumaRegister DGU.

PATIENTS

Major thoracic injury was defined as an Abbreviated Injury Scale (AIS) 3 or greater. Patients with severe head injury (AIS ≥ 4) or injuries to other body regions with AIS being greater than the thoracic injury (AIS other >AIS thorax) were excluded to ensure that the most severe injury described was primarily thoracic related.

MAIN OUTCOME MEASURES

Incidence and time distribution of mortality were considered the primary outcome measures. Patient and clinical characteristics and resuscitative interventions were analysed in relation to the time distribution of death.

RESULTS

Among adult major trauma cases with direct admission from the accident scene, 45% had thoracic injuries and overall mortality was 9.3%. In those with major thoracic trauma ( n  = 24 332) mortality was 5.9% ( n  = 1437). About 25% of these deaths occurred within the first hour after admission and 48% within the first day. No peak in late mortality was seen. The highest incidences of hypoxia and shock were seen in non-survivors with immediate death within 1 h and early death (1 to 6 h). These groups received the largest number of resuscitative interventions. Haemorrhage was the leading cause of death in these groups, whereas organ failure was the leading cause of death amongst those who survived the first 6 h after admission.

CONCLUSION

About half of adult major trauma cases had thoracic injuries. In non-survivors with primarily major thoracic trauma, most deaths occurred immediately (<1h) or within the first 6 h after injury. Further research should analyse if improvements in trauma resuscitation performed within this time frame will reduce preventable deaths.

TRIAL REGISTRATION

The present study is reported within the publication guidelines of the TraumaRegister DGU® and registered as TR-DGU project ID 2020-022.

Extracorporeal cardiopulmonary resuscitation for hypothermic refractory cardiac arrests in urban areas with temperate climates

BACKGROUND

Accidental hypothermia designates an unintentional drop in body temperature below 35 °C. There is a major risk of ventricular fibrillation below 28 °C and cardiac arrest is almost inevitable below 24 °C. In such cases, conventional cardiopulmonary resuscitation is often inefficient. In urban areas with temperate climates, characterized by mild year-round temperatures, the outcome of patients with refractory hypothermic out-of-hospital cardiac arrest (OHCA) treated with extracorporeal cardiopulmonary resuscitation (ECPR) remains uncertain.

METHODS

We conducted a retrospective monocentric observational study involving patients admitted to a university hospital in Paris, France. We reviewed patients admitted between January 1, 2011 and April 30, 2022. The primary outcome was survival at 28 days with good neurological outcomes, defined as Cerebral Performance Category 1 or 2. We performed a subgroup analysis distinguishing hypothermic refractory OHCA as either asphyxic or non-asphyxic.

RESULTS

A total of 36 patients were analysed, 15 of whom (42%) survived at 28 days, including 13 (36%) with good neurological outcomes. Within the asphyxic subgroup, only 1 (10%) patient survived at 28 days, with poor neurological outcomes. A low-flow time of less than 60 min was not significantly associated with good neurological outcomes (P = 0.25). Prehospital ECPR demonstrated no statistically significant difference in terms of survival with good neurological outcomes compared with inhospital ECPR (P = 0.55). Among patients treated with inhospital ECPR, the HOPE score predicted a 30% survival rate and the observed survival was 6/19 (32%).

CONCLUSION

Hypothermic refractory OHCA occurred even in urban areas with temperate climates, and survival with good neurological outcomes at 28 days stood at 36% for all patients treated with ECPR. We found no survivors with good neurological outcomes at 28 days in submersed patients.

The Role of Extracorporeal Membrane Oxygenation ECMO in Accidental Hypothermia and Rewarming in Out-of-Hospital Cardiac Arrest Patients-A Literature Review

Accidental hypothermia, defined as an unintentional drop of the body core temperature below 35 °C, is one of the causes of cardiocirculatory instability and reversible cardiac arrest. Currently, extracorporeal life support (ECLS) rewarming is recommended as a first-line treatment for hypothermic cardiac arrest patients. The aim of the ECLS rewarming is not only rapid normalization of core temperature but also maintenance of adequate organ perfusion. Veno-arterial extracorporeal membrane oxygenation (ECMO) is a preferred technique due to its lower anticoagulation requirements and potential to prolong circulatory support. Although highly efficient, ECMO is acknowledged as an invasive treatment option, requiring experienced medical personnel and is associated with the risk of serious complications. In this review, we aimed to discuss the clinical aspects of ECMO management in severely hypothermic cardiac arrest patients.

