Part 1: Executive Summary: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

Resuscitation registers: How many active registers are there and how many collect data on paediatric cardiac arrests?

BACKGROUND

Cardiac arrest, particularly in children, often has a poor outcome and international guidelines highlight significant gaps in the evidence base for effective resuscitation. Whilst randomised controlled trials for some interventions can be justified, they are not appropriate for many aspects of resuscitation. Therefore, guidelines must use other sources of data such as epidemiological evidence from cardiac arrest registries, to improve the efficacy of resuscitation. The aim of our study was to identify existing national cardiac arrest registries and document key information about the registries, including whether they contain data on paediatric arrests.

METHODS

Key bibliographic databases were searched for papers about or using data from cardiac arrest registries. Two reviewers independently screened the search results for relevant papers. A list of registers named in the papers was compiled and information obtained from the papers and the websites of registers where possible.

RESULTS

Twenty three active national or large regional cardiac arrest registries were identified. These included five international collaborations and 10 registries that cover a population of at least 10 million people. Twelve registries are based in Europe, five in North America, four in Asia and two in Australasia. The registries vary in their organisation, but the majority (20) defer to the Utstein reporting guidelines for cardiac arrest. Registries covered populations between 0.4 and 174.5 million and contained between 100 and 605,505 records. Sixteen collected data on out-of-hospital arrests only; three in-hospital arrests only; and four included both. For ten registers the number of paediatric arrests was available and ranged from 56 to 3900.

CONCLUSIONS

To our knowledge this report contains the most complete list of active national and large regional cardiac arrest registries. Register data support current guidelines on effective resuscitation however, even the largest registries include relatively small numbers, particularly of paediatric events. A less fragmented approach has the potential to improve the utility of registration data for the benefit of patients.

Utility of Low Fidelity Manikins for Learning High Quality Chest Compressions

OBJECTIVES

Primarily, to measure the adequacy of chest compression depth after training on low fidelity manikins and secondarily to assess the comparative experience of the learners on high fidelity and low fidelity simulators.

METHODS

An observational cohort study in which seventy-two first year postgraduate students underwent a Basic Life Support (BLS) workshop conducted by AHA accredited BLS trainers and they were then required to perform on a high fidelity manikin to objectively record the quality of their performance.

RESULTS

There were 34 (47.22%) male and 38 (52.77%) female participants. CPR skills, as judged by checklist of sequential actions and visual inspection during the BLS training on low fidelity simulators (LFS) were correctly performed by majority (95.89%) participants. However, none of the participants could achieve the recommended depth for high quality chest compressions. The participants' perception of degree of realism and their practical experience on both the types of manikins were similar.

CONCLUSIONS

Low fidelity manikins are useful for training CPR in sequential manner but fail to impart quality of chest compressions as per AHA recommendations.

Association Between Early Hyperoxia Exposure After Resuscitation From Cardiac Arrest and Neurological Disability: Prospective Multicenter Protocol-Directed Cohort Study

BACKGROUND

Studies examining the association between hyperoxia exposure after resuscitation from cardiac arrest and clinical outcomes have reported conflicting results. Our objective was to test the hypothesis that early postresuscitation hyperoxia is associated with poor neurological outcome.

METHODS

This was a multicenter prospective cohort study. We included adult patients with cardiac arrest who were mechanically ventilated and received targeted temperature management after return of spontaneous circulation. We excluded patients with cardiac arrest caused by trauma or sepsis. Per protocol, partial pressure of arterial oxygen (Pao₂) was measured at 1 and 6 hours after return of spontaneous circulation. Hyperoxia was defined as a Pao₂ >300 mm Hg during the initial 6 hours after return of spontaneous circulation. The primary outcome was poor neurological function at hospital discharge, defined as a modified Rankin Scale score >3. Multivariable generalized linear regression with a log link was used to test the association between Pao₂ and poor neurological outcome. To assess whether there was an association between other supranormal Pao₂ levels and poor neurological outcome, we used other Pao₂ cut points to define hyperoxia (ie, 100, 150, 200, 250, 350, 400 mm Hg).

RESULTS

Of the 280 patients included, 105 (38%) had exposure to hyperoxia. Poor neurological function at hospital discharge occurred in 70% of patients in the entire cohort and in 77% versus 65% among patients with versus without exposure to hyperoxia respectively (absolute risk difference, 12%; 95% confidence interval, 1-23). Hyperoxia was independently associated with poor neurological function (relative risk, 1.23; 95% confidence interval, 1.11-1.35). On multivariable analysis, a 1-hour-longer duration of hyperoxia exposure was associated with a 3% increase in risk of poor neurological outcome (relative risk, 1.03; 95% confidence interval, 1.02-1.05). We found that the association with poor neurological outcome began at ≥300 mm Hg.

CONCLUSIONS

Early hyperoxia exposure after resuscitation from cardiac arrest was independently associated with poor neurological function at hospital discharge.

Clinical outcome of canine cardiopulmonary resuscitation following the RECOVER clinical guidelines at a Japanese nighttime animal hospital

A set of evidence-based consensus guidelines for cardiopulmonary resuscitation (CPR) in dogs and cats (RECOVER guidelines) was published in 2012. The purpose of this study was to investigate the clinical outcomes of CPR performed according to those guidelines in dogs. A total of 141 dogs with cardiopulmonary arrest (CPA) were identified and underwent CPR between January 2012 and December 2015 at the Sapporo Nighttime Animal Hospital. CPR was performed according to no-consensus traditional veterinary CPR procedures in 68 dogs (TRADITIONAL group), and according to the RECOVER guidelines in 73 dogs (RECOVER group). There was no significant difference in the age, body weight, or time from CPA identification to initiation of CPR between the TRADITIONAL and RECOVER groups (median [range]: 10 [0–16] vs. 11 [0–16] years; 6.6 [1.0–58.6] vs. 5.5 [1.1–30.4] kg; and 0 [0–30] vs. 0 [0–30] min, respectively). In the TRADITIONAL group, 12 dogs (17%) achieved a return of spontaneous circulation (ROSC), but none survived to hospital discharge. However, 32 dogs (43%) in the RECOVER group achieved ROSC, and 4 dogs (5%) were discharged from the hospital. Incorporating the RECOVER guidelines into clinical practice significantly improved the ROSC rate (P<0.001). However, the rate of survival to hospital discharge was still low. This may suggest that a superior intensive care unit that provides advanced post-CPA care could benefit veterinary CPR patients.

