Part 4: Advanced Life Support: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

Advanced airway management in out of hospital cardiac arrest: A systematic review and meta-analysis

OBJECTIVES

To assess the difference in survival and neurological outcomes between endotracheal tube (ETT) intubation and supraglottic airway (SGA) devices used during out-of-hospital cardiac arrest (OHCA).

METHODS

A systematic search of five databases was performed by two independent reviewers until September 2018. Included studies reported on (1) OHCA or cardiopulmonary resuscitation, and (2) endotracheal intubation versus supraglottic airway device intubation. Exclusion criteria (1) stimulation studies, (2) selectively included/excluded patients, (3) in-hospital cardiac arrest. Odds Ratios (OR) with random effect modelling was used. Primary outcomes: (1) return of spontaneous circulation (ROSC), (2) survival to hospital admission, (3) survival to hospital discharge, (4) discharge with a neurologically intact state.

RESULTS

Twenty-nine studies (n = 539,146) showed that overall, ETT use resulted in a heterogeneous, but significant increase in ROSC (OR = 1.44; 95%CI = 1.27 to 1.63; I² = 91%; p < 0.00001) and survival to admission (OR = 1.36; 95%CI = 1.12 to 1.66; I² = 91%; p = 0.002). There was no significant difference in survival to discharge or neurological outcome (p > 0.0125). On sensitivity analysis of RCTs, there was no significant difference in ROSC, survival to admission, survival to discharge or neurological outcome (p > 0.0125). On analysis of automated chest compression, without heterogeneity, ETT provided a significant increase in ROSC (OR = 1.55; 95%CI = 1.20 to 2.00; I² = 0%; p = 0.0009) and survival to admission (OR = 2.16; 95%CI = 1.54 to 3.02; I² = 0%; p < 0.00001).

CONCLUSIONS

The overall heterogeneous benefit in survival with ETT was not replicated in the low risk RCTs, with no significant difference in survival or neurological outcome. In the presence of automated chest compressions, ETT intubation may result in survival benefits.

Effect of Emergency Department Mattress Compressibility on Chest Compression Depth Using a Standardized Cardiopulmonary Resuscitation Board, a Slider Transfer Board, and a Flat Spine Board: A Simulation-Based Study

INTRODUCTION

Cardiopulmonary resuscitation (CPR) performed on a mattress decreases effective chest compression depth. Using a CPR board partially attenuates mattress compressibility. We aimed to determine the effect of a CPR board, a slider transfer board, a CPR board with a slider transfer board, and a flat spine board on chest compression depth with a mannequin placed on an emergency department mattress.

METHODS

The study used a cross-over study design. The CPR-certified healthcare providers performed 2 minutes of compressions on a mannequin in five conditions, an emergency department mattress with: (a) no hard surface, (b) a CPR board, (c) a slider transfer board, (d) a CPR board and slider transfer board, and (e) a flat spine board. Compression depths were measured from two sources for each condition: (a) an internal device measuring sternum-to-spine compression and (b) an external device measuring sternum-to-spine compression plus mattress compression. The difference of the two measures (ie, depleted compression depth) was summarized and compared between conditions.

RESULTS

A total of 10,203 individual compressions from 10 participants were analyzed. The mean depleted compression depths (percentage depletion) secondary to mattress effect were the following: 23.6 mm (29.7%) on a mattress only, 13.7 mm (19.5%) on a CPR board, 16.9 mm (23.1%) on a slider transfer board, 11.9 mm (17.3%) on a slider transfer board plus backboard, and 10.3 mm (15.4%) on a flat spine board. The differences in percentage depletion across conditions were statistically significant.

CONCLUSION

Cardiopulmonary resuscitation providers should use a CPR board and slider transfer board or a flat spine board alone because these conditions are associated with the smallest amount of mattress compressibility.

Mechanical versus manual chest compressions for cardiac arrest

BACKGROUND

Mechanical chest compression devices have been proposed to improve the effectiveness of cardiopulmonary resuscitation (CPR).

OBJECTIVES

To assess the effectiveness of resuscitation strategies using mechanical chest compressions versus resuscitation strategies using standard manual chest compressions with respect to neurologically intact survival in patients who suffer cardiac arrest.

SEARCH METHODS

On 19 August 2017 we searched the Cochrane Central Register of Controlled Studies (CENTRAL), MEDLINE, Embase, Science Citation Index-Expanded (SCI-EXPANDED) and Conference Proceedings Citation Index-Science databases. Biotechnology and Bioengineering Abstracts and Science Citation abstracts had been searched up to November 2009 for prior versions of this review. We also searched two clinical trials registries for any ongoing trials not captured by our search of databases containing published works: Clinicaltrials.gov (August 2017) and the World Health Organization International Clinical Trials Registry Platform portal (January 2018). We applied no language restrictions. We contacted experts in the field of mechanical chest compression devices and manufacturers.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-RCTs and quasi-randomised studies comparing mechanical chest compressions versus manual chest compressions during CPR for patients with cardiac arrest.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included five new studies in this update. In total, we included 11 trials in the review, including data from 12,944 adult participants, who suffered either out-of-hospital cardiac arrest (OHCA) or in-hospital cardiac arrest (IHCA). We excluded studies explicitly including patients with cardiac arrest caused by trauma, drowning, hypothermia and toxic substances. These conditions are routinely excluded from cardiac arrest intervention studies because they have a different underlying pathophysiology, require a variety of interventions specific to the underlying condition and are known to have a prognosis different from that of cardiac arrest with no obvious cause. The exclusions were meant to reduce heterogeneity in the population while maintaining generalisability to most patients with sudden cardiac death.The overall quality of evidence for the outcomes of included studies was moderate to low due to considerable risk of bias. Three studies (N = 7587) reported on the designated primary outcome of survival to hospital discharge with good neurologic function (defined as a Cerebral Performance Category (CPC) score of one or two), which had moderate quality evidence. One study showed no difference with mechanical chest compressions (risk ratio (RR) 1.07, 95% confidence interval (CI) 0.82 to 1.39), one study demonstrated equivalence (RR 0.79, 95% CI 0.60 to 1.04), and one study demonstrated reduced survival (RR 0.41, CI 0.21 to 0.79). Two other secondary outcomes, survival to hospital admission (N = 7224) and survival to hospital discharge (N = 8067), also had moderate quality level of evidence. No studies reported a difference in survival to hospital admission. For survival to hospital discharge, two studies showed benefit, four studies showed no difference, and one study showed harm associated with mechanical compressions. No studies demonstrated a difference in adverse events or injury patterns between comparison groups but the quality of data was low. Marked clinical and statistical heterogeneity between studies precluded any pooled estimates of effect.