Cardiopulmonary resuscitation during hyperbaric oxygen therapy: a comprehensive review and recommendations for practice

BACKGROUND

Cardiopulmonary resuscitation (CPR) during hyperbaric oxygen therapy (HBOT) presents unique challenges due to limited access to patients in cardiac arrest (CA) and the distinct physiological conditions present during hyperbaric therapy. Despite these challenges, guidelines specifically addressing CPR during HBOT are lacking. This review aims to consolidate the available evidence and offer recommendations for clinical practice in this context.

MATERIALS AND METHODS

A comprehensive literature search was conducted in PubMed, EMBASE, Cochrane Library, and CINAHL using the search string: "(pressure chamber OR decompression OR hyperbaric) AND (cardiac arrest OR cardiopulmonary resuscitation OR advanced life support OR ALS OR life support OR chest compression OR ventricular fibrillation OR heart arrest OR heart massage OR resuscitation)". Additionally, relevant publications and book chapters not identified through this search were included.

RESULTS

The search yielded 10,223 publications, with 41 deemed relevant to the topic. Among these, 18 articles (primarily case reports) described CPR or defibrillation in 22 patients undergoing HBOT. The remaining 23 articles provided information or recommendations pertaining to CPR during HBOT. Given the unique physiological factors during HBOT, the limitations of current resuscitation guidelines are discussed.

CONCLUSIONS

CPR in the context of HBOT is a rare, yet critical event requiring special considerations. Existing guidelines should be adapted to address these unique circumstances and integrated into regular training for HBOT practitioners. This review serves as a valuable contribution to the literature on "CPR under special circumstances".

Suspected Rivaroxaban-Induced Anaphylaxis Secondary to Ingestion of Rivaroxaban and Nimesulide Without Cross-Reactivity to Dabigatran - A Case Report

Here, we describe a case of anaphylaxis secondary to rivaroxaban in a 61-year-old woman 24 hours after orthopedic surgery. 10-15 minutes after ingestion of rivaroxaban and nimesulide, the patient's palms started itching, her face and lips swelled, her face flushed, she developed shortness of breath and subsequently lost consciousness. Serum tryptase levels at the time of the anaphylactic reaction were elevated, with subsequent measurement one month later returning a value within the normal range. Dabigatran and meloxicam were identified as suitable alternative drugs by oral provocation at an allergy clinic. Even though rivaroxaban rarely causes serious allergic reactions, when prescribing it, it is important to analyze patients' medical history for possible previously experienced drug-induced allergic reactions and to be aware of the risks of possible undesired drug interactions.

Dental students' attitudes on cardiopulmonary resuscitation training via virtual reality: an exploratory study

Purpose Resuscitation guidelines have advocated the use of virtual learning as a form of pre-course e-learning. Virtual reality (VR) has been identified to provide a method of constructive learning with instant feedback. There are increasing publications of VR use in cardiopulmonary resuscitation (CPR) training; however, there is a dearth from the dental profession. Therefore, the aim of this exploratory study was to investigate dental students' opinions in CPR training using VR.Methods In total, 120 dental students undertook both conventional (manikin) and VR CPR training in a cross-over design. The VR scenario was in a hospital setting. Following, students completed a questionnaire evaluating their experiences.Results The majority of students (n = 88) reported that this was the first time that they had utilised VR. The experience of using VR in CPR training was rated as very good. Most students felt that the inclusion of VR in CPR training created a better learning experience and had a high learning potential. However, the hospital setting was not entirely relevant.Conclusion Dental students recommended that VR CPR training should be used as an adjunct to conventional training in dental education, but the VR scenario would benefit being a virtual dental environment.

Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery

INTRODUCTION

Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council guidelines.

MATERIAL AND METHODS

The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment, and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches.

RESULTS

This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage, resuscitative endovascular balloon occlusion and resuscitative thoracotomy, pericardiocentesis, needle decompression, and thoracostomy.

CONCLUSIONS

Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition, and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well-organised team using crew resource management, but also on an institutional safety culture embedded in everyday practice through continuous education, training, and multidisciplinary co-operation.

Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery

INTRODUCTION

Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council (ERC) guidelines.

MATERIAL AND METHODS

The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches.