Semiprone position is superior to supine position for paediatric endotracheal intubation during massive regurgitation, a randomized crossover simulation trial

BACKGROUND

Endotracheal intubation of patients with massive regurgitation represents a challenge in emergency airway management. Gastric contents tend to block suction catheters, and few treatment alternatives exist. Based on a technique that was successfully applied in our district, we wanted to examine if endotracheal intubation would be easier and quicker to perform when the patient is turned over to a semiprone position, as compared to the supine position.

METHODS

In a randomized crossover simulation trial, a child manikin with on-going regurgitation was intubated both in the supine and semiprone positions. Endpoints were experienced difficulty with the procedure and time to intubation, as well as visually confirmed intubation and first-pass success rate.

RESULTS

Intubation in the semiprone position was significantly easier and faster compared to the supine position; the median experienced difficulty on a visual analogue scale was 27 and 65, respectively (p = 0.004), and the median time to intubation was 26 and 45 s, respectively (p = 0.001). There were no significant differences in frequency of visually confirmed intubation (16 and 18, p = 0.490) of first-pass success rate (17 and 18, p = 1.000).

CONCLUSION

In this experiment, endotracheal intubation during massive regurgitation with the patient in the semiprone position was significantly easier and quicker to perform than in the supine position. Endotracheal intubation in the semiprone position can provide a quick rescue method in situations where airway management is hindered by massive regurgitation, and it represents a possible supplement to current airway management training.

Evolved role of the cardiovascular intensive care unit (CICU)

Cardiovascular intensive care refers to special systemic management for the patients with severe cardiovascular disease (CVD), which consists of heart disease and vascular disease. CVD is one of the leading causes of death in the world. In order to prevent death due to CVDs, an intensive care unit for severe CVD patients, so-called cardiovascular intensive care unit (CICU), has been developed in many general hospitals. The technological developments of clinical cardiology, such as invasive hemodynamic monitoring and intracoronary interventional procedures and devices, have resulted in evolution of intensive care for CVDs. Subsequently, severe CVD patients admitted to CICU are increasing year by year. Dedicated medical staff is required for CICU in order to perform best patient management. It is necessary for optimal patient care to select effective means from various hemodynamic tools and to adjust the usage according to the clinical situation such as cardiogenic shock and acute heart failure. Furthermore, the patients in the CICU often have various complications such as respiratory failure and renal failure. Therefore, medical staffs who work at CICU are required to have the ability to practice systemic intensive care.

Prehospital intravenous access for survival from out-of-hospital cardiac arrest: propensity score matched analyses from a population-based cohort study in Osaka, Japan

OBJECTIVES

Prehospital intravenous access is a common intervention for patients with out-of-hospital cardiac arrest (OHCA). We aimed to assess the effectiveness of prehospital intravenous access and subsequent epinephrine administration on outcomes among OHCA patients.

METHODS

We conducted a prospective cohort study of patients with OHCA from non-traumatic causes aged ≥18 years in Osaka, Japan from January 2005 through December 2012. The primary outcome was 1-month survival with favourable neurological outcome defined as a cerebral performance category of 1 or 2. The association between intravenous line placement and survival with favourable neurological outcome was evaluated by logistic regression, after propensity score matching for the intravenous access attempt stratified by initial documented rhythm of ventricular fibrillation (VF) or non-VF. The contribution of epinephrine administration to the outcome was also explored.

RESULTS

Among OHCA patients during the study period, 3208 VF patients and 38 175 non-VF patients were included in our analysis. Intravenous access attempt was negatively associated with 1-month survival with a favourable neurological outcome in VF group (OR 0.76, 95% CI 0.59 to 0.98), while no association was observed in the non-VF group (OR 1.06, 95% CI 0.84 to 1.34). Epinephrine administration had no positive association in the VF patients (OR 0.75, 95% CI 0.51 to 1.07) and positively associated in the non-VF patients (OR 1.52, 95% CI 1.08 to 2.08) with the favourable neurological outcome.

CONCLUSIONS

Intravenous access attempt could be negatively associated with survival with a favourable neurological outcome after OHCA. Subsequent epinephrine administration might be effective for non-VF OHCAs.

2017 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary

The International Liaison Committee on Resuscitation has initiated a near-continuous review of cardiopulmonary resuscitation science that replaces the previous 5-year cyclic batch-and-queue approach process. This is the first of an annual series of International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations summary articles that will include the cardiopulmonary resuscitation science reviewed by the International Liaison Committee on Resuscitation in the previous year. The review this year includes 5 basic life support and 1 pediatric Consensuses on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Each of these includes a summary of the science and its quality based on Grading of Recommendations, Assessment, Development, and Evaluation criteria and treatment recommendations. Insights into the deliberations of the International Liaison Committee on Resuscitation task force members are provided in Values and Preferences sections. Finally, the task force members have prioritized and listed the top 3 knowledge gaps for each population, intervention, comparator, and outcome question.

Compression-only life support (COLS) for cardiopulmonary resuscitation by layperson outside the hospital

The cardiopulmonary resuscitation (CPR) guidelines of compression-only life support (COLS) for management of the victim with cardiopulmonary arrest in adults provide a stepwise algorithmic approach for optimal outcome of the victim outside the hospital by untrained laypersons. These guidelines have been developed to recommend practical, uniform and acceptable resuscitation algorithms across India. As resuscitation data of the Indian population are inadequate, these guidelines have been based on international literature. The guidelines have been recommended after discussion among Indian experts and the recommendations modified to ensure its practical applicability across the country. The COLS emphasises on early recognition of cardiac arrest and activation, early chest compression and early transfer to medical facility. The guidelines emphasise avoidance of any interruption of chest compression, and thus relies primarily on chest compression-only CPR by laypersons.