AUTHORS' CONCLUSIONS

The evidence does not suggest that CPR protocols involving mechanical chest compression devices are superior to conventional therapy involving manual chest compressions only. We conclude on the balance of evidence that mechanical chest compression devices used by trained individuals are a reasonable alternative to manual chest compressions in settings where consistent, high-quality manual chest compressions are not possible or dangerous for the provider (eg, limited rescuers available, prolonged CPR, during hypothermic cardiac arrest, in a moving ambulance, in the angiography suite, during preparation for extracorporeal CPR [ECPR], etc.). Systems choosing to incorporate mechanical chest compression devices should be closely monitored because some data identified in this review suggested harm. Special attention should be paid to minimising time without compressions and delays to defibrillation during device deployment.

A better understanding of ambulance personnel's attitude towards real-time resuscitation feedback

Objective

High-quality chest compressions during cardiopulmonary resuscitation (CPR) play a significant role in surviving cardiac arrest. Chest-compression quality can be measured and corrected by real-time CPR feedback devices, which are not yet commonly used. This article looks at the acceptance of such systems in comparison of equipped and unequipped personnel.

Design

Two groups of emergency medical services' (EMS) personnel were interviewed using standardized questionnaires.

Setting

The survey was conducted in the German cities Dortmund and Münster.

Participants

Overall, 205 persons participated in the survey: 103 paramedics and emergency physicians from the Dortmund fire service and 102 personnel from the Münster service.

Intervention

The staff of the Dortmund service were not equipped with real-time feedback systems. The test group of equipped personnel of the ambulance service of Münster Fire brigade uses real-time feedback systems since 2007.

Main outcome measure

What is the acceptance level of real-time feedback systems? Are there differences between equipped and unequipped personnel?

Results

The total sample is receptive towards real-time feedback systems. More than 80% deem the system useful. However, this study revealed concerns and prejudices by unequipped personnel. Negative ratings are significantly lower at the Münster site that is experienced with the use of the real-time feedback system in contrast to the Dortmund site where no such experience exists-the system's use in daily routine results in better evaluation than the expectations of unequipped personnel.

Conclusions

Real-time feedback systems receive overall positive ratings. Prejudices and concerns seem to decrease with continued use of the system.

Exposure to Stress-Dose Steroids and Lethal Septic Shock After In-Hospital Cardiac Arrest: Individual Patient Data Reanalysis of Two Prior Randomized Clinical Trials that Evaluated the Vasopressin-Steroids-Epinephrine Combination Versus Epinephrine Alone

PURPOSE

Low-dose steroids may reduce the mortality of severely ill patients with septic shock. We sought to determine whether exposure to stress-dose steroids during and/or after cardiopulmonary resuscitation is associated with reduced risk of death due to postresuscitation septic shock.

METHODS

We analyzed pooled, individual patient data from two prior, randomized clinical trials (RCTs). RCTs evaluated vasopressin, steroids, and epinephrine (VSE) during resuscitation and stress-dose steroids after resuscitation in vasopressor-requiring, in-hospital cardiac arrest. In the second RCT, 15 control group patients received open-label, stress-dose steroids. Patients with postresuscitation shock were assigned to a Steroids (n = 118) or No Steroids (n = 73) group according to an "as-treated" principle. We used cumulative incidence competing risks Cox regression to determine cause-specific hazard ratios (CSHRs) for pre-specified predictors of lethal septic shock (primary outcome). In sensitivity analyses, data were analyzed according to the intention-to-treat (ITT) principle (VSE group, n = 103; control group, n = 88).

RESULTS

Lethal septic shock was less likely in Steroids versus No Steroids group, CSHR, 0.40, 95% confidence interval (CI), 0.20-0.82; p = 0.012. ITT analysis yielded similar results: VSE versus Control, CSHR, 0.44, 95% CI, 0.23-0.87; p = 0.019. Adjustment for significant, between-group baseline differences in composite cardiac arrest causes such as "hypotension and/or myocardial ischemia" did not appreciably affect the aforementioned CSHRs.

CONCLUSIONS

In this reanalysis, exposure to stress-dose steroids (primarily in the context of a combined VSE intervention) was associated with lower risk of postresuscitation lethal septic shock.

Drugs in cardiac arrest: the rise and fall of antiarrhythmics

Since the publication of 2000 guidelines for resuscitation, amiodarone is considered the antiarrhythmic drug of choice for refractory ventricular fibrillation/pulseless ventricular tachycardia. However, to date there is no proven benefit in terms of neurologically intact survival to hospital discharge. A comprehensive search of the recent literature on amiodarone, nifekalant and lidocaine in cardiac arrest was performed. Amiodarone and nifekalant are superior to lidocaine with regards to the return of spontaneous circulation and survival to hospital admission. Nifekalant shows a trend towards quicker termination of ventricular fibrillation compared to amiodarone. There is great uncertainty about the efficacy of antiarrhythmics in cardiac arrest. Failure to show improvements regarding meaningful survival questions their current use and suggests the need for re-evaluating their place in cardiopulmonary resuscitation.