RESULTS

This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage (OCCM), resuscitative endovascular balloon occlusion (REBOA) and resuscitative thoracotomy, pericardiocentesis, needle decompression and thoracostomy.

CONCLUSION

Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well organised team using crew resource management but also on an institutional safety culture embedded in everyday practice through continuous education, training and multidisciplinary co-operation.

Hypothermic cardiac arrest patients admitted to hospital who were not rewarmed with extracorporeal life support: A retrospective study

Aims

Our goal was to study hypothermic cardiac arrest (CA) patients who were not rewarmed by Extracorporeal Life Support (ECLS) but were admitted to a hospital equipped for it. The focus was on whether the decisions of non-rewarming, meaning termination of resuscitation, were compliant with international guidelines based on serum potassium at hospital admission.

Methods

We retrospectively included all hypothermic CA who were not rewarmed, from three Swiss centers between 1st January 2000 and 2nd May 2021. Data were extracted from medical charts and assembled into two groups for analysis according to serum potassium. We identified the criteria used to terminate resuscitation. We also retrospectively calculated the HOPE score, a multivariable tool predicting the survival probability in hypothermic CA undergoing ECLS rewarming.

Results

Thirty-eight victims were included in the study. The decision of non-rewarming was compliant with international guidelines for 12 (33%) patients. Among the 36 patients for whom the serum potassium was measured at hospital admission, 24 (67%) had a value that - alone - would have indicated ECLS. For 13 of these 24 (54%) patients, the HOPE score was <10%, meaning that ECLS was not indicated. The HOPE estimation of the survival probabilities, when used with a 10% threshold, supported 23 (68%) of the non-rewarming decisions made by the clinicians.

Conclusions

This study showed a low adherence to international guidelines for hypothermic CA patients. In contrast, most of these non-rewarming decisions made by clinicians would have been compliant with current guidelines based on the HOPE score.

[Prehospital perimortem cesarean section during cardiopulmonary resuscitation for traumatic cardiac arrest : Case report and lessons learned]

The following case report discusses the resuscitation of a pregnant woman in traumatic cardiac arrest after a fall from a height with consecutive resuscitative hysterotomy for maternal and fetal salvage. The report illustrates all lessons learned from critical appraisal amid new guideline recommendations and gives an overview of the published literature on the matter. Despite extensive resuscitation efforts, ultimately both the mother and the newborn were pronounced life extinct at the scene. Prehospital treatment of (traumatic) cardiac arrest in a pregnant patient as well as performing a perimortem cesarean section remain infrequent but challenging scenarios.

Hands-free continuous carotid Doppler ultrasound for detection of the pulse during cardiac arrest in a porcine model

Background/Purpose

Pulse palpation is an unreliable method for diagnosing cardiac arrest. To address this limitation, continuous hemodynamic monitoring may be a viable solution. Therefore, we developed a novel, hands-free Doppler system, RescueDoppler, to detect the pulse continuously in the carotid artery.

Methods

In twelve pigs, we evaluated RescueDoppleŕs potential to measure blood flow velocity in three situations where pulse palpation of the carotid artery was insufficient: (1) systolic blood pressure below 60 mmHg, (2) ventricular fibrillation (VF) and (3) pulseless electrical activity (PEA). (1) Low blood pressure was induced using a Fogarty balloon catheter to occlude the inferior vena cava. (2) An implantable cardioverter-defibrillator induced VF. (3) Myocardial infarction after microembolization of the left coronary artery caused True-PEA. Invasive blood pressure was measured in the contralateral carotid artery. Time-averaged blood flow velocity (TAV) in the carotid artery was related to mean arterial pressure (MAP) in a linear mixed model.

Results

RescueDoppler identified pulsatile blood flow in 41/41 events with systolic blood pressure below 60 mmHg, with lowest blood pressure of 19 mmHg. In addition the absence of spontaneous circulation was identified in 21/21 VF events and true PEA in 2/2 events. The intraclass correlation coefficient within animals for TAV and MAP was 0.94 (95% CI. 0.85-0.98).

Conclusions

In a porcine model, RescueDoppler reliably identified pulsative blood flow with blood pressures below 60 mmHg. During VF and PEA, circulatory arrest was rapidly and accurately demonstrated. RescueDoppler could potentially replace unreliable pulse palpation during cardiac arrest and cardiopulmonary resuscitation.