Out of hospital cardiac arrest in Vienna: Incidence and outcome

Global Sex Disparities in Bystander Cardiopulmonary Resuscitation After Out-of-Hospital Cardiac Arrest: A Scoping Review

This scoping review collates evidence for sex biases in the receipt of bystander cardiopulmonary resuscitation (BCPR) among patients with out-of-hospital cardiac arrest patients globally. The MEDLINE, PsycINFO, CENTRAL, and Embase databases were screened for relevant literature, dated from inception to March 9, 2022. Studies evaluating the association between BCPR and sex/gender in patients with out-of-hospital cardiac arrest, except for pediatric populations and cardiac arrest cases with traumatic cause, were included. The review included 80 articles on BCPR in men and women globally; 58 of these studies evaluated sex differences in BCPR outcomes. Fifty-nine percent of the relevant studies (34/58) indicated that women are less likely recipients of BCPR, 36% (21/58) observed no significant sex differences, and 5% (3/58) reported that women are more likely to receive BCPR. In other studies, women were found to be less likely to receive BCPR in public but equally or more likely to receive BCPR in residential settings. The general reluctance to perform BCPR on women in the Western countries was attributed to perceived frailty of women, chest exposure, pregnancy, gender stereotypes, oversexualization of women's bodies, and belief that women are unlikely to experience a cardiac arrest. Most studies worldwide indicated that women were less likely to receive BCPR than men. Further research from non-Western countries is needed to understand the impact of cultural and socioeconomic settings on such biases and design customized interventions accordingly.

Prehospital emergency medicine research by additional teams on scene - Concepts and lessons learned

While the initial minutes of acute emergencies significantly influence clinical outcomes, prehospital research often receives inadequate attention due to several challenges. Retrospective chart reviews carry the risk of incomplete and inaccurate data. Furthermore, prehospital intervention trials frequently encounter difficulties related to extensive training requirements, even during the planning phase. Consequently, we have implemented prospective research concepts involving additional paramedics and physicians directly at the scene during major emergency calls. Three concepts were used: (I) Paramedic field supervisor units, (II) a paramedic + physician field supervisor unit, (III) a special physician-based research car. This paper provides insights into our historical perspective, the current situation, and the lessons learned while overcoming certain barriers and using existing and novel facilitators. Our objective is to support other research groups with our experiences in their planning of upcoming prehospital trials.

Differences in Automated External Defibrillator Types in Out-of-Hospital Cardiac Arrest Treated by Police First Responders

Background: Police first responder systems also including automated external defibrillation (AED) has in the past shown considerable impact on favourable outcomes after out-of-hospital cardiac arrest (OHCA). While short hands-off times in chest compressions are known to be beneficial, various AED models use different algorithms, inducing longer or shorter durations of crucial timeframes along basic life support (BLS). Yet, data on details of these differences, and also of their potential impact on clinical outcomes are scarce. Methods: For this retrospective observational study, patients with OHCA of presumed cardiac origin and initially shockable rhythm treated by police first responders in Vienna, Austria, between 01/2013 and 12/2021 were included. Data from the Viennese Cardiac Arrest Registry and AED files were extracted, and exact timeframes were analyzed. Results: There were no significant differences in the 350 eligible cases in demographics, return of spontaneous circulation, 30-day survival, or favourable neurological outcome between the used AED types. However, the Philips HS1 and -FrX AEDs showed immediate rhythm analysis after electrode placement (0 [0-1] s) and almost no shock loading time (0 [0-1] s), as opposed to the LP CR Plus (3 [0-4] and 6 [6-6] s, respectively) and LP 1000 (3 [2-10] and 6 [5-7] s, respectively). On the other hand, the HS1 and -FrX had longer analysis times of 12 [12-16] and 12 [11-18] s than the LP CR Plus (5 [5-6] s) and LP 1000 (6 [5-8] s). The duration from when the AED was turned on until the first defibrillation were 45 [28-61] s (Philips FrX), 59 [28-81] s (LP 1000), 59 [50-97] s (HS1), and 69 [55-85] s (LP CR Plus). Conclusion: In a retrospective analysis of OHCA-cases treated by police first responders, we could not find significant differences in clinical patient outcomes concerning the respective used AED model. However, various differences in time durations (e.g., electrode placement to rhythm analysis, analysis duration, or AED turned on until first defibrillation) along the BLS algorithm were seen. This opens up the question of AED-adaptations and tailored training methods for professional first responders.

Effect of cooling methods and target temperature on outcomes in comatose patients resuscitated from cardiac arrest: Systematic review and network meta-analysis of randomized trials

BACKGROUND

Targeted temperature management (TTM) has been recommended after cardiac arrest (CA), however the specific temperature targets and cooling methods (intravascular cooling (IVC) versus surface cooling (SC)) remain uncertain.

METHODS

PUBMED and EMBASE were searched until October 8, 2022 for randomized clinical trials (RCTs) investigating the efficacy of TTM after CA. The randomized treatment arms were categorized into the following 6 groups: 31..C to 33..C IVC, 31..C to 33..C SC, 34..C to 36..C IVC, 34..C to 36..C SC, strict normothermia or fever prevention (Strict NT or FP), and standard of care without TTM (No-TTM). The primary outcome was neurological recovery. P-score was used to rank the treatments, where a larger value indicates better performance.

RESULTS

We identified 15 RCTs, involving 5,218 patients with CA. Compared to No-TTM as the reference, the other therapeutic options significantly improved neurological outcomes (vs No-TTM; 31..C to 33..

C IVC

RR = 0.67, 95% CI 0.54 to 0.83; 31..C to 33..C SC RR = 0.73, 95% CI 0.61 to 0.87; 34..C to 36..

C IVC

RR = 0.66, 95% CI 0.51 to 0.86; 34..C to 36..C SC: RR = 0.73, 0.59 to 0.90; Strict NT or FP: RR = 0.75, 95% CI 0.62 to 0.90). Overall, 31-33..C IVC had the highest probability to be the best therapeutic option to improve outcomes (the ranking P-score of 0.836). As a subgroup analysis, the ranking P-score showed that IVC might be a better cooling method compared to SC (IVC vs SC P-score: 0.960 vs 0.670).

CONCLUSIONS

Hypothermia (31..C to 36..C IVC and SC) and active normothermia (Strict-NT and Strict-FP) were associated with better neurological outcomes compared to No-TTM, with IVC having a greater probability of being the better cooling method than SC.