Ideal (i) CPR: Looking beyond shadows in a cave

Survival rates after cardiac arrest have shown minimal improvement in the last 60 years. However, in some forward-thinking cities and hospitals, out-of and in-hospital cardiac arrest survival rates exceed 20% and 40% respectively. These beacons of hope can enlighten us, providing a clearer vision of what it takes to provide Ideal cardiopulmonary resuscitation. To make progress in a field that has seemingly stagnated for too many decades, we must be open to new ideas and develop bundles of care that work in communities with varying EMS systems and various existing infrastructure to bring the best practices to the rest of the country.

The International Liaison Committee on Resuscitation-Review of the last 25 years and vision for the future

2017 marks the 25th anniversary of the International Liaison Committee on Resuscitation (ILCOR). ILCOR was formed in 1992 to create a forum for collaboration among principal resuscitation councils worldwide. Since then, ILCOR has established and distinguished itself for its pioneering vision and leadership in resuscitation science. By systematically assessing the evidence for resuscitation standards and guidelines and by identifying national and regional differences, ILCOR reached consensus on international resuscitation guidelines in 2000, and on international science and treatment recommendations in 2005, 2010 and 2015. However, local variation and contextualization of guidelines are evident by subtle differences in regional and national resuscitation guidelines. ILCOR's efforts to date have enhanced international cooperation, and progressively more transparent and systematic collection and analysis of pertinent scientific evidence. Going forward, this sets the stage for ILCOR to pursue its vision to save more lives globally through resuscitation.

The effect of distraction by dual work on a CPR practitioner's efficiency in chest compression: A randomized controlled simulation study

BACKGROUND

In the clinical setting, the dispersed practitioners' attention often leads to decreased competence in their performance. We aimed to investigate the effect of distracted practitioners on the quality of chest compression during cardiopulmonary resuscitation.

METHODS

A randomized controlled crossover simulation study was conducted. Participants were recruited from among doctors, nurses, and paramedics working in a university tertiary hospital. The paced auditory serial addition test (PASAT) was used as a tool for distracting participants. In the crossover design, each participant played 2 scenarios with a 20-minute time gap, by a random order; 2-minute continuous chest compressions with and without PASAT being conducted. The primary outcome was the percentage of compression with an adequate compression rate. Secondary outcomes were the percentage of compression with adequate depth, the percentage of compression with full chest wall recoil, mean compression rate (per minute), mean compression depth, and subjective difficulty of chest compression.

RESULTS

Forty-four participants were enrolled, and all of them completed the study. It was found that the percentage of compression with an adequate compression rate was lower when the PASAT was conducted. Although there was no difference in the percentage of compression with adequate depth (P = .88), the percentage of compression with complete chest recoil was lower when PASAT was conducted. In addition, while the mean compression rate was higher when PASAT was conducted, the mean compression depth was not significantly different (P = .65). The subjective difficulty was not different (P = .69).

CONCLUSIONS

Health care providers who are distracted have a negative effect on the quality of chest compression, in terms of its rate and chest wall recoil.

TRIAL REGISTRATION

www.ClinicalTrials.gov, NCT03124290.

Amiodarone, lidocaine, magnesium or placebo in shock refractory ventricular arrhythmia: A Bayesian network meta-analysis

Recent evidence challenges, the superiority of amiodarone, compared to other anti-arrhythmic medications, as the agent of choice in pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF). We conducted Bayesian network and traditional meta-analyses to investigate the relative efficacies of amiodarone, lidocaine, magnesium (MgSO4) and placebo as treatments for pulseless VT or VF. Eleven studies [5200 patients, 7 randomized trials (4, 611 patients) and 4 non-randomized studies (589 patients)], were included in this meta-analysis. The search was conducted, from 1981 to February 2017, using MEDLINE, EMBASE and The Cochrane Library. Estimates were reported as odds ratio (OR) with 95% Credible Interval (CrI). Markov chain Monte Carlo (MCMC) modeling was used to estimate the relative ranking probability of each treatment group based on surface under cumulative ranking curve (SUCRA). Bayesian analysis demonstrated that lidocaine had superior effects on survival to hospital discharge, compared to amiodarone (OR, 2.18, 95% Cr.I 1.26-3.13), MgSO4 (OR, 2.03, 95% Cr.I 0.74-4.82) and placebo (OR, 2.42, 95% Cr.I 1.39-3.54). There were no statistical differences among treatment groups regarding survival to hospital admission/24 h (hrs) and return of spontaneous circulation (ROSC). Probability analysis revealed that lidocaine was the most effective therapy for survival to hospital discharge (SUCRA, 97%). We conclude that lidocaine may be the most effective anti-arrhythmic agent for survival to hospital discharge in patients with pulseless VT or VF.

Effect of national implementation of utstein recommendation from the global resuscitation alliance on ten steps to improve outcomes from Out-of-Hospital cardiac arrest: a ten-year observational study in Korea

OBJECTIVES

The Utstein ten-step implementation strategy (UTIS) proposed by the Global Resuscitation Alliance, a bundle of community cardiopulmonary resuscitation (CPR) programs to improve outcomes after out-of-hospital cardiac arrests (OHCAs), has been developed. However, it is not documented whether UTIS programs are associated with better outcomes or not. The study aimed to test the association between the UTIS programme and better outcomes after OHCA.