Cardiac arrest during pregnancy: ongoing clinical conundrum

While global maternal mortality has decreased in the last 25 years, the maternal mortality ratio in the United States has actually increased. Maternal mortality is a complex phenomenon involving multifaceted socioeconomic and clinical parameters including inequalities in access to health care, racial and ethnic disparities, maternal comorbidities, and epidemiologic ascertainment bias. Escalating maternal mortality underscores the importance of clinician preparedness to respond to maternal cardiac arrest that may occur in any maternal health care setting. Management of maternal cardiac arrest requires an interdisciplinary team familiar with the physiologic changes of pregnancy and the maternal resuscitation algorithm. Interventions intended to mitigate obstacles such as aortocaval compression, which may undermine the success of resuscitation interventions, must be performed concurrent to standard basic and advanced cardiac life support maneuvers. High-quality chest compressions and oxygenation must be performed along with manual left lateral uterine displacement when the uterine size is ≥20 weeks. While deciphering the etiology of maternal cardiac arrest, diagnoses unique to pregnancy and those of the nonpregnant state should be considered at the same time. If initial basic life support and advanced cardiac life support interventions fail to restore maternal circulation within 4 minutes of cardiac arrest, perimortem delivery is advised provided the uterus is ≥20 weeks' size. Preparations for perimortem delivery are best anticipated by the resuscitation team for the procedure to be executed opportunely. Following delivery, intraabdominal examination may reveal a vascular catastrophe, hematoma, or both. If return of spontaneous circulation has not been achieved, additional interventions may include cardiopulmonary bypass and/or extracorporeal membrane oxygenation. Simulation and team training enhance institution readiness for maternal cardiac arrest. Knowledge gaps are significant in the science of maternal resuscitation. Further research is required to fully optimize: relief of aortocaval compression during the resuscitation process, gestational age and timing of perimortem delivery, and other interventions that deviate from nonpregnant standard resuscitation protocol to achieve successful maternal resuscitation. A robust detailed national and international prospective database was recommended by the International Liaison Committee on Resuscitation in 2015 to facilitate further research unique to cardiac arrest during pregnancy that will produce optimal resuscitation techniques for maternal cardiac arrest.

The Contribution of Taiwan in International Liaison Committee on Resuscitation Consensus on Science and Treatment Recommendation 2015 (ILCOR CoSTR 2015)

Taiwan has begun its board certification of emergency medicine since 1998. The scholars have also devoted themselves to research in the related fi elds including resuscitation for decades. On the other hand, International Liaison Committee on Resuscitation (ILCOR) was established to build up international expert consensus on resuscitation science in 1992. The National Resuscitation Council of Taiwan (NRCT) is a multidisciplinary organization and becomes one of the founding members of the Resuscitation Council of Asia (RCA) in 2005, whereas the RCA has also become currently the final regional member of ILCOR. Under these international platforms, the experts from Taiwan have significant contributions in establishment of evidence review and clinical guidelines on resuscitation such as ILCOR Consensus on Science and Treatment Recommendation (CoSTR). This brief review will introduce explicitly these important Taiwan investigations cited in ILCOR CoSTR 2015.

Prognostic value of adrenal gland volume after cardiac arrest: Association of CT-scan evaluation with shock and mortality

BACKGROUND

Adrenal gland volume is associated with survival in septic shock. As sepsis and post-cardiac arrest syndrome share many pathophysiological features, we assessed the association between adrenal gland volume measured by computerized tomography (CT)-scan and post-cardiac arrest shock and intensive care unit (ICU) mortality, in a large cohort of out-of-hospital cardiac arrest (OHCA) patients. We also investigated the association between adrenal hormonal function and both adrenal gland volume and outcomes.

PATIENTS AND METHODS

Prospective analysis of CT-scan performed at hospital admission in patients admitted after OHCA (2007-2012). A pair of blinded radiologist calculated manually adrenal gland volume. In a subgroup of patients, plasma cortisol was measured at admission and 60 min after a cosyntropin test. Factors associated with post-cardiac arrest shock and ICU mortality were identified using multivariate logistic regression.

RESULTS

Among 775 patients admitted during this period after OHCA, 138 patients were included: 72 patients (52.2%) developed a post-cardiac arrest shock, and 98 patients (71.1%) died. In univariate analysis, adrenal gland volume was not different between patients with and without post-cardiac arrest shock: 10.6 and 11.3 cm³, respectively (p = 0.9) and between patients discharged alive or dead: 10.2 and 11.8 cm³, respectively (p = 0.4). Multivariate analysis confirmed that total adrenal gland volume was associated neither with post-cardiac arrest shock nor mortality. Neither baseline cortisol level nor delta between baseline and after cosyntropin test cortisol levels were associated with adrenal volume, post-cardiac arrest shock onset or mortality.

CONCLUSION

After OHCA, adrenal gland volume is not associated with post-cardiac arrest shock onset or ICU mortality. Adrenal gland volume does not predict adrenal gland hormonal response.