Carotid Artery Ultrasound in the (peri-) Arrest Setting—A Prospective Pilot Study

Point-of-care ultrasounds (US) are used during cardiopulmonary resuscitation (CPR) and after return of spontaneous circulation (ROSC). Carotid ultrasounds are a potential non-invasive monitoring tool for chest compressions, but their general value and feasibility during CPR are not fully determined. In this prospective observational study, we performed carotid US during conventional- and extracorporeal CPR and after ROSC with at least one transverse and coronal image, corresponding loops with and without color doppler, and pulsed-wave doppler loops. The feasibility of carotid US during (peri-)arrest and type and frequency of diagnostic findings were examined. We recruited 16 patients and recorded utilizable US images in 14 cases (88%; complete imaging protocols in 11 patients [69%]). In three of all patients (19%) and in 60% (3/5) of cases during CPR plus a full imaging protocol, we observed: (i) in one patient a collapse of the common carotid artery linked to hypovolemia, and (ii) in two patients a biphasic flow during CPR linked to prolonged low-flow time prior to admission and adverse outcome. Carotid artery morphology and carotid blood flow characteristics may serve as therapeutic target and prognostic parameters. However, future studies with larger sample sizes are needed.

Targeted temperature management after cardiac arrest is associated with reduced metabolism of pantoprazole - A probe drug of CYP2C19 metabolism

OBJECTIVE

Targeted temperature management (TTM) is part of standard post-resuscitation care. TTM may downregulate cytochrome enzyme activity and thus impact drug metabolism. This study compared the pharmacokinetics (PK) of pantoprazole, a probe drug of CYP2C19-dependent metabolism, at different stages of TTM following cardiac arrest.

METHODS

This prospective controlled study was performed at the Medical University of Vienna and enrolled 16 patients following cardiac arrest. The patients completed up to three study periods (each lasting 24 h) in which plasma concentrations of pantoprazole were quantified: (P1) hypothermia (33 °C) after admission, (P2) normothermia after rewarming (36 °C, intensive care), and (P3) normothermia during recovery (normal ward, control group). PK was analysed using non-compartmental analysis and nonlinear mixed-effects modelling.

RESULTS

16 patients completed periods P1 and P2; ten completed P3. The median half-life of pantoprazole was 2.4 h (quartiles: 1.8-4.8 h) in P1, 2.8 h (2.1-6.8 h, p = 0.046 vs. P1, p = 0.005 vs. P3) in P2 and 1.2 h (0.9 - 2.3 h, p = 0.007 vs. P1) in P3. A two-compartment model described the PK data best. Typical values for clearance were estimated separately for each study period, indicating 40% and 29% reductions during P1 and P2, respectively, compared to P3. The central volume of distribution was estimated separately for P2, indicating a 64% increase compared to P1 and P3.

CONCLUSION

CYP2C19-dependent drug metabolism is downregulated during TTM following cardiac arrest. These results may influence drug choice and dosing of similarly metabolized drugs and may be helpful for designing studies in similar clinical situations.

CA1 Hippocampal Pyramidal Cells in Rats, Resuscitated From 8 Minutes of Ventricular Fibrillation Cardiac Arrest, Recover After 20 Weeks of Survival: A Retrospective Pilot Study

PURPOSE

The cornu ammonis 1 (CA1) region of the hippocampus is specifically vulnerable to global ischemia. We hypothesized that histopathological outcome in a ventricular fibrillation cardiac arrest (VFCA) rat model depends on the time point of the examination.

METHODS

Male Sprague-Dawley rats were put into VFCA for 8 min, received chest compressions for 2 min, and were defibrillated to achieve return of spontaneous circulation. Animals surviving for 80 min, 14 days and 140 days were compared with controls. Viable neurons were counted in a 500 μm sector of the CA1 region and layer thickness measured. Microglia cells and astrocytes were counted in a 250×300 μm aspect.

RESULTS

Control and 80 min surviving animals had similar numbers of pyramidal neurons in the CA1 region. In 14 days and 140 days survivors neuron numbers and layer thickness were severely diminished compared with controls (P < 0.001). Two-thirds of the 140 days survivors showed significantly more viable neurons than the last third. Microglia was increased in 14 days survivors compared with controls and 140 days survivors, while astrocytes increased in 14 days and 140 days survivors compared with controls (P < 0.001). 140 days survivors had significantly higher astrocyte counts compared with 14 days survivors.

CONCLUSIONS

The amount and type of brain lesions present after global ischemia depend on the survival time. A consistent reduction in pyramidal cells in the CA1 region was present in all animals 14 days after VFCA, but in two-thirds of animals a repopulation of pyramidal cells seems to have taken place after 140 days.

Coronary angiography in patients after cardiac arrest without ST-elevation myocardial infarction : A retrospective cohort analysis

BACKGROUND

Coronary artery disease (CAD) is the most common cause of sudden cardiac arrest (SCA). Although coronary angiography (CAG) should be performed also in the absence of ST-elevation (STE) after sustained return of spontaneous circulation (ROSC), this recommendation is not well implemented in daily routine.

METHODS

A retrospective database analysis was conducted in a tertiary care center between January 2005 and December 2014. We included all SCA patients aged ≥ 18 years with presumed cardiac cause and sustained ROSC in the absence of STE at hospital admission. The rate and timing of CAG were defined as the primary endpoints. As secondary endpoints, the reasons pro and contra CAG were analyzed. Furthermore, we observed if the signs and symptoms used for decision making occurred more often in patients with treatable CAD.

RESULTS

We included 645 (53.6%) of the 1203 screened patients, CAG was performed in 343 (53.2%) patients with a diagnosis of occlusive CAD in 214 (62.4%) patients. Of these, 151 (71.0%) patients had occlusive CAD treated with coronary intervention, thrombus aspiration, or coronary artery bypass grafting. In an adjusted binomial logistic regression analysis, age ≥ 70 years, female sex, non-shockable rhythms, and cardiomyopathy were associated with withholding of CAG. In patients diagnosed and treated with occlusive CAD, initially shockable rhythms, previously diagnosed CAD, hypertension, and smoking were found more often.

CONCLUSION

Although selection bias is unavoidable due to the retrospective design of this study, a high proportion of the examined patients had occlusive CAD. The criteria used for patient selection may be suboptimal.