METHODS

The study was a before- and after-intervention study. Adults OHCAs treated by emergency medical service (EMS) from 2006 to 2015 in Korea were collected, excluding patients witnessed by ambulance personnel and without outcomes. Phase 1 (2009-2011) after implementing three programs (national OHCA registry, obligatory CPR education, and public report of OHCA outcomes), and phase 2 (2012-2015) after implementing two programs (telephone-assisted CPR and EMS quality assurance programme) were compared with the control period (2006-2008) when no UTIS programme were implemented. The primary outcome was good neurological recovery (cerebral performance scale 1 or 2). We tested the association between the phases and outcomes, adjusting for confounders using a multivariate logistic regression model to calculate adjusted odds ratios (AORs) with 95% confidence intervals (CIs).

RESULTS

A total of 1 28 888 eligible patients were analysed. The control, phase 1, and phase two study groups were 19.4%, 30.5%, and 50.0% of the whole, respectively. There were significant changes in pre-hospital ROSC (0.8% in 2006 and 7.1% in 2015), survival to discharge (3.0% in 2006 and 6.1% in 2015), and good neurological recovery (1.2% in 2006 and 4.1% in 2015). The AORs (95% CIs) for good neurological recovery were 1.82 (1.53-2.15) or phase 1 and 2.21 (1.78-2.75) for phase two compared with control phase.

CONCLUSION

The national implementation of the five UTIS programs was significantly associated with better OHCA outcomes in Korea.

The critical care literature 2016

An emergency physician (EP) is often the first health care provider to evaluate, resuscitate, and manage a critically ill patient. Between 2001 and 2009, the annual hours of critical care delivered in emergency departments (EDs) across the United States increased >200%! (Herring et al., 2013). This trend has persisted since then. In addition to seeing more critically ill patients, EPs are often tasked with providing critical care long beyond the initial resuscitation period. In fact, >33% of critically ill patients who are brought to an ED remain there for >6h (Herring et al., 2013). During these crucial early hours of illness, detrimental pathophysiologic processes begin to take hold. During this time, lives can be saved or lost. Therefore, it is important for the EP to be knowledgeable about recent developments in critical care medicine. This review summarizes important articles published in 2016 pertaining to the care of select critically ill patients in the ED. The following topics are covered: intracerebral hemorrhage, traumatic brain injury, anti-arrhythmic therapy in cardiac arrest, therapeutic hypothermia, mechanical ventilation, sepsis, and septic shock.

Research protocol for platelets in out-of-hospital cardiac arrest: an observational, case-controlled, feasibility study to assess coagulation and platelet function abnormalities with ROTEM following out-of-hospital cardiac arrest (PoHCAR)

INTRODUCTION

Out-of-hospital cardiac arrest (OHCA) has an annual incidence of approximately 60 000 in the UK. Less than 10% of those who receive resuscitation survive to hospital discharge. For OHCA of a presumed cardiac cause, the optimal antiplatelet therapy is currently unknown. Previous studies indicate that a procoagulopathic state exists postcardiac arrest which may contribute to the formation of thrombi and contribute to poor outcomes. However, the administration of antiplatelet therapies needs to be balanced against the increased risk of bleeding that these individuals face.

METHODS AND ANALYSIS

This observational feasibility study will recruit 30 individuals who achieve return of spontaneous circulation post-OHCA, are admitted to a single tertiary centre over a 6-month period and meet Utstein cohort criteria (witnessed cardiac arrest, VF or pulseless VT and cardiac cause of arrest likely). Rotational thromboelastometry and platelet function assessment will be performed on hospital arrival, postemergency percutaneous coronary intervention (PCI) and 12 hours, 24 hours and 48 hours post-PCI. As a comparator, 30 individuals presenting to our institution with ST-segment elevation myocardial infarction and undergoing primary PCI will have the same blood sampling performed. Plasma samples will be retained and batch tested on completion of the study for levels of protein C, protein S, thrombin-antithrombin complex, thrombin, antithrombin, plasminogen activator inhibitor-1, plasmin-antiplasmin complex, d-dimer, platelet factor-4, P selectin, E selectin and prothrombin fragments 1 and 2. 30-day follow-up for complications will be undertaken.

ETHICS AND DISSEMINATION

This study has been approved by the Wales REC 7Research Ethics Committee. The results will be submitted to peer-reviewed medical journals and suitable national and international meetings. Results will be locally disseminated via our patient and public interest group.

TRIAL REGISTRATION NUMBER

Pre-results; ISRCTN34122839.

Cardiopulmonary resuscitation by trained responders versus lay persons and outcomes of out-of-hospital cardiac arrest: A community observational study

OBJECTIVES

The study aims to compare bystander processes of care (cardiopulmonary resuscitation (CPR) and defibrillation) and outcomes for witnessed presumed cardiac etiology in OHCA patients in whom initial resuscitation was provided by dedicated trained responder (TR) versus lay person (LP) bystanders.

METHODS

Data on witnessed and presumed cardiac OHCA in adults (15 years or older) from 2011 to 2015 in a metropolitan city with 10 million persons were collected, excluding cases in which the information on TRs, bystander CPR, defibrillation, and clinical outcomes was unknown. Exposure variables were TRs who were legally designated with CPR education and response and LPs who were bystanders who witnessed the OHCA by chance. The primary/secondary/tertiary outcomes were a good cerebral performance category (CPC) of 1 or 2, survival to discharge, and bystander defibrillation. A multivariable logistic regression analysis was used to calculate the adjusted odds ratio (AOR) with 95% confidence intervals (CIs), adjusting for potential confounders.

RESULTS

Of 20,984 OHCA events, 6475 cases were ultimately analyzed. The TR group constituted 6.4% of the cases, and the patients showed significantly better survival and a good CPC. From the multivariable logistic regression analysis of the outcomes, by comparing the TR group with the LP group, the AOR (95% CIs) was 1.49 (1.04-2.15) for a good CPC, 1.59 (1.20-2.11) for survival to discharge, and 10.02 (7.04-14.26) for bystander defibrillation.

CONCLUSION

The TR group witnessed a relatively low proportion of OHCA but was associated with better survival outcomes and good neurological recovery through higher CPR rates and defibrillation of adults older than 15 years with witnessed OHCA in a metropolitan city.

Targeted temperature management in neurological intensive care unit

Targeted temperature management (TTM) shows the most promising neuroprotective therapy against hypoxic/ischemic encephalopathy (HIE). In addition, TTM is also useful for treatment of elevated intracranial pressure (ICP). HIE and elevated ICP are common catastrophic conditions in patients admitted in Neurologic intensive care unit (ICU). The most common cause of HIE is cardiac arrest. Randomized control trials demonstrate clinical benefits of TTM in patients with post-cardiac arrest. Although clinical benefit of ICP control by TTM in some specific critical condition, for an example in traumatic brain injury, is still controversial, efficacy of ICP control by TTM is confirmed by both in vivo and in vitro studies. Several methods of TTM have been reported in the literature. TTM can apply to various clinical conditions associated with hypoxic/ischemic brain injury and elevated ICP in Neurologic ICU.

Exercise-Related Out-of-Hospital Cardiac Arrest Among the General Population in the Era of Public-Access Defibrillation: A Population-Based Observation in Japan

BACKGROUND

Exercise can trigger sudden cardiac arrest. Early initiation of cardiopulmonary resuscitation and automated external defibrillator use by laypersons could maximize the survival rate following exercise-related out-of-hospital cardiac arrest (OHCA).

METHODS AND RESULTS

OHCA data between 2005 and 2012 were obtained from a prospective population-based OHCA registry in Osaka Prefecture. Patients with OHCA of presumed cardiac origin and occurring before emergency medical service personnel arrival were included. The incidence trends of exercise-related OHCA over the 8-year study period were assessed. Among patients with bystander-witnessed, exercise-related OHCA, the trends in the initiation of bystander cardiopulmonary resuscitation, public-access defibrillation, and outcome were evaluated. The primary outcome was 1-month survival with favorable neurological outcome, defined as cerebral performance category 1 or 2. During the study period, 0.7% of OHCAs of cardiac origin (222/31 030) were exercise related. The incidence of exercise-related OHCA increased from 1.8 (per million population per year) in 2005 to 4.3 in 2012. Of these, 83.8% (186/222) were witnessed by bystanders. Among the patients with bystander-witnessed, exercise-related OHCA, the proportion that received bystander cardiopulmonary resuscitation (50.0% in 2005 and 86.2% in 2012) and public-access defibrillation (7.1% in 2005 and 62.1% in 2012) significantly increased during the study period. Furthermore, the rate of 1-month survival with favorable neurological outcome among these patients significantly improved (from 28.6% in 2005 to 58.6% in 2012).

CONCLUSIONS

The incidence rate of exercise-related OHCA was low in the study population. The increase in bystander cardiopulmonary resuscitation and public-access defibrillation rates were associated with improved outcome among patients with bystander-witnessed, exercise-related OHCA.

Adherence to AHA Guidelines When Adapted for Augmented Reality Glasses for Assisted Pediatric Cardiopulmonary Resuscitation: A Randomized Controlled Trial

Background

The American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) are nowadays recognized as the world’s most authoritative resuscitation guidelines. Adherence to these guidelines optimizes the management of critically ill patients and increases their chances of survival after cardiac arrest. Despite their availability, suboptimal quality of CPR is still common. Currently, the median hospital survival rate after pediatric in-hospital cardiac arrest is 36%, whereas it falls below 10% for out-of-hospital cardiac arrest. Among emerging information technologies and devices able to support caregivers during resuscitation and increase adherence to AHA guidelines, augmented reality (AR) glasses have not yet been assessed. In order to assess their potential, we adapted AHA Pediatric Advanced Life Support (PALS) guidelines for AR glasses.

Objective

The study aimed to determine whether adapting AHA guidelines for AR glasses increased adherence by reducing deviation and time to initiation of critical life-saving maneuvers during pediatric CPR when compared with the use of PALS pocket reference cards.

Methods

We conducted a randomized controlled trial with two parallel groups of voluntary pediatric residents, comparing AR glasses to PALS pocket reference cards during a simulation-based pediatric cardiac arrest scenario—pulseless ventricular tachycardia (pVT). The primary outcome was the elapsed time in seconds in each allocation group, from onset of pVT to the first defibrillation attempt. Secondary outcomes were time elapsed to (1) initiation of chest compression, (2) subsequent defibrillation attempts, and (3) administration of drugs, as well as the time intervals between defibrillation attempts and drug doses, shock doses, and number of shocks. All these outcomes were assessed for deviation from AHA guidelines.

Results

Twenty residents were randomized into 2 groups. Time to first defibrillation attempt (mean: 146 s) and adherence to AHA guidelines in terms of time to other critical resuscitation endpoints and drug dose delivery were not improved using AR glasses. However, errors and deviations were significantly reduced in terms of defibrillation doses when compared with the use of the PALS pocket reference cards. In a total of 40 defibrillation attempts, residents not wearing AR glasses used wrong doses in 65% (26/40) of cases, including 21 shock overdoses >100 J, for a cumulative defibrillation dose of 18.7 Joules per kg. These errors were reduced by 53% (21/40, P<.001) and cumulative defibrillation dose by 37% (5.14/14, P=.001) with AR glasses.

Conclusions

AR glasses did not decrease time to first defibrillation attempt and other critical resuscitation endpoints when compared with PALS pocket cards. However, they improved adherence and performance among residents in terms of administering the defibrillation doses set by AHA.

Effective deployment of public-access automated external defibrillators to improve out-of-hospital cardiac arrest outcomes

Out‐of‐hospital cardiac arrest (OHCA) is a major health concern in Japan and other developed countries with aging populations. Improvements in OHCA outcomes require streamlining the chain of survival. Deployment of public‐access automated external defibrillators (PADs) and defibrillation by bystanders is one strategy that may streamline the chain by reducing the time to defibrillation in individuals with shockable rhythms. Although the effectiveness of PAD programs in increasing survival to discharge has been reported, there have been criticisms and concerns about the small population impact, cost‐effectiveness, and potential negative impact on those with nonshockable rhythms. This article reviews relevant literature regarding the effectiveness and concerns regarding PAD for OHCA.

The association between AHA CPR quality guideline compliance and clinical outcomes from out-of-hospital cardiac arrest

BACKGROUND

Measures of chest compression fraction (CCF), compression rate, compression depth and pre-shock pause have all been independently associated with improved outcomes from out-of-hospital (OHCA) cardiac arrest. However, it is unknown whether compliance with American Heart Association (AHA) guidelines incorporating all the aforementioned metrics, is associated with improved survival from OHCA.

METHODS

We performed a secondary analysis of prospectively collected data from the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest database. As per the 2015 American Heart Association (AHA) guidelines, guideline compliant cardiopulmonary resuscitation (CPR) was defined as CCF >0.8, chest compression rate 100-120/minute, chest compression depth 50-60mm, and pre-shock pause <10s. Multivariable logistic regression models controlling for Utstein variables were used to assess the relationship between global guideline compliance and survival to hospital discharge and neurologically intact survival with MRS ≤3. Due to potential confounding between CPR quality metrics and cases that achieved early ROSC, we performed an a priori subgroup analysis restricted to patients who obtained ROSC after ≥10min of EMS resuscitation.

RESULTS

After allowing for study exclusions, 19,568 defibrillator records were collected over a 4-year period ending in June 2015. For all reported models, the reference standard included all cases who did not meet all CPR quality benchmarks. For the primary model (CCF, rate, depth), there was no significant difference in survival for resuscitations that met all CPR quality benchmarks (guideline compliant) compared to the reference standard (OR 1.26; 95% CI: 0.80, 1.97). When the dataset was restricted to patients obtaining ROSC after ≥10min of EMS resuscitation (n=4,158), survival was significantly higher for those resuscitations that were guideline compliant (OR 2.17; 95% CI: 1.11, 4.27) compared to the reference standard. Similar findings were obtained for neurologically intact survival with MRS ≤3 (OR 3.03; 95% CI: 1.12, 8.20).

CONCLUSIONS

In this observational study, compliance with AHA guidelines for CPR quality was not associated with improved outcomes from OHCA. Conversely, when restricting the cohort to those with late ROSC, compliance with guidelines was associated with improved clinical outcomes. Strategies to improve overall guideline compliance may have a significant impact on outcomes from OHCA.

The implementation of cardiac arrest treatment recommendations in English acute NHS trusts: a national survey

PURPOSE OF THE STUDY

There are approximately 35 000 in-hospital cardiac arrests in the UK each year. Successful resuscitation requires integration of the medical science, training and education of clinicians and implementation of best practice in the clinical setting. In 2015, the International Liaison Committee on Resuscitation (ILCOR) published its latest resuscitation treatment recommendations. It is currently unknown the extent to which these treatment recommendations have been successfully implemented in practice in English NHS acute hospital trusts.

METHODS

We conducted an electronic survey of English acute NHS trusts to assess the implementation of key ILCOR resuscitation treatment recommendations in relation to in-hospital cardiac arrest practice at English NHS acute hospital trusts.

RESULTS

Of 137 eligible trusts, 73 responded to the survey (response rate 53.3%). The survey identified significant variation in the implementation of ILCOR recommendations. In particular, the use of waveform capnography (n=33, 45.2%) and ultrasound (n=29, 39.7%) was often reported to be available only in specialist areas. Post-resuscitation debriefing occurs following every in-hospital cardiac arrest in few trusts (5.5%, n=4), despite a strong ILCOR recommendation. In contrast, participation in a range of quality improvement strategies such as the National Cardiac Arrest Audit (90.4%, n=66) and resuscitation equipment provision/audit (91.8%, n=67) were high. Financial restrictions were identified by 65.8% (n=48) as the main barrier to guideline implementation.

CONCLUSION

Our survey found that ILCOR treatment recommendations had not been fully implemented in most English NHS acute hospital trusts. Further work is required to better understand barriers to implementation.

Myocardial Infarction in Neonates: A Review of an Entity with Significant Morbidity and Mortality

Coronary artery disease is a global problem with high mortality rates and significant residual sequelae that affect long-term quality of life. Myocardial infarction (MI) in neonates is a recognized, uncommon entity, but the incidence and broad spectrum of the disease is unknown and likely underestimated due to limited reporting which in the majority is confined to acute ischemic events. The challenges involve clinical diagnosis which masquerades in the early phase as non-specific symptoms and signs that are commonly found in a host of neonatal disorders. Precise diagnostic criteria for neonatal MI are lacking, and management is driven by clinical presentation and hemodynamic stabilization rather than an attempt to rapidly establish the root cause of the condition. We conducted a review of the published reports of neonatal MI from 2000 to 2014, to establish an approach to the diagnosis and management based on the existing evidence. The overall evidence from 32 scientific articles stemmed from case reports and case series which were graded as low-to-very low quality. Neonatal MI resembles childhood and adult MI with features that involve characteristic ECG changes, raised biomarkers, and diagnostic imaging, but with lack of robust, standardized criteria to facilitate prompt diagnosis and timely intervention. The mortality rate of neonatal MI ranges from 40 to 50% based on inclusion criteria, but the short-term data reflect normal quality of life in survivors. An algorithm for the diagnosis and management of neonatal MI may optimize outcomes, but at the present time is based on limited evidence. Well-designed clinical studies focusing on the definition, diagnosis, and management of neonatal MI, backed by international consensus guidelines, are needed to alter the prognosis of this serious condition.

Targeted temperature management after intraoperative cardiac arrest: a multicenter retrospective study

PURPOSE

Few outcome data are available about temperature management after intraoperative cardiac arrest (IOCA). We describe targeted temperature management (TTM) (32-34 °C) modalities, adverse events, and association with 1-year functional outcome in patients with IOCA.

METHODS

Patients admitted to 11 ICUs after IOCA in 2008-2013 were studied retrospectively. The main outcome measure was 1-year functional outcome.

RESULTS

Of the 101 patients [35 women and 66 men; median age, 62 years (interquartile range, 42-72)], 68 (67.3%) were ASA PS I to III and 57 (56.4%) had emergent surgery. First recorded rhythms were asystole in 44 (43.6%) patients, pulseless electrical activity in 36 (35.6%), and ventricular fibrillation/tachycardia in 20 (19.8%). Median times from collapse to cardiopulmonary resuscitation and return of spontaneous circulation (ROSC) were 0 min (0-0) and 10 min (4-20), respectively. The 30 (29.7%) patients who received TTM had an increased risk of infection (P = 0.005) but not of arrhythmia, bleeding, or metabolic/electrolyte disorders. By multivariate analysis, one or more defibrillation before ROSC was positively associated with a favorable functional outcome at 1-year (OR 3.06, 95% CI 1.05-8.95, P = 0.04) and emergency surgery was negatively associated with 1-year favorable functional outcome (OR 0.36; 95% CI 0.14-0.95, P = 0.038). TTM use was not independently associated with 1-year favorable outcome (OR 0.82; 95% CI 0.27-2.46, P = 0.72).

CONCLUSIONS

TTM was used in less than one-third of patients after IOCA. TTM was associated with infection but not with bleeding or coronary events in this setting. TTM did not independently predict 1-year favorable functional outcome after IOCA in this study.

Public-Access Defibrillation and Out-of-Hospital Cardiac Arrest in Japan

BACKGROUND

Early defibrillation plays a key role in improving survival in patients with out-of-hospital cardiac arrests due to ventricular fibrillation (ventricular-fibrillation cardiac arrests), and the use of publicly accessible automated external defibrillators (AEDs) can help to reduce the time to defibrillation for such patients. However, the effect of dissemination of public-access AEDs for ventricular-fibrillation cardiac arrest at the population level has not been extensively investigated.

METHODS

From a nationwide, prospective, population-based registry of patients with out-of-hospital cardiac arrest in Japan, we identified patients from 2005 through 2013 with bystander-witnessed ventricular-fibrillation arrests of presumed cardiac origin in whom resuscitation was attempted. The primary outcome measure was survival at 1 month with a favorable neurologic outcome (Cerebral Performance Category of 1 or 2, on a scale from 1 [good cerebral performance] to 5 [death or brain death]). The number of patients in whom survival with a favorable neurologic outcome was attributable to public-access defibrillation was estimated.

RESULTS

Of 43,762 patients with bystander-witnessed ventricular-fibrillation arrests of cardiac origin, 4499 (10.3%) received public-access defibrillation. The percentage of patients receiving public-access defibrillation increased from 1.1% in 2005 to 16.5% in 2013 (P<0.001 for trend). The percentage of patients who were alive at 1 month with a favorable neurologic outcome was significantly higher with public-access defibrillation than without public-access defibrillation (38.5% vs. 18.2%; adjusted odds ratio after propensity-score matching, 1.99; 95% confidence interval, 1.80 to 2.19). The estimated number of survivors in whom survival with a favorable neurologic outcome was attributed to public-access defibrillation increased from 6 in 2005 to 201 in 2013 (P<0.001 for trend).

CONCLUSIONS

In Japan, increased use of public-access defibrillation by bystanders was associated with an increase in the number of survivors with a favorable neurologic outcome after out-of-hospital ventricular-fibrillation cardiac arrest.

Identifying Important Gaps in Randomized Controlled Trials of Adult Cardiac Arrest Treatments: A Systematic Review of the Published Literature

BACKGROUND

Cardiac arrest is a major public health concern worldwide. The extent and types of randomized controlled trials (RCT)-our most reliable source of clinical evidence-conducted in these high-risk patients over recent years are largely unknown.

METHODS AND RESULTS

We performed a systematic review, identifying all RCTs published in PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Library from 1995 to 2014 that focused on the acute treatment of nontraumatic cardiac arrest in adults. We then extracted data on the setting of study populations, types and timing of interventions studied, risk of bias, outcomes reported, and how these factors have changed over time. Over this 20-year period, 92 RCTs were published containing 64 309 patients (median, 225.5 per trial). Of these, 81 RCTs (88.0%) involved out-of-hospital cardiac arrest, whereas 4 (4.3%) involved in-hospital cardiac arrest and 7 (7.6%) included both. Eighteen RCTs (19.6%) were performed in the United States, 68 (73.9%) were performed outside the United States, and 6 (6.5%) were performed in both settings. Thirty-eight RCTs (41.3%) evaluated drug therapy, 39 (42.4%) evaluated device therapy, and 15 (16.3%) evaluated protocol improvements. Seventy-four RCTs (80.4%) examined interventions during the cardiac arrest, 15 (16.3%) examined post cardiac arrest treatment, and 3 (3.3%) studied both. Overall, reporting of the risk of bias was limited. The most common outcome reported was return of spontaneous circulation: 86 (93.5%) with only 22 (23.9%) reporting survival beyond 6 months. Fifty-three RCTs (57.6%) reported global ordinal outcomes, whereas 15 (16.3%) reported quality-of-life. RCTs in the past 5 years were more likely to be focused on protocol improvements and postcardiac arrest care.

CONCLUSIONS

Important gaps in RCTs of cardiac arrest treatments exist, especially those examining in-hospital cardiac arrest, protocol improvement, postcardiac arrest care, and long-term or quality-of-life outcomes.

Recognition of out-of-hospital cardiac arrest by medical dispatchers in emergency medical dispatch centres in two countries

INTRODUCTION

Survival after out-of-hospital cardiac arrest (OHCA) remains low. Early recognition by emergency medical dispatchers is essential for an effective chain of actions, leading to early cardiopulmonary resuscitation, use of an automated external defibrillator and rapid dispatching of the emergency medical services.

AIM

To analyse and compare the accuracy of OHCA recognition by medical dispatchers in two countries.

METHOD

An observational register-based study collecting data from national cardiac arrest registers in Denmark and Sweden during a six-month period in 2013. Data were analysed in two steps; registry data were merged with electronically registered emergency call data from the emergency medical dispatch centres in the two regions. Cases with missing or non-OHCA dispatch codes were analysed further by auditing emergency call recordings using a uniform data collection template.

RESULTS

The sensitivity for recognition of OHCA was 40.9% (95% CI: 37.1-44.7%) in the Capital Region of Denmark and 78.4% (95% CI: 73.2-83.0%) in the Skåne Region in Sweden (p<0.001). With additional data from the emergency call recordings, the sensitivity was 80.7% (95% CI: 77.7-84.3%) and 86.0% (95% CI: 81.3-89.8%) for the two regions (p=0.06). The majority of the non-recognised OHCA were dispatched with the highest priority.

CONCLUSION

The accuracy of OHCA recognition was high and comparable. We identified large differences in data registration practices despite the use of similar dispatch tools. This raises a discussion of definitions and transparency in general in scientific reporting of OHCA recognition, which is essential if used as quality indicator in emergency medical services.

Mechanical chest compression devices are associated with poor neurological survival in a statewide registry: A propensity score analysis

OBJECTIVE

To compare functional survival (discharge cerebral performance category 1 or 2) among victims of out-of-hospital cardiac arrest (OHCA) who had resuscitations performed using mechanical chest compression (mech-CC) devices vs. those using manual chest compressions (man-CC).

METHODS

Observational cohort of 2600 cases of OHCA from a statewide, prospectively-collected cardiac arrest registry (Utah Cardiac Arrest Registry to Enhance Survival). Comparison of functional survival among those receiving mech-CC vs man-CC was performed using a mixed-effects Poisson model with inverse probability weighted propensity scores to control for selection bias.

RESULTS

Overall, mech-CC was utilized in 405/2600 (16%) of the total arrests in Utah during this period. 371/405 (92%) were of the load-distributing band type (AutoPulse(®)) and 22/405 (5%) were mechanical piston devices (LUCAS™), while 12/405 (3%) employed other devices. The relative risk (RR) for functional survival comparing mech-CC to man-CC after propensity score adjustment was 0.41 (95% CI 0.24-0.70, p=0.001).

CONCLUSIONS

Mechanical chest compression device use was associated with lower rates of functional survival in this propensity score analysis, controlling for Utstein variables and early return of spontaneous circulation.

Public-access AED pad application and outcomes for out-of-hospital cardiac arrests in Osaka, Japan

BACKGROUND

Actual application of public-access automated external defibrillator (AED) pads to patients with an out-of-hospital cardiac arrest (OHCA) by the public has been poorly investigated.

METHODS

AED applications, prehospital characteristics, and one-month outcomes of OHCAs occurring in Osaka Prefecture from 2011 to 2012 were obtained from the Utstein Osaka Project registry. Patients with a non-traumatic OHCA occurring before emergency medical service attendance were enrolled. The proportion of AED pads that were applied to the patients' chests by the public and one-month outcomes were analysed according to the location of OHCA.

RESULTS

In total, public-access AED pads were applied to 3.5% of OHCA patients (351/9978) during the study period. In the multivariate analyses, OHCAs that occurred in public places and received bystander-initiated cardiopulmonary resuscitation were associated with significantly higher application of public-access AEDs. Among the patients for whom public-access AED pads were applied, 29.6% (104/351) received public-access defibrillation. One-month survival with a favourable neurological outcome was significantly higher among patients who had an AED applied compared to those who did not (19.4% vs. 3.0%; OR: 2.76 [95% CI: 1.92-3.97]).

CONCLUSION

The application of public-access AEDs leads to favourable outcomes after an OHCA, but utilisation of available equipment remains insufficient, and varies considerably according to the location of the OHCA event. Alongside disseminating public-access AEDs, further strategic approaches for the deployment of AEDs at the scene, as well as basic life support training for the public are required to improve survival rates after OHCAs.

Epidemiology of Out-of-Hospital Cardiac Arrests Among Japanese Centenarians: 2005 to 2013

Although the number of centenarians has been rapidly increasing in industrialized countries, no clinical studies evaluated their characteristics and outcomes from out-of-hospital cardiac arrests (OHCAs). This nationwide, population-based, observation of the whole population of Japan enrolled consecutive OHCA centenarians with resuscitation attempts before emergency medical service arrival from 2005 to 2013. The primary outcome measure was 1-month survival from OHCAs. The multivariate logistic regression model was used to assess factors associated with 1-month survival in this population. Among a total of 4,937 OHCA centenarians before emergency medical service arrival, the numbers of those with OHCAs increased from 70 in 2005 to 136 in 2013 in men and from 227 in 2005 to 587 in 2013 in women. Women accounted for 80.3%. Ventricular fibrillation (VF) as first documented rhythm was 2.5%. The proportions of victims receiving bystander cardiopulmonary resuscitation were 64.2%. The proportion of 1-month survival from OHCAs in centenarians was only 1.1%. In a multivariate analysis, age was not associated with 1-month survival from OHCAs (adjusted odds ratio [OR] for one increment of age 1.01; 95% confidence interval [CI] 0.87 to 1.18). Witness by a bystander (adjusted OR 3.45; 95% CI 1.88 to 6.31) and VF as first documented rhythm (adjusted OR 5.49; 95% CI 2.24 to 13.43) were significant positive predictors for 1-month survival. Cardiac origin was significantly poor in 1-month survival compared with noncardiac origin (adjusted OR 0.37; 95% CI 0.21 to 0.64). In conclusion, survival from OHCAs in centenarians was very poor, but witness by a bystander and VF as first documented rhythm were associated with improved survival.