Prognosis among patients with out-of-hospital cardiac arrest judged as being caused by deterioration of obstructive pulmonary disease

[Cardiac arrest under special circumstances]

These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).

European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances

These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).

Low rate of secondary prevention ICDs in the general population: multiple-year multiple-source surveillance of sudden cardiac death in the Oregon Sudden Unexpected Death Study

INTRODUCTION

Sudden cardiac death (SCD) is a large public health problem that warrants on-going evaluation in the general population. While single-year community-based studies have been performed there is a lack of studies that have extended evaluation to multiple years in the same community.

METHODS AND RESULTS

From the on-going Oregon Sudden Unexpected Death Study, we analyzed prospectively identified SCD cases in Multnomah County, Ore, (population ≈700,000) from February 1, 2002 to January 31, 2005. Detailed information ascertained from multiple sources (first responders, clinical records, and medical examiner) was analyzed. A total of 1,175 SCD cases were identified (61% male) with a mean age of 65 ± 18 years for men versus 70 ± 20 for women (P < 0.001). The overall incidence rate for the period was 58/100,000 residents/year. One-quarter (24.6%) was ≤ 55 years of age. The most common initial rhythm was ventricular tachycardia or fibrillation (39% of cases, survival 27%) followed by asystole (36%, survival 0.7%) and pulseless electrical activity (23%, survival 6%). Among subjects that underwent resuscitation, the rate of survival to hospital discharge was 12% and overall survival to hospital discharge irrespective of resuscitation was 8%. Of the 68 survivors, 16 (24%) received a secondary prevention ICD.

CONCLUSION

We report annualized SCD incidence from a multiple-year, multiple-source community-based study, with higher than expected rates of women and subjects age ≤ 55 years. The low implantation rate of secondary prevention ICDs is likely to be multifactorial, but there are potential implications for recalibration of the projected need for ICD implantation; larger and more detailed studies are warranted.

Factors associated with pulseless electric activity versus ventricular fibrillation: the Oregon sudden unexpected death study

BACKGROUND

Corresponding with a continuing decline in the prevalence of sudden cardiac arrest cases presenting with ventricular fibrillation (VF), there has been a significant rise in the prevalence of pulseless electrical activity (PEA). Given significantly lower survival from PEA versus VF, we comprehensively investigated PEA correlates by incorporating first-responder data with lifetime clinical history information.

METHODS AND RESULTS

In the Portland, Ore, metropolitan area (population ≈1 million), cases of out-of-hospital sudden cardiac arrest who underwent attempted resuscitation were identified prospectively (2002-2007). Those presenting with PEA versus VF and asystole were compared with χ² tests, ANOVA, and logistic regression. A total of 1277 cases aged ≥18 years underwent resuscitation by first responders (mean age, 65±16 years; 67% male). Presenting arrhythmia was VF in 48%, PEA in 25%, and asystole/other in the remainder. Compared with VF cases, PEA cases were older (mean age, 68 versus 63 years; P=0.0002), more likely to be female (37% versus 26%; P=0.0008), and less likely to survive to hospital discharge (6% versus 25%; P<0.0001). A history of syncope was strongly associated with PEA (odds ratio, 2.6; confidence interval, 1.3 to 5.3) after adjustment for age, gender, response time, and arrest circumstances. Black race was also independently associated with PEA (odds ratio, 2.6; confidence interval, 1.3 to 5.4). Pulmonary disease and female gender were significant factors associated with PEA (P for interaction=0.04). In a subgroup analysis of resting ECGs (n=391), there were no differences in cardiac clinical history or prevalence of cardiac conduction system disease (PEA, 31.6% versus VF, 32.2%; P=0.48).

CONCLUSIONS

PEA cases had a significantly higher prevalence of syncope in their lifetime, with other correlates, including black race, that were distinct from VF cases. Potential mechanistic links between syncope and future manifestation with PEA warrant further exploration.

Out-of-hospital cardiac arrest and airborne fine particulate matter: a case-crossover analysis of emergency medical services data in Indianapolis, Indiana

BACKGROUND

Previous studies have found particulate matter (PM) < 2.5 microm in aerodynamic diameter (PM2.5) associated with heart disease mortality. Although rapid effects of PM2.5 exposure on the cardiovascular system have been proposed, few studies have investigated the effect of short-term exposures on out-of-hospital cardiac arrest (OHCA).

OBJECTIVES

We aimed to determine whether short-term PM2.5 exposures increased the risk of OHCA and whether risk depended on subject characteristics or presenting heart rhythm.

METHODS

A case-crossover analysis determined hazard ratios (HRs) for OHCAs logged by emergency medical systems (EMS) versus hourly and daily PM2.5 exposures at the time of the OHCA and for daily and hourly periods before it.

RESULTS

For all OHCAs (n = 1,374), exposures on the day of the arrest or 1-3 days before arrest had no significant effect on the incidence of OHCA. For cardiac arrests witnessed by bystanders (n = 511), OHCA risk significantly increased with PM2.5 exposure during the hour of the arrest (HR for a 10-microg/m3 increase in PM2.5 exposure = 1.12; 95% confidence interval, 1.01-1.25). For the subsets of subjects who were white, 60-75 years of age, or presented with asystole, OHCA risk significantly increased with PM2.5 during the hour of the arrest (HRs for a 10-microg/m3 increase in PM2.5 = 1.18, 1.25, or 1.22, respectively; p < 0.05). HR generally decreased as the time lag between PM2.5 exposure and OHCA increased.

CONCLUSION

The results suggest an acute effect of short-term PM2.5 exposure in precipitating OHCAs, and a need to investigate further the role of subject factors in the effects of PM on the risk of OHCA.

Experience of an emergency mobile asthma treatment programme

In order to reduce mortality and the need for hospital care for patients suffering from acute asthma, an emergency programme was set up. An ambulance crew, trained in coronary-pulmonary resuscitation was instructed in dealing with acute asthma and delegated to give 24 h treatment with bronchodilators (inhaled salbutamol and ipratropium bromide). If there was no, or only slight, improvement with this therapy, nurses (daytime) were delegated to give injections with corticosteroids (terbutaline and theophylline). Over a period of 2 years, 240 patients, 115 women and 125 men, were treated on 367 occasions. In 127 patients (53%), two or more treatments were given. The number of times treatment was given, as well as the proportion of females to males, increased the younger the patients were. Out of all the cases, more than 70% improved after treatment. On arrival, 21 patients (6%) were unconscious. After therapy, 15/21 patients (71%) survived. This may correspond to a similar reduction in mortality (population about 350,000 inhabitants), as it is unlikely that unconscious patients can survive without intensive care.