Change of Hemoglobin Levels in the Early Post-cardiac Arrest Phase Is Associated With Outcome

Background: The post-cardiac arrest (CA) phase is characterized by high fluid requirements, endothelial activation and increased vascular permeability. Erythrocytes are large cells and may not leave circulation despite massive capillary leak. We hypothesized that dynamic changes in hemoglobin concentrations may reflect the degree of vascular permeability and may be associated with neurologic function after CA.

Methods: We included patients ≥18 years, who suffered a non-traumatic CA between 2013 and 2018 from the prospective Vienna Clinical Cardiac Arrest Registry. Patients without return of spontaneous circulation (ROSC), with extracorporeal life support, with any form of bleeding, undergoing surgery, receiving transfusions, without targeted temperature management or with incomplete datasets for multivariable analysis were excluded. The primary outcome was neurologic function at day 30 assessed by the Cerebral Performance Category scale. Differences of hemoglobin concentrations at admission and 12 h after ROSC were calculated and associations with neurologic function were investigated by uni- and multivariable logistic regression.

Results: Two hundred and seventy-five patients were eligible for analysis of which 143 (52%) had poor neurologic function. For every g/dl increase in hemoglobin from admission to 12 h the odds of poor neurologic function increased by 26% (crude OR 1.26, 1.07–1.49, p = 0.006). The effect remained unchanged after adjustment for fluid balance and traditional prognostication markers (adjusted OR 1.27, 1.05–1.54, p = 0.014).

Conclusion: Increasing hemoglobin levels in spite of a positive fluid balance may serve as a surrogate parameter of vascular permeability and are associated with poor neurologic function in the early post-cardiac arrest period.

Management of EMS on-scene time during advanced life support in out-of-hospital cardiac arrest: a retrospective observational trial

Objective

Most western emergency medical services provide advanced life support in out-of-hospital cardiac arrest aiming for a return of spontaneous circulation at the scene. Little attention is given to prehospital time management in the case of out-of-hospital cardiac arrest with regard to early coronary angiography or to the start of extracorporeal cardiopulmonary resuscitation treatment within 60 minutes after out-of-hospital cardiac arrest onset. We investigated the emergency medical services on-scene time, defined as emergency medical services arrival at the scene until departure to the hospital, and its association with 30-day survival with favourable neurological outcome after out-of-hospital cardiac arrest.

Methods

All patients of over 18 years of age with non-traumatic, non-emergency medical services witnessed out-of-hospital cardiac arrest between July 2013 and August 2015 from the Vienna Cardiac Arrest Registry were included in this retrospective observational study.

Results

Out of 2149 out-of-hospital cardiac arrest patients, a total of 1687 (79%) patients were eligible for analyses. These patients were stratified into groups according to the on-scene time (&lt;35 minutes, 35–45 minutes, 45–60 minutes, &gt;60 minutes). Within short on-scene time groups, out-of-hospital cardiac arrest occurred more often in public and bystander cardiopulmonary resuscitation was more common (both P&lt;0.001). Patients who did not achieve return of spontaneous circulation at the scene showed higher rates of 30-day survival with favourable neurological outcome with an on-scene time of less than 35 minutes (adjusted odds ratio 5.00, 95% confidence interval 1.39–17.96).

Conclusion

An emergency medical services on-scene time of less than 35 minutes was associated with higher rates of survival and favourable outcomes. It seems to be reasonable to develop time optimised advance life support protocols to minimise the on-scene time in view of further treatments such as early coronary angiography as part of post-resuscitation care or extracorporeal cardiopulmonary resuscitation in refractory out-of-hospital cardiac arrest.

Predictive model of return of spontaneous circulation among patients with out-of-hospital cardiac arrest in Thailand: The WATCH-CPR Score

BACKGROUND

Out-of-hospital cardiac arrest is an emergency that requires immediate management to save lives. However, some predictive scores for the immediate outcomes of patients with out-of-hospital cardiac arrest are difficult to use in clinical practice.

AIMS

This study aimed to identify predictors of sustained return of spontaneous circulation and to develop a predictive score.

METHODS

This prospective observational study evaluated sustained return of spontaneous circulation among out-of-hospital cardiac arrest patients in a Thai emergency department between July 2014 and March 2018. The baseline characteristics and prehospital and hospital findings were analysed.

RESULTS

Of 347 patients, 126 (36.3%) had sustained return of spontaneous circulation and 20 (5.8%) were discharged. Witnessed arrest (odds ratio = 2.9, 95% confidence interval 1.3-6.2), time from arrest to chest compression <15 min (odds ratio = 3.0, 95% confidence interval 1.3-7.0) and chest compression duration <30 min (odds ratio = 15.6, 95% confidence interval 8.7-28.0) predicted sustained return of spontaneous circulation; these were developed into the WATCH-CPR (Witnessed Arrest, Time from arrest to CHest compression-CPR duration) score. A score of ≥2 was optimal for predicting sustained return of spontaneous circulation, which provided an area under the receiver operating characteristic of 0.775 (95% confidence interval 0.724-0.825) and a sensitivity of 72.2% (95% confidence interval 63.4-79.6%) and specificity of 76.0% (95% confidence interval 69.8-81.4%).

CONCLUSIONS

The factors including witnessed arrest, time from arrest to chest compression and chest compression duration were developed as the WATCH-CPR score for predicting sustained return of spontaneous circulation among patients with out-of-hospital cardiac arrest.

Recruiting Medical Students for a First Responder Project in the Social Age: Direct Contact Still Outperforms Social Media

Introduction

Efficient recruitment of first responders (FRs) is crucial for long-term success of any FR project. FRs are laypersons who are trained in cardiopulmonary resuscitation (CPR), medical professionals, and firemen, police officers, and other professions with a duty of help. As social media are widely used for rapid communication, we carried out a prospective observational study to test the hypothesis that recruitment of FRs via social media is more efficient than recruitment via direct face-to-face contact.

Methods

Following ethics committee agreement, we informed 600 medical students about becoming FRs when they attended a didactic lecture about the FR project or during their mandatory CPR-course. Furthermore, recruitment was opened to medical students through Facebook, which accessed ∼1,000 medical students to see if they expressed interest in becoming FRs. All of the recruited students successfully completed the FR training. We then used an online questionnaire to ask these students how they had been recruited.

Results

Out of 63 registered student FRs, 59 responded to the online questionnaire. Overall, 15.3% of these FR students were recruited via social media. The majority (78.0%) were recruited through direct contact.