Position paper for the organization of ECMO programs for cardiac failure in adults

Extracorporeal membrane oxygenation (ECMO) has been used increasingly for both respiratory and cardiac failure in adult patients. Indications for ECMO use in cardiac failure include severe refractory cardiogenic shock, refractory ventricular arrhythmia, active cardiopulmonary resuscitation for cardiac arrest, and acute or decompensated right heart failure. Evidence is emerging to guide the use of this therapy for some of these indications, but there remains a need for additional evidence to guide best practices. As a result, the use of ECMO may vary widely across centers. The purpose of this document is to highlight key aspects of care delivery, with the goal of codifying the current use of this rapidly growing technology. A major challenge in this field is the need to emergently deploy ECMO for cardiac failure, often with limited time to assess the appropriateness of patients for the intervention. For this reason, we advocate for a multidisciplinary team of experts to guide institutional use of this therapy and the care of patients receiving it. Rigorous patient selection and careful attention to potential complications are key factors in optimizing patient outcomes. Seamless patient transport and clearly defined pathways for transition of care to centers capable of providing heart replacement therapies (e.g., durable ventricular assist device or heart transplantation) are essential to providing the highest level of care for those patients stabilized by ECMO but unable to be weaned from the device. Ultimately, concentration of the most complex care at high-volume centers with advanced cardiac capabilities may be a way to significantly improve the care of this patient population.

Barriers and opportunities related to extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest in Canada: A report from the first meeting of the Canadian ECPR Research Working Group

For a French translation of the executive summary, please see the Supplementary Material at DOI: 10.1017/cem.2017.429.

Sex, race, and insurance status differences in hospital treatment and outcomes following out-of-hospital cardiac arrest

BACKGROUND

Sex, race, and insurance status are associated with treatment and outcomes in several cardiovascular diseases. These disparities, however, have not been well-studied in out-of-hospital cardiac arrest (OHCA).

OBJECTIVE

Our objective was to evaluate the association of patient sex, race, and insurance status with hospital treatments and outcomes following OHCA.

METHODS

We studied adult patients in the 2011-2015 California Office of Statewide Health Planning and Development (OSHPD) Patient Discharge Database with a "present on admission" diagnosis of cardiac arrest (ICD-9-CM 427.5). Insurance status was classified as private, Medicare, and Medi-Cal/government/self-pay. Our primary outcome was good neurologic recovery at hospital discharge, which was determined by discharge disposition. Secondary outcomes were survival to hospital discharge, treatment at a 24/7 percutaneous coronary intervention (PCI) center, "do not resuscitate" orders within 24 h of admission, and cardiac catheterization during hospitalization. Data were analyzed with hierarchical multiple logistic regression models.

RESULTS

We studied 38,163 patients in the OSHPD database. Female sex, non-white race, and Medicare insurance status were independently associated with worse neurologic recovery [OR 0.94 (0.89-0.98), 0.93 (0.88-0.98), and 0.85 (0.79-0.91), respectively], lower rates of treatment at a 24/7 PCI center [OR 0.89 (0.85-0.93), 0.88 (0.85-0.93), and 0.87 (0.82-0.94), respectively], and lower rates of cardiac catheterization [OR 0.61 (0.57-0.65), 0.90 (0.84-0.97), and 0.44 (0.40-0.48), respectively]. Female sex, white race, and Medicare insurance were associated with DNR orders within 24 h of admission [OR 1.16 (1.10-1.23), 1.14 (1.07-1.21), and 1.25 (1.15-1.36), respectively].

CONCLUSIONS

Sex, race, and insurance status were independently associated with post-arrest care interventions, patient outcomes and treatment at a 24/7 PCI center. More studies are needed to fully understand the causes and implications of these disparities.

Post-resuscitation care

Following return of spontaneous circulation (ROSC) after cardiac arrest, the challenge is to institute measures that ensure a higher likelihood of neurologically intact survival. Regardless of the cause of collapse, multiple organ systems may be affected secondary to post-cardiac arrest syndrome. Interventions required for post-ROSC care are bundled into a care regimen: prompt identification and treatment of the cause of cardiac arrest; and treatment of electrolyte abnormalities. It is also essential to establish definitive airway management to maintain normocapnic ventilation, prevent hyperoxia, and optimise haemodynamic management via judicious intravenous fluids and vasoactive drugs. Targeted temperature management after ROSC confers neuroprotection and leads to improved neurological outcomes. Glycaemic control of blood glucose levels at 6-10 mmol/L, adequate seizure management and measures to optimise neurological functions should be integrated into the care bundle. The interventions outlined can potentially lead to more patients being discharged from hospital alive with good neurological function.

Effects of inhaled nitric oxide on outcome after prolonged cardiac arrest in mild therapeutic hypothermia treated rats

Guidelines endorse targeted temperature management to reduce neurological sequelae and mortality after cardiac arrest (CA). Additional therapeutic approaches are lacking. Inhaled nitric oxide (iNO) given post systemic ischemia/reperfusion injury improves outcomes. Attenuated inflammation by iNO might be crucial in brain protection. iNO augmented mild therapeutic hypothermia (MTH) may improve outcome after CA exceeding the effect of MTH alone. Following ten minutes of CA and three minutes of cardiopulmonary resuscitation, 20 male Sprague-Dawley rats were randomized to receive MTH at 33 °C for 6hrs or MTH + 20ppm iNO for 5hrs; one group served as normothermic control. During the experiment blood was taken for biochemical evaluation. A neurological deficit score was calculated daily for seven days post CA. On day seven, brains and hearts were harvested for histological evaluation. Treatment groups showed a significant decrease in lactate levels six hours post resuscitation in comparison to controls. TNF-α release was significantly lower in MTH + iNO treated animals only at four hours post ROSC. While only the combination of MTH and iNO improved neurological function in a statistically significant manner in comparison to controls on days 4–7 after CA, there was no significant difference between groups treated with MTH and MTH + iNO.

ILCOR Scientific Knowledge Gaps and Clinical Research Priorities for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: A Consensus Statement

Despite significant advances in the field of resuscitation science, important knowledge gaps persist. Current guidelines for resuscitation are based on the International Liaison Committee on Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, which includes treatment recommendations supported by the available evidence. The writing group developed this consensus statement with the goal of focusing future research by addressing the knowledge gaps identified during and after the 2015 International Liaison Committee on Resuscitation evidence evaluation process. Key publications since the 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations are referenced, along with known ongoing clinical trials that are likely to affect future guidelines.

Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory Arrest: A Randomized Clinical Trial

IMPORTANCE

Bag-mask ventilation (BMV) is a less complex technique than endotracheal intubation (ETI) for airway management during the advanced cardiac life support phase of cardiopulmonary resuscitation of patients with out-of-hospital cardiorespiratory arrest. It has been reported as superior in terms of survival.

OBJECTIVES

To assess noninferiority of BMV vs ETI for advanced airway management with regard to survival with favorable neurological function at day 28.

DESIGN, SETTINGS, AND PARTICIPANTS

Multicenter randomized clinical trial comparing BMV with ETI in 2043 patients with out-of-hospital cardiorespiratory arrest in France and Belgium. Enrollment occurred from March 9, 2015, to January 2, 2017, and follow-up ended January 26, 2017.

INTERVENTION

Participants were randomized to initial airway management with BMV (n = 1020) or ETI (n = 1023).

MAIN OUTCOMES AND MEASURES

The primary outcome was favorable neurological outcome at 28 days defined as cerebral performance category 1 or 2. A noninferiority margin of 1% was chosen. Secondary end points included rate of survival to hospital admission, rate of survival at day 28, rate of return of spontaneous circulation, and ETI and BMV difficulty or failure.

RESULTS

Among 2043 patients who were randomized (mean age, 64.7 years; 665 women [32%]), 2040 (99.8%) completed the trial. In the intention-to-treat population, favorable functional survival at day 28 was 44 of 1018 patients (4.3%) in the BMV group and 43 of 1022 patients (4.2%) in the ETI group (difference, 0.11% [1-sided 97.5% CI, -1.64% to infinity]; P for noninferiority = .11). Survival to hospital admission (294/1018 [28.9%] in the BMV group vs 333/1022 [32.6%] in the ETI group; difference, -3.7% [95% CI, -7.7% to 0.3%]) and global survival at day 28 (55/1018 [5.4%] in the BMV group vs 54/1022 [5.3%] in the ETI group; difference, 0.1% [95% CI, -1.8% to 2.1%]) were not significantly different. Complications included difficult airway management (186/1027 [18.1%] in the BMV group vs 134/996 [13.4%] in the ETI group; difference, 4.7% [95% CI, 1.5% to 7.9%]; P = .004), failure (69/1028 [6.7%] in the BMV group vs 21/996 [2.1%] in the ETI group; difference, 4.6% [95% CI, 2.8% to 6.4%]; P < .001), and regurgitation of gastric content (156/1027 [15.2%] in the BMV group vs 75/999 [7.5%] in the ETI group; difference, 7.7% [95% CI, 4.9% to 10.4%]; P < .001).

CONCLUSIONS AND RELEVANCE

Among patients with out-of-hospital cardiorespiratory arrest, the use of BMV compared with ETI failed to demonstrate noninferiority or inferiority for survival with favorable 28-day neurological function, an inconclusive result. A determination of equivalence or superiority between these techniques requires further research.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02327026.

End-Tidal Carbon Dioxide Use for Tracheal Intubation: Analysis From the National Emergency Airway Registry for Children (NEAR4KIDS) Registry

OBJECTIVE

Waveform capnography use has been incorporated into guidelines for the confirmation of tracheal intubation. We aim to describe the trend in waveform capnography use in emergency departments and PICUs and assess the association between waveform capnography use and adverse tracheal intubation-associated events.

DESIGN

A multicenter retrospective cohort study.

SETTING

Thirty-four hospitals (34 ICUs and nine emergency departments) in the National Emergency Airway Registry for Children quality improvement initiative.

PATIENTS

Primary tracheal intubation in children younger than 18 years.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patient, provider, and practice data for tracheal intubation procedure including a type of end-tidal carbon dioxide measurement, as well as the procedural safety outcomes, were prospectively collected. The use of waveform capnography versus colorimetry was evaluated in association with esophageal intubation with delayed recognition, cardiac arrest, and oxygen desaturation less than 80%. During January 2011 and December 2015, 9,639 tracheal intubations were reported. Waveform capnography use increased over time (39% in 2010 to 53% in 2015; p < 0.001), whereas colorimetry use decreased (< 0.001). There was significant variability in waveform capnography use across institutions (median 49%; interquartile range, 25-85%; p < 0.001). Capnography was used more often in emergency departments as compared with ICUs (66% vs. 49%; p < 0.001). The rate of esophageal intubation with delayed recognition was similar with waveform capnography versus colorimetry (0.39% vs. 0.46%; p = 0.62). The rate of cardiac arrest was also similar (p = 0.49). Oxygen desaturation occurred less frequently when capnography was used (17% vs. 19%; p = 0.03); however, this was not significant after adjusting for patient and provider characteristics.

CONCLUSIONS

Significant variations existed in capnography use across institutions, with the use increasing over time in both emergency departments and ICUs. The use of capnography during intubation was not associated with esophageal intubation with delayed recognition or the occurrence of cardiac arrest.

Survival after Cardiac Arrest Secondary to Massive Pulmonary Embolism

Introduction

It is estimated that the diagnosis of pulmonary embolism (PE) is missed in as many as 84% of all cases of PE. Cardiac arrest following PE is generally associated with poor outcomes.