Conclusions

Despite widespread use of social media, over three-quarters of these medical students were recruited to the FR project via direct personal contact. This suggests that the advantage of a larger reachable population using social media does not outweigh the impact of personal contact with experts.

Factors associated with return of spontaneous circulation after out-of-hospital cardiac arrest in Poland: a one-year retrospective study

Background

Out-of-hospital cardiac arrest (OHCA) is a common reason for calls for intervention by emergency medical teams (EMTs) in Poland. Regardless of the mechanism, OHCA is a state in which the chance of survival is dependent on rapid action from bystanders and responding health professionals in emergency medical services (EMS). We aimed to identify factors associated with return of spontaneous circulation (ROSC).

Methods

The medical records of 2137 EMS responses to OHCA in the city of Wroclaw, Poland between July 2017 and June 2018 were analyzed.

Results

The OHCA incidence rate for the year studied was 102 cases per 100,000 inhabitants. EMS were called to 2317 OHCA events of which 1167 (50.4%) did not have resuscitation attempted on EMS arrival. The difference between the number of successful and failed cardiopulmonary resuscitations (CPRs) was statistically significant (p < 0.001). Of 1150 patients in whom resuscitation was attempted, ROSC was achieved in 250 (27.8%). Rate of ROSC was significantly higher when CPR was initiated by bystanders (p < 0.001). Patients presenting with asystole or pulseless electrical activity (PEA) had a higher risk of CPR failure (86%) than those with ventricular fibrillation/ventricular tachycardia (VF/VT). Patients with VF/VT had a higher chance of ROSC (OR 2.68, 1.86–3.85) than those with asystole (p < 0.001). The chance of ROSC was 1.78 times higher when the event occurred in a public place (p < 0.001).

Conclusions

The factors associated with ROSC were occurrence in a public place, CPR initiation by witnesses, and presence of a shockable rhythm. Gender, age, and the type of EMT did not influence ROSC. Low bystander CPR rates reinforce the need for further efforts to train the public in CPR.

The impact of a high-quality basic life support police-based first responder system on outcome after out-of-hospital cardiac arrest

BACKGROUND

Laypersons' efforts to initiate basic life support (BLS) in witnessed Out-of-Hospital Cardiac Arrest (OHCA) remain comparably low within western society. Therefore, in order to shorten no-flow times in cardiac arrest, several police-based first responder systems equipped with automated external defibrillators (Pol-AED) were established in urban areas, which subsequently allow early BLS and AED administration by police officers. However, data on the quality of BLS and AED use in such a system and its impact on patient outcome remain scarce and inconclusive.

METHODS

A total of 85 Pol-AED cases were randomly assigned to a gender, age and first rhythm matched non-Pol-AED control group (n = 170) in a 1:2 ratio. Data on quality of BLS were extracted via trans-thoracic impedance tracings of used AED devices.

RESULTS

Comparing Pol-AED cases and the control group, we observed a similar compression rate per minute (p = 0.677) and compression ratio (p = 0.651), mirroring an overall high quality of BLS administered by police officers. Time to the first shock was significantly shorter in Pol-AED cases (6 minutes [IQR: 2-10] vs. 12 minutes [IQR: 8-17]; p<0.001). While Pol-AED was not associated with increased sustained return of spontaneous circulation (p = 0.564), a strong and independent impact on survival until hospital discharge (adj. OR: 1.85 [95%CI: 1.06-3.23; p = 0.030]) and a borderline significance for the association with favorable neurological outcome (adj. OR: 1.58 [95%CI: 0.96-2.89; p = 0.052) were observed.

CONCLUSION

We were able to demonstrate an early start and a high quality of BLS and AED use in Pol-AED assessed OHCA cases. Moreover, the presence of Pol-AED care was associated with better patient survival and borderline significance for favorable neurological outcome.

Establishing a Rodent Model of Ventricular Fibrillation Cardiac Arrest With Graded Histologic and Neurologic Damage With Different Cardiac Arrest Durations

Purpose:

The aim of the study was to establish a ventricular fibrillation (VF) cardiac arrest (CA) resuscitation model with consistent neurologic and neuropathologic damage as potential therapeutic target.

Methods:

Prospectively randomized groups of experiments in two phases. In phase 1 four groups of male Sprague–Dawley rats (n = 5) were resuscitated after 6 min VFCA with 2 and 6 min basic life support durations (BLS) with and without adrenaline. In phase 2 the most promising group regarding return of spontaneous circulation (ROSC) and survival was compared with a group of 8 min CA. Resuscitability, neurologic deficit scores (NDS), and overall performance category (OPC) were assessed daily; histolopathology of the hippocampal CA1 region [hematoxylin and eosin- (viable neurons), Fluoro-Jade- (dying neurons), and Iba-1 immunostaining (microglial activation–semiquantitative)] on day 14.

Results:

Two minutes BLS and with adrenaline as most promising group of phase 1 compared with an 8 min group in phase 2 exhibited ROSC in 8 (80%) vs. 9 (82%) animals and survivors till day 14 in 7 (88%) (all OPC 1, NDS 0 ± 0) vs. 6 (67%) (5 OPC 1, 1 OPC 2, NDS 0.83 ± 2.4) animals. OPC and NDS were only significantly different at day 1 (OPC: P = 0.035; NDS: P = 0.003). Histopathologic results between groups were not significantly different; however, a smaller variance of extent of lesions was found in the 8 min group. Both CA durations caused graded neurologic, overall, such as histopathologic damage.

Conclusions:

This dynamic global ischemia model offers the possibility to evaluate further cognitive and novel neuroprotective therapy testing after CA.

The Effect of Ambulance Response Time on Survival Following Out-of-Hospital Cardiac Arrest

BACKGROUND

Out of hospital cardiac arrest (OHCA) is one of the more common causes of death in Germany. Ambulance response time is an important planning parameter for emergency medical services (EMS) systems. We studied the effect of ambulance response time on survival after resuscitation from OHCA.

METHODS

We analyzed data from the German Resuscitation Registry for the years 2010-2016. First, we used a multivariate logistic regression analysis to determine the effect of ambulance response time (defined as the interval from the alarm to the arrival of the first rescue vehicle) on the hospital-discharge rate (in percent), depending on various factors, including resuscitation by bystanders. Second, we compared faster and slower EMS systems (defined as those arriving on the scene within 8 minutes in more than 75% of cases or in ≤ 75% of cases) with respect to the frequency of resuscitation and the number of surviving patients.

RESULTS

Our analysis of data from a total of 10 853 patients in the logistical regression model revealed that the rate of hospital discharge was significantly affected by the ambulance response time, bystander resuscitation, past medical history, age, witnessed vs. unwitnessed collapse, the initial heart rhythm, and the site of the collapse. The success of resuscitation was inversely related to the ambulance response time; thus, among patients who did not receive bystander resuscitation, the discharge rate declined from 12.9% at a mean response time of 1 minute and 10 seconds to 6.4% at a mean response time of 9 minutes and 47 seconds. Twelve faster EMS systems and 13 slower ones were identified, with a total of 9669 and 7865 resuscitated patients, respectively. The faster EMS systems initiated resuscitation more frequently and also had a higher discharge rate with good neurological outcome in proportion to the population of the catchment area (7.7 versus 5.6 persons per 100 000 population per year, odds ratio [OR] 0.72, 95% confidence interval [0.66; 0.79], p<0.001).

CONCLUSION

Rapid ambulance response is associated with a higher rate of survival from OHCA with good neurological outcome. The response time, independently of whether bystander resuscitation measures are provided, ha^ a significant independent effect on the survival rate. In drawing conclusions from these findings, one should bear in mind that this was a retrospective registry study, with the corresponding limitations.

Hypoxic liver injury after in- and out-of-hospital cardiac arrest: Risk factors and neurological outcome

BACKGROUND

Hypoxic liver injury (HLI) is a frequent and life-threatening complication in critically ill patients that occurs in up to ten percent of critically ill patients. However, there is a lack of data on HLI following cardiac arrest and its clinical implications on outcome. Aim of this study was to investigate incidence, outcome and functional outcome of patients with HLI after in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA).

METHODS

We conducted an analysis of a cardiac arrest registry data over a 7-year period. All patients with non-traumatic OHCA and IHCA with return of spontaneous circulation (ROSC) treated at the emergency department of a tertiary care hospital were included in the study. HLI was defined according to established criteria. Predictors of HLI, occurrence, clinical and neurological outcome were assessed using multivariable regression.

RESULTS

Out of 1068 patients after IHCA and OHCA with ROSC, 219 (21%) patients developed HLI. Rate of HLI did not differ significantly in IHCA and OHCA patients. Multivariate regression analysis identified time-to-ROSC [OR 1.18, 95% CI (1.01-1.38); p < 0.05], presence of cardiac failure [OR 2.57, 95% CI (1.65-4.01); p < 0.001] and Charlson comorbidity index [OR 0.83, 95% CI (0.72-0.95); p < 0.01] as independent predictors for occurrence of HLI. Good functional outcome was significantly lower in patients suffering from HLI after 28-days (35% vs. 48%, p < 0.001) and 1-year (34% vs. 44%, p < 0.001). Occurrence of HLI was associated with unfavourable neurological outcome [OR 1.74, 95% CI (1.16-2.61); p < 0.01] in multivariate regression analysis.

CONCLUSION

New onset of HLI is a frequent finding after IHCA and OHCA. HLI is associated with increased mortality, unfavourable neurological and overall outcome.

The evaluation of laypersons awareness of basic life support at the university in Izmir

Objectives

Basic Life Support (BLS) is the application of cardiopulmonary resuscitation (CPR) in order to save the lives of cardiac arrest victims by members of the public pending the arrival of the Emergency Medical Service (EMS). The aim of this study was to evaluate the effectiveness of training in order to ensure society understands the importance of early initiation of BLS, and to provide information concerning BLS and automated external defibrillators (AED).

Methods

This study consisted of 150 participants, of whom none were healthcare professionals. The research data were collected from 150 pre-tests and 100 post-tests. A Comparison of nominal data was analyzed by both McNemar's test and Pearson's chi-square exact test.

Results

Of the participants, 39% had received the BLS training prior to the study. It was observed that the participants' desire for applying BLS increased from 43% to 78% post training, and the ratio of ability to distinguish the need for BLS increased from 54% to 79%. Our results also indicated that the knowledge level of the CPR application increased after the study. The proportion of participants who knew the purpose of using AED increased from 79.8% to 95.7%.

Conclusions

It was concluded that the BLS Awareness training increased in relation to the application of BLS, improved the BLS knowledge and increased awareness of the use of AED.

A five-year retrospective study of out-of-hospital cardiac arrest in a north-east Italian urban area

BACKGROUND

The reporting and analysing of data of out-of-hospital cardiac arrests encourages the quality improvement of the emergency medical services. For this reason, the establishment of a sufficiently large patient database is intended to allow analysis of resuscitation treatments for out-of-hospital cardiac arrests and performances of different emergency medical services.

AIMS

The aim of this study was to describe the demographics, characteristics, outcomes and determinant factors of survival for patients who suffered an out-of-hospital cardiac arrest.

METHODS

this was a retrospective study including all out-of-hospital cardiac arrest cases treated by the emergency medical service in the district of Udine (Italy) from 1 January 2010-31 December 2014.

RESULTS

A total of 1105 out-of-hospital cardiac arrest patients were attended by the emergency medical service. Of these, 489 (44.2%) underwent cardiopulmonary resuscitation, and return of spontaneous circulation was achieved in 142 patients (29%). There was a male predominance overall, and the main age was 72.6 years (standard deviation 17.9). Cardiopulmonary resuscitation before emergency medical service arrival was performed on 62 cases (44%) in the return of spontaneous circulation group, and on 115 cases (33%) in the no return of spontaneous circulation group ( p<0.024). Among the 142 cases of return of spontaneous circulation, 29 (5.9%) survived to hospital discharge. There was a smaller likelihood of return of spontaneous circulation when patients were female (odds ratio 0.61, 0.40-0.93). Patients who had an out-of-hospital cardiac arrest with an initial shockable rhythm (odds ratio 6.33, 3.86-10.39) or an age <60 years (odds ratio 2.91, 1.86-4.57) had a greater likelihood of return of spontaneous circulation. In addition, bystander cardiopulmonary resuscitation (odds ratio 1.56, 1.04-2.33) was associated with an increased chance of return of spontaneous circulation.

CONCLUSION

The incidence of out-of-hospital cardiac arrest and survival rate lies within the known range. A wider database is necessary to achieve a better knowledge of out-of-hospital cardiac arrest and to drive future investments in the healthcare system.