Case Report

A 43-year-old man presented to the Emergency Department (ED) in cardiac arrest. Swelling of his right lower limb was noted on arrival. Point of care ultrasound was performed during ongoing cardiopulmonary resuscitation (CPR) and showed a thrombus in the right iliofemoral vein as well as dilatation of the right ventricle. Fibrinolytic therapy was initiated immediately and a return of spontaneous circulation (ROSC) was achieved 30 minutes later. The diagnosis of PE was finally confirmed on computed tomography pulmonary angiography once haemodynamic stability was achieved. The patient was thereafter transferred to the intensive care unit for postresuscitation care and further management. Several days later, he was discharged home neurologically intact and fully recovered.

Discussion

Since outcomes after cardiac arrest following PE are generally dismal, available and potentially life-saving interventions to restore pulmonary circulation should be rapidly implemented when PE is the likely cause of cardiac arrest.

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.

Noteworthy Literature published in 2017 for Cardiac Critical Care

In 2017, many high-impact articles appeared in the literature. This is the third edition of an annual review of articles related to postoperative cardiac critical care that may affect the cardiac anesthesiologist. This year explores vasopressor and inotropic support, timing of renal replacement therapy, management of postoperative respiratory insufficiency, and targeted temperature therapy.

Cardiac arrest due to pulmonary embolism

Pulmonary embolism (PE) is a potentially life threatening clinical condition that is fairly non-specific in presentation. Massive pulmonary embolism (PE) without cardiac arrest has been associated with a mortality rate of 30%. However, when cardiac arrest ensues, mortality may be as high as 95%. Since outcomes of cardiac arrest following PE are generally dismal, any available potentially life-saving measure must be instituted when the diagnosis of PE is suspected. Despite a lack of randomized controlled trials guiding the management of suspected PE in the cardiac arrest victim, thrombolysis and other therapies have been associated with good outcomes in the handful of published case reports and other small studies.

Future Directions: Management of Sudden Cardiac Death

There will always be a need to optimize early recognition and treatment of sudden cardiac arrest. For out-of-hospital cardiac arrest, this requires a complex system of care involving bystanders, 911 dispatchers, and emergency medical service and hospital-based providers. Optimizing this system is fundamental to improving outcomes. In addition, personnel and resources are needed to develop and sustain a research pipeline that will bring new scientific discoveries and technologies to the field. The 2015 Institute of Medicine report, "Strategies to Improve Cardiac Arrest Survival: A Time to Act," provides a roadmap.

Critical Care and Personalized or Precision Medicine: Who needs whom?

The current paradigm of modern healthcare is a reactive response to patient symptoms, subsequent diagnosis and corresponding treatment of the specific disease(s). This approach is predicated on methodologies first espoused by the Cnidean School of Medicine approximately 2500years ago. More recently escalating healthcare costs and relatively poor disease treatment outcomes have fermented a rethink in how we carry out medical practices. This has led to the emergence of "P-Medicine" in the form of Personalized and Precision Medicine. The terms are used interchangeably, but in fact there are significant differences in the way they are implemented. The former relies on an "N-of-1" model whereas the latter uses a "1-in-N" model. Personalized Medicine is still in a fledgling and evolutionary phase and there has been much debate over its current status and future prospects. A confounding factor has been the sudden development of Precision Medicine, which has currently captured the imagination of policymakers responsible for modern healthcare systems. There is some confusion over the terms Personalized versus Precision Medicine. Here we attempt to define the key differences and working definitions of each P-Medicine approach, as well as a taxonomic relationship tree. Finally, we discuss the impact of Personalized and Precision Medicine on the practice of Critical Care Medicine (CCM). Practitioners of CCM have been participating in Personalized Medicine unknowingly as it takes the protocols of sepsis, mechanical ventilation, and daily awakening trials and applies it to each individual patient. However, the immediate next step for CCM should be an active development of Precision Medicine. This developmental process should break down the silos of modern medicine and create a multidisciplinary approach between clinicians and basic/translational scientists.

Tibial Osteomyelitis Following Prehospital Intraosseous Access

Intraosseous (IO) access is a lifesaving alternative to peripheral or central venous access in emergency care. However, emergency physicians and prehospital care providers must be aware of the potential for infectious complications associated with this intervention. We describe the case of a HIV-negative, otherwise immunocompetent adult patient who underwent prehospital insertion of a tibial IO device. Following successful resuscitation, the patient developed tibial osteomyelitis requiring multiple operative debridements, soft tissue coverage, and several courses of prolonged antimicrobial therapy. Skin antisepsis prior to device insertion followed by early device removal are important strategies for reducing the risk of infection associated with IO access.

Comprehensive cardiopulmonary life support (CCLS) for cardiopulmonary resuscitation by trained paramedics and medics inside the hospital

The cardiopulmonary resuscitation (CPR) guideline of comprehensive cardiopulmonary life support (CCLS) for management of the patient with cardiopulmonary arrest in adults provides an algorithmic step-wise approach for optimal outcome of the patient inside the hospital by trained medics and paramedics. This guideline has been developed considering the infrastructure of healthcare delivery system in India. This is based on evidence in the international and national literature. In the absence of data from the Indian population, the extrapolation has been made from international data, discussed with Indian experts and modified accordingly to ensure their applicability in India. The CCLS guideline emphasise the need to recognise patients at risk for cardiac arrest and their timely management before a cardiac arrest occurs. The basic components of CPR include chest compressions for blood circulation; airway maintenance to ensure airway patency; lung ventilation to enable oxygenation and defibrillation to convert a pathologic 'shockable' cardiac rhythm to one capable to maintaining effective blood circulation. CCLS emphasises incorporation of airway management, drugs, and identification of the cause of arrest and its correction, while chest compression and ventilation are ongoing. It also emphasises the value of organised team approach and optimal post-resuscitation care.

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.

Meta-analysis of the efficacies of amiodarone and nifekalant in shock-resistant ventricular fibrillation and pulseless ventricular tachycardia

Amiodarone (AMD) and nifekalant (NIF) are used in the treatment of ventricular fibrillation or tachycardia; however, only few studies have been conducted on their efficacies. Therefore, a meta-analysis was conducted. Relevant sources were identified from PubMed, Cochrane Central Register of Controlled Trials, and Igaku Chuo Zasshi. The outcomes were short-term and long-term survival in patients with shock-resistant ventricular fibrillation /pulseless ventricular tachycardia. Thirty-three studies were analysed. The results showed that, compared to the control treatment, AMD did not improve short-term survival (odds ratio (OR): 1.25, 95% confidence interval (CI): 0.91-1.71) or long-term survival (OR: 1.00, 95% CI: 0.63-1.57). However, compared to the control treatment, NIF significantly improved short-term survival (OR: 3.23, 95% CI: 2.21-4.72) and long-term survival (OR: 1.88, 95% CI: 1.36-2.59). No significant difference was observed in short-term survival (OR: 0.85, 95% CI: 0.63-1.15) or long-term survival (OR: 1.25, 95% CI: 0.67-2.31) between AMD- and NIF-treated patients. The results suggest that NIF is beneficial for short-term and long-term survival in shock-resistant ventricular fibrillation/pulseless ventricular tachycardia; however, the efficacy of AMD in either outcome is not clear.

Systemic impact on secondary brain aggravation due to ischemia/reperfusion injury in post-cardiac arrest syndrome: a prospective observational study using high-mobility group box 1 protein

BACKGROUND

Ischemia/reperfusion injury (I/R) is an important pathophysiology of post-cardiac arrest syndrome (PCAS) against multiple organ dysfunction and mortality. The inflammatory response in PCAS causes systemic I/R. The purpose of this study was to demonstrate the pathophysiology of systemic I/R for secondary brain damage using the biomarkers high-mobility group box 1 (HMGB1), neuron-specific enolase (NSE), and interleukin-6 (IL-6).

METHODS

This study was designed as a single-institution prospective observational study. Subjects were observed for 90 days, and neurological outcome was classified according to the Glasgow-Pittsburgh Cerebral Performance Categories Scale (CPC). Serum HMGB1, NSE, and IL-6 were evaluated for variability, correlation with each biomarker, or the Sequential Organ Function Assessment (SOFA) score and CPC at return of spontaneous circulation at 0, 24, 48, and 168 h.

RESULTS

A total of 128 patients were enrolled in this study. Initial HMGB1 correlated with CPC (ρ = 0.27, p = 0.036) and SOFA score (ρ = 0.33, p < 0.001). The early phase of HMGB1 (0-24 h), all phases of IL-6, and the delayed phase of NSE (24-168 h) manifested poor neurological outcome. HMGB1 showed a significant correlation with NSE (ρ = 0.29, p = 0.002 at 0 h; ρ = 0.42, p < 0.001 at 24 h) and IL-6 (ρ = 0.36, p < 0.001 at 24 h).

CONCLUSIONS

Serum HMGB1 for first 24 h after cardiac arrest was significantly correlated with SOFA score, NSE, and IL-6. This result suggests that systemic I/R may contribute to secondary brain aggravation. It is expected that research on HMGB1 focused on systemic I/R will help prevent aggravating neurological outcomes.

Extracorporeal Cardiopulmonary Resuscitation for Refractory Out-of-Hospital Cardiac Arrest: The State of the Evidence and Framework for Application

Out-of-hospital cardiac arrest (OHCA) affects 134 per 100,000 citizens annually. Extracorporeal cardiopulmonary resuscitation (ECPR), providing mechanical circulatory support, may improve the likelihood of survival among those with refractory OHCA. Compared with in-hospital ECPR candidates, those in the out-of-hospital setting tend to be sudden unexpected arrests in younger and healthier patients. The aims of this review were to summarize, and identify the limitations of, the evidence evaluating ECPR for OHCA, and to provide an approach for ECPR program application. Although there are many descriptions of ECPR-treated cohorts, we identified a paucity of robust data showing ECPR effectiveness compared with conventional resuscitation. However, it is highly likely that ECPR, provided after a prolonged attempt with conventional resuscitation, does benefit select patient populations compared with conventional resuscitation alone. Although reliable data showing the optimal patient selection criteria for ECPR are lacking, most implementations sought young previously healthy patients with rapid high-quality cardiopulmonary resuscitation. Carefully planned development of ECPR programs, in high-performing emergency medical systems at experienced extracorporeal membrane oxygenation centres, may be reasonable as part of systematic efforts to determine ECPR effectiveness and globally improve care. Protocol evaluation requires regional-level assessment, examining the incremental benefit of survival compared with standard care, while accounting for resource utilization.

Prognostic indicators of survival and survival prediction model following extracorporeal cardiopulmonary resuscitation in patients with sudden refractory cardiac arrest

Background

Extracorporeal cardiopulmonary resuscitation (ECPR) has been considered in selected candidates with potentially reversible causes during a limited period. Candidate selection and the identification of predictable conditions are important factors in determining outcomes during CPR in the emergency department (ED). The objective of this study was to determine the key indicators and develop a prediction model for survival to hospital discharge in patients with sudden cardiac arrest who received ECPR.

Methods

This retrospective analysis was based on a prospective cohort, which included data on CPR with ECPR-related variables. Patients with sudden cardiac arrest who received ECPR at the ED from May 2006 to June 2016 were included. The primary outcome was survival to discharge. Prognostic indicators and the prediction model were analyzed using logistic regression.

Results

Out of 111 ECPR patients, there were 18.9% survivors. Survivors showed younger age, shorter CPR duration (p < 0.05) and had tendencies of higher rate of initial shockable rhythm (p = 0.055) and higher rate of any ROSC event before ECPR (p = 0.066) than non-survivors. Eighty-one percent of survivors showed favorable neurologic outcome at discharge. In univariate analysis, the following factors were associated with survival: no preexisting comorbidities, initial serum hemoglobin level ≥14 g/dL, and mean arterial pressure ≥60 mmHg after ECPR. Based on multivariate logistic regression, predictors for survival in ECPR were as follows: age ≤56 years, no asystole as the initial arrest rhythm, CPR duration of ≤55 min, and any return of spontaneous circulation (ROSC) event before ECPR. The prediction scoring model for survival had a c-statistic of 0.875.

Conclusions

With careful consideration of differences in the inclusion criteria, the prognostic indicators and prediction scoring model for survival in our study may be helpful in the rapid decision-making process for ECPR implementation during CPR in the ED.

Favorable Neurocognitive Outcome with Low Tidal Volume Ventilation after Cardiac Arrest

RATIONALE

Neurocognitive outcome after out-of-hospital cardiac arrest (OHCA) is often poor, even when initial resuscitation succeeds. Lower tidal volumes (Vts) attenuate extrapulmonary organ injury in other disease states and are neuroprotective in preclinical models of critical illness.

OBJECTIVE

To evaluate the association between Vt and neurocognitive outcome after OHCA.

METHODS

We performed a propensity-adjusted analysis of a two-center retrospective cohort of patients experiencing OHCA who received mechanical ventilation for at least the first 48 hours of hospitalization. Vt was calculated as the time-weighted average over the first 48 hours, in milliliters per kilogram of predicted body weight (PBW). The primary endpoint was favorable neurocognitive outcome (cerebral performance category of 1 or 2) at discharge.

MEASUREMENTS AND MAIN RESULTS

Of 256 included patients, 38% received time-weighted average Vt greater than 8 ml/kg PBW during the first 48 hours. Lower Vt was independently associated with favorable neurocognitive outcome in propensity-adjusted analysis (odds ratio, 1.61; 95% confidence interval [CI], 1.13-2.28 per 1-ml/kg PBW decrease in Vt; P = 0.008). This finding was robust to several sensitivity analyses. Lower Vt also was associated with more ventilator-free days (β = 1.78; 95% CI, 0.39-3.16 per 1-ml/kg PBW decrease; P = 0.012) and shock-free days (β = 1.31; 95% CI, 0.10-2.51; P = 0.034). Vt was not associated with hypercapnia (P = 1.00). Although the propensity score incorporated several biologically relevant covariates, only height, weight, and admitting hospital were independent predictors of Vt less than or equal to 8 ml/kg PBW.

CONCLUSIONS

Lower Vt after OHCA is independently associated with favorable neurocognitive outcome, more ventilator-free days, and more shock-free days. These findings suggest a role for low-Vt ventilation after cardiac arrest.

Prolonged targeted temperature management compromises thrombin generation: A randomised clinical trial

AIM

To investigate whether prolonged compared with standard duration of targeted temperature management (TTM) compromises coagulation.

METHODS

Comatose survivors after out-of-hospital cardiac arrest (n=82) were randomised to standard (24h) or prolonged (48h) duration of TTM at 33±1°C. Blood samples were drawn 22, 46 and 70h after attaining the target temperature. Samples were analysed for rotational thromboelastometry (ROTEM^® (EXTEM^®, INTEM^®, FIBTEM^® and HEPTEM^®)) and thrombin generation using the Calibrated Automated Thrombogram^® assay.

RESULTS

With the 22-h sample, we revealed no difference between groups in the ROTEM^® and thrombin generation results beside a slightly higher EXTEM^® and INTEM^® maximum velocity in the prolonged group (p-values≤0.04). With the 46-h sample, ROTEM^® showed no differences when using EXTEM^®; however, 11% (p<0.01) longer clotting time and 12% (p<0.01) longer time to maximum velocity were evident in the prolonged group than in the standard group when using INTEM^®. The prolonged group had reduced thrombin generation compared with the standard group as indicated by 30% longer lag time (p=0.04), 106nM decreased peak concentration (p<0.001), 36% longer time to peak (p=0.01) and 411 nM*minute decreased endogenous thrombin potential (p<0.001). With the 70-h sample, no differences in ROTEM^® results were found between groups. However, the prolonged group had reduced thrombin generation indicated by longer lag time, decreased peak concentration and longer time to peak (all p-values≤0.02) compared with the standard group.

CONCLUSION

Prolonged TTM in post-cardiac arrest patients impairs thrombin generation. ClinicalTrials.gov identifier: NCT02258360.

Prognosis of neurologic complications in critical illness

Neurologic complications of critical illness require extensive clinical and neurophysiologic evaluation to establish a reliable prognosis. Many sequelae of intensive care unit (ICU) treatment, such as delirium and ICU-acquired weakness, although highly associated with adverse outcomes, are less suitable for prognostication, but should rather prompt clinicians to seek previously unnoticed persisting underlying illnesses. Prognostication can be confounded by drug administration particularly because its clearance is abnormal in critical illness. Some neurological complications are severe, and can last for months or years after discharge from ICU. The most important ethical aspects regarding neurologic complications in critically ill patients are prevention, recognition, and identification, and prevention of self-fulfilling prophecies. This chapter summarizes the tool of prognostication of major neurological complications of critical illness.

Antiarrhythmic drugs for out-of-hospital cardiac arrest with refractory ventricular fibrillation

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency medicine 2017. Other selected articles can be found online at http://ccforum.com/series/annualupdate2017. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.