Gender and age-specific aspects of awareness and knowledge in basic life support

Background

The ‘chain of survival’—including early call for help, early cardiopulmonary resuscitation (CPR) and early defibrillation—represents the most beneficial approach for favourable patient outcome after out-of-hospital cardiac arrest (OHCA). Despite increasing numbers of publicly accessible automated external defibrillators (AED) and interventions to increase public awareness for basic life support (BLS), the number of their use in real-life emergency situations remains low.

Methods

In this prospective population-based cross-sectional study, a total of 501 registered inhabitants of Vienna (Austria) were randomly approached via telephone calls between 08/2014 and 09/2014 and invited to answer a standardized questionnaire in order to identify public knowledge and awareness of BLS and AED-use.

Results

We found that more than 52 percent of participants would presume OHCA correctly and would properly initiate BLS attempts. Of alarming importance, only 33 percent reported that they would be willing to perform CPR and 50 percent would use an AED device. There was a significantly lower willingness to initiate BLS attempts (male: 40% vs. female: 25%; OR: 2.03 [95%CI: 1.39–2.98]; p<0.001) and to use an AED device (male: 58% vs. female: 44%; OR: 1.76 [95%CI: 1.26–2.53]; p = 0.002) in questioned female individuals compared to their male counterparts. Interestingly, we observed a strongly decreasing level of knowledge and willingness for BLS attempts (-14%; OR: 0.72 [95%CI: 0.57–0.92]; p = 0.027) and AED-use (-19%; OR: 0.68 [95%CI: 0.54–0.85]; p = 0.001) with increasing age.

Conclusion

We found an overall poor knowledge and awareness concerning BLS and the use of AEDs among the Viennese population. Both female and elderly participants reported the lowest willingness to perform BLS and use an AED in case of OHCA. Specially tailored programs to increase awareness and willingness among both the female and elderly community need to be considered for future educational interventions.

Epidemiology of out-of-hospital cardiac arrest: A French national incidence and mid-term survival rate study

Out-of-hospital cardiac arrest (OHCA) is considered an important public health issue but its incidence has not been examined in France. The aim of this study is to define the incidence of OHCA in France and to compare this to other neighbouring countries. Data were extracted from the French OHCA registry. Only exhaustive centres during the period from January 1, 2013, to September 30, 2014 were included. All patients were included, regardless of their age and cause of OHCA. The participating centres covered about 10% of the French population. The study involved 6918 OHCA. The median age was 68 years, with 63% of males. Paediatric population (<15years) represented 1.8%. The global incidence of OHCA was 61.5 per 100,000 inhabitants per year in the total population corresponding to approximately 46,000 OHCA per year. In the adult population, we found an incidence of 75.3 cases per 100,000 inhabitants per year. In adults, the incidences were 100.3 and 52.7 in males and females, respectively. Most (75%) OHCA occurred at home and were due to medical causes (88%). Half of medical OHCA had cardiovascular causes. Survival rates at 30 days was 4.9% [4.4; 5.4] and increased to 10.4% [9.1; 11.7] when resuscitation was immediately performed by bystander at patient's collapse. The incidence and survival at 30 days of OHCA in France appeared similar to that reported in other European countries. Compared to other causes of deaths in France, OHCA is one of the most frequent causes, regardless of the initial pathology.

Initial electrical frequency predicts survival and neurological outcome in out of hospital cardiac arrest patients with pulseless electrical activity

BACKGROUND

Outcome is generally poor in out of hospital cardiac arrests (OHCA) with initial non-shockable rhythms. Termination of resuscitation rules facilitate early prognostication at the scene to cease resuscitation attempts in futile situations and to proceed advanced life support in promising conditions. As pulseless electrical activity (PEA) is present as first rhythm in every 4th OHCA we were interested if the initial electrical frequency in PEA predicts survival.

METHODS

All patients >18 years of age with non-traumatic OHCA and PEA as first rhythm between August 2013 and August 2015 from the Vienna Cardiac Arrest Registry were included in this retrospective observational study. Defibrillator and epidemiological data from the emergency medical system as survival data were processed considering the initial electrical activity in PEA and 30 days survival.

RESULTS

Out of 2149 OHCA patients, a total of 504 PEA patients were eligible for analyses. These patients were stratified into 4 groups according the initial electrical frequency in PEA: 10-24/min, 25-39/min, 40-59/min, >60/min. Compared to a frequency >60/min all other subgroups were associated with higher mortality especially those with an initial electrical frequency 10-24 (adjusted OR 0.56 (0.39-0.79) p = .001 for each category chance). QRS duration in PEA did not influence outcome. Patients in the >60/min group showed a 30-days-survival rate of 22% and a good neurological outcome in 15% of all patients - comparable to shockable cardiac arrest rhythms.

CONCLUSION

Regardless of other resuscitation factors, higher initial electrical frequency in PEA is associated with increased odds of survival and good neurological outcome.

Regional cerebral oxygen saturation during cardiopulmonary resuscitation as a predictor of return of spontaneous circulation and favourable neurological outcome - A review of the current literature

INTRODUCTION

Regional cerebral oxygen saturation (rSO2) can be measured non-invasively even at no- or low-flow states. It thus allows assessment of brain oxygenation during CPR. Certain rSO2 values had been associated with return of spontaneous circulation (ROSC) and neurological outcome in the past. Clear-cut thresholds for the prediction of beneficial outcome, however, are still lacking.

METHODS

We conducted a database search to extract all available investigations on rSO2 measurement during CPR. Mean, median, and ΔrSO2 values were either taken from the studies or calculated. Thresholds for the outcome "ROSC" and "neurological outcome" were sought.

RESULTS

We retrieved 26 publications for the final review. The averaged mean rSO2 for patients achieving ROSC was 41 ± 12% vs. 30 ± 12% for non-ROSC (p = .009). ROSC was not observed when mean rSO2 remained <26%. In ROSC patients, ΔrSO2 was 22 ± 16% vs. 7 ± 10% in non-ROSC patients (p = .009). A rSO2 threshold of 36% predicted ROSC with a sensitivity of 67% and specificity of 69% while ΔrSO2 of 7% showed a sensitivity of 100% and a specificity of 86% (AUC = 0.733 and 0.893, respectively). Mean rSO2 of 47 ± 11% was associated with favourable and 38 ± 12% with poor neurological outcome. There was, however, a great overlap between groups due to scarce data.

CONCLUSION

Higher rSO2 consistently correlated with increased rates of ROSC. The discriminatory power of rSO2 to prognosticate favourable neurological outcome remains unclear. Measuring rSO2 during CPR could potentially facilitate clinical decision-making.

New Therapeutic Concepts in Post-Resuscitation Care

After the return of spontaneous circulation (ROSC), as a result of global ischaemia due to cardiac arrest followed by reperfusion, a condition develops called post-cardiac arrest syndrome. It manifests, alongside the pathology that caused the cardiac arrest, as a systemic inflammatory response, including severe cardio-circulatory and neurological dysfunction, leading to a fatal outcome. Th e aim of post-resuscitation care is to reduce the consequences of circulatory arrest, reperfusion, and the inflammatory response of the body on vital organ functions. The basis of post-resuscitation care comprises application of therapeutic hypothermia and early coronary angiography with PCI. However, after the initial enthusiasm, the validity of applying these aggressive methods in all comatose post-cardiac arrest patients was questioned. Currently, instead of therapeutic hypothermia, a strategy of maintaining a targeted body temperature, usually 36 °C, is being applied because there is no clear evidence of benefit for maintaining a lower body temperature in relation to the outcome. Additionally, patients with an obvious cardiac aetiology of cardiac arrest do not undergo early coronarography unless there is a clear indication of coronary artery occlusion. In the post-resuscitation period, the maintenance of adequate ventilation, maintaining levels of oxygen and carbon dioxide in the normal range, haemodynamic stability, control of blood glucose and electrolytes, and epileptic attack prevention are all strongly recommended measures. Th ere is no evidence to suggest that the application of the so-called neuroprotective agents affects the outcome of cardiac arrest.

Outcome of in- and out-of-hospital cardiac arrest survivors with liver cirrhosis

Background

Organ failure increases mortality in patients with liver cirrhosis. Data about resuscitated cardiac arrest patients with liver cirrhosis are missing. This study aims to assess aetiology, survival and functional outcome in patients after successful cardiopulmonary resuscitation (CPR) with and without liver cirrhosis.

Methods

Analysis of prospectively collected cardiac arrest registry data of consecutively hospital-admitted patients following successful CPR was performed. Patient’s characteristics, admission diagnosis, severity of disease, course of disease, short- and long-term mortality as well as functional outcome were assessed and compared between patients with and without cirrhosis.

Results

Out of 1068 patients with successful CPR, 47 (4%) had liver cirrhosis. Acute-on-chronic liver failure (ACLF) was present in 33 (70%) of these patients on admission, and four patients developed ACLF during follow-up. Mortality at 1 year was more than threefold increased in patients with liver cirrhosis (OR 3.25; 95% CI 1.33–7.96). Liver cirrhosis was associated with impaired neurological outcome (OR for a favourable cerebral performance category: 0.13; 95% CI 0.04–0.36). None of the patients with Child–Turcotte–Pugh (CTP) C cirrhosis survived 28 days with good neurological outcome. Overall nine (19%) patients with cirrhosis survived 28 days with good neurological outcome. All patients with ACLF grade 3 died within 28 days.

Conclusion

Cardiac arrest survivors with cirrhosis have worse outcome than those without. Although one quarter of patients with liver cirrhosis survived longer than 28 days after successful CPR, patients with CTP C as well as advanced ACLF did not survive 28 days with good neurological outcome.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-017-0322-1) contains supplementary material, which is available to authorized users.

Continuous versus intermittent neuromuscular blockade in patients during targeted temperature management after resuscitation from cardiac arrest-A randomized, double blinded, double dummy, clinical trial

AIM OF THE STUDY

Current guidelines recommend targeted temperature management to improve neurological outcome after cardiac arrest. Evidence regarding an ideal sedative/analgesic regimen including skeletal muscle paralysis is limited.

METHODS

Patients were randomized to either a continuous administration of rocuronium (continuous-NMB-group) or to a continuous administration of saline supplemented by rocuronium bolus administration if demanded (bolus-NMB-group). The primary outcome was the number of shivering episodes. Secondary outcomes included survival and neurological status one year after cardiac arrest, time to awakening, length of stay as well as required cumulative dose of rocuronium, midazolam and fentanyl.

RESULTS

Sixty-three patients (32 continuous-NMB-group; 31 bolus-NMB-group) were enrolled. Differences in baseline characteristics were not significant. Shivering episodes were detected in 94% of the patients in the bolus-NMB-group compared to 25% of the patients receiving continuous rocuronium infusion (p<0.01). The continuous-NMB-group received significant lower doses of midazolam (4.3±0.8mg/kg vs. 5.1±0.9mg/kg, p<0.01) and fentanyl (62±14μg/kg vs. 71±7μg/kg, p<0.01), but higher cumulative doses of rocuronium (7.8±1.8mg/kg vs. 2.3±1.6mg/kg, p<0.01). Earlier awakening (2 [IQR 2;3] vs. 4 [IQR 2;7.5] days, p=0.04) and decreased length of stay at the ICU (6 [IQR 3;5.9] vs. 10 [IQR 5;15] days, p=0.03) were observed in the continuous-NMB-group. There were no significant differences in survival and quality of life 12 months after cardiac arrest.

CONCLUSIONS

Continuous neuromuscular blockade during the first day after resuscitation reduced shivering, midazolam and fentanyl requirement, time to awakening and discharge from intensive care unit. There were no differences in overall survival, cooling rate and time to target temperature.

Non-occlusive mesenteric ischaemia in out of hospital cardiac arrest survivors

BACKGROUND AND AIM OF THE STUDY

Non-occlusive mesenteric ischaemia (NOMI) is characterised by hypoperfusion of the intestines without evidence of mechanical obstruction, potentially leading to extensive ischaemia and necrosis. Low cardiac output appears to be a major risk factor. Cardiopulmonary resuscitation aims at restoring blood flow after cardiac arrest. However, post restoration of spontaneous circulation, myocardial stunning limits immediate recovery of sufficient cardiac function. Since after successful cardiopulmonary resuscitation patients are often ventilated and sedated, NOMI might be underdiagnosed and potentially life-saving treatment delayed.

MATERIAL AND METHODS

A prospectively maintained multi-purpose cohort of out of hospital cardiac arrest survivors, who had successful restoration of spontaneous circulation, was used for this retrospective database analysis. Patients' charts were screened for clinical, radiological or pathological evidence of NOMI and clinical data were collected.

RESULTS

Between 2000 and 2014, 1780 patients who were successfully resuscitated after out of hospital cardiac arrest were screened for NOMI. Twelve patients (0.68 %) suffered from NOMI and six of those died (50 %). Patients suffering from NOMI tended to have a longer duration until restoration of spontaneous circulation (27 vs. 20 min, p=0.128) and had significantly higher lactate (14 mmol/l vs. 8 mmol/l, p=0.002) and base deficit levels at admission (-17 vs. -10, p=0.012). Median leukocyte counts in NOMI patients peaked at the day of diagnosis.

CONCLUSION

NOMI is a rare but life-threatening and potentially curable complication following successful cardiopulmonary resuscitation. Lactate and base deficit at admission could help to identify patients at risk for developing NOMI who might benefit from increased clinical attention.

Echocardiography for patients undergoing extracorporeal cardiopulmonary resuscitation: a primer for intensive care physicians

Echocardiography is an invaluable tool in the management of patients with extracorporeal cardiopulmonary resuscitation (ECPR) and subsequent extracorporeal membrane oxygenation (ECMO) support and weaning. At the very beginning, echocardiography can identify the etiology of cardiac arrest, such as massive pulmonary embolism and cardiac tamponade. Eliminating these culprits saves life and may avoid the initiation of extracorporeal cardiopulmonary resuscitation. If the underlying causes are not identified or intrinsic to the heart (e.g., such as those caused by cardiomyopathy and myocarditis), conventional cardiopulmonary resuscitation (CCPR) will continue to maintain cardiac output. The quality of CCPR can be monitored, and if cardiac output cannot be maintained, early institution of extracorporeal cardiopulmonary resuscitation may be reasonable. Cannulation is sometimes challenging for extracorporeal cardiopulmonary resuscitation patients. Fortunately, with the help of ultrasonography procedures including localization of vessels, selecting a cannula of appropriate size and confirmation of catheter tip may become easy under sophisticated hand. Monitoring of cardiac function and complications during extracorporeal membrane oxygenation support can be done with echocardiography. However, the cardiac parameters should be interpreted with understanding of hemodynamic configuration of extracorporeal membrane oxygenation. Thrombus and blood stasis can be identified with ultrasound, which may prompt mechanical and pharmacological interventions. The final step is extracorporeal membrane oxygenation weaning. A number of studies investigated the accuracy of some echocardiographic parameters in predicting success rate and demonstrated promising results. Parameters and threshold for successful weaning include aortic VTI ≥ 10 cm, LVEF > 20-25%, and lateral mitral annulus peak systolic velocity >6 cm/s. However, the effectiveness of echocardiography in ECPR patients cannot be determined in observational studies and requires randomized controlled trials in the future. The contents in this review are well known to echocardiography specialists; thus, it should be used as an educational material for emergency or intensive care physicians. There is a trend that focused echocardiography is performed by intensivists and emergency physicians.

Neurology of cardiopulmonary resuscitation

This chapter aims to provide an up-to-date review of the science and clinical practice pertaining to neurologic injury after successful cardiopulmonary resuscitation. The past two decades have seen a major shift in the science and practice of cardiopulmonary resuscitation, with a major emphasis on postresuscitation neurologic care. This chapter provides a nuanced and thoughtful historic and bench-to-bedside overview of the neurologic aspects of cardiopulmonary resuscitation. A particular emphasis is made on the anatomy and pathophysiology of hypoxic-ischemic encephalopathy, up-to-date management of survivors of cardiopulmonary resuscitation, and a careful discussion on neurologic outcome prediction. Guidance to practice evidence-based clinical care when able and thoughtful, pragmatic suggestions for care where evidence is lacking are also provided. This chapter serves as both a useful clinical guide and an updated, thorough, and state-of-the-art reference on the topic for advanced students and experienced practitioners in the field.

A comparison between intravascular and traditional cooling for inducing and maintaining temperature control in patients following cardiac arrest

Therapeutic temperature control has been widely used during the last decade to improve clinical outcomes. We conducted this retrospective observational study to compare traditional cooling with endovascular cooling in post-cardiac arrest comatose survivors and to compare results with current guidelines.

PATIENTS AND METHODS

All patients admitted to our ICU for cardiac arrest and for whom temperature control was performed were included. Traditional cooling included cold infusions, ice packs and cooling blankets. Endovascular cooling consisted in the insertion of a catheter in which cold fluid circulates in a closed circuit provided by a heat exchanger. Temperature control was started at a target temperature of 32°C to 34°C. Rewarming was performed passively in the traditional group and via computer-assistance in endovascular group. We evaluated the delay prior to and speed of cooling, thermic stability during the maintenance phase and the speed of rewarming.

RESULTS

Thirty-four patients were included. The speed of cooling was faster with the endovascular (-0.66±0.35°C/h) compared to the traditional (-0.35±0.38°C/h, P=0.006) technique, with target temperatures reached in 4.0 and 6.0h, respectively (P=0.14). Temperatures were more stable with the endovascular technique (0.03±0.05°C2) than with the traditional technique (0.26±0.16°C2, P<10^-4). There were more deviations from the guideline target range in the traditional group (64.7% versus 17.6%, P=0.008). Rewarming was faster in the traditional group (+0.64±0.33°C/h, versus +0.36±0.12°C/h, P=0.01). No significant difference was found concerning mortality or length of stay in the ICU.

CONCLUSION

Temperature control with a cooling catheter was associated with faster cooling, improved thermic stability in the target range, less overcooling or overheating and slower rewarming in comparison with traditional techniques.

Determinants of unfavorable prognosis for out-of-hospital sudden cardiac arrest in Bielsko-Biala district

INTRODUCTION

The prognosis in out-of-hospital sudden cardiac arrest (OHCA) remains unfavorable and depends on a number of demographic and clinical variables, the reversibility of its causes and its mechanisms.

AIM

To investigate the risk factors of prehospital death in patients with OHCA in Bielsko County.

MATERIAL AND METHODS

The study analyzed all dispatch cards of the National Emergency Medical Services (EMS) teams in Bielsko-Biala for the year 2013 (n = 23 400). Only the cards related to sudden cardiac arrest in adults were ultimately included in the study (n = 272; 190 men, 82 women; median age: 71 years).

RESULTS

Sixty-seven victims (45 men, 22 women) were pronounced dead upon the arrival of the EMS team, and cardiopulmonary resuscitation (CPR) was not undertaken. In the remaining group of 205 subjects, CPR was commenced but was ineffective in 141 patients (97 male, 44 female). Although univariate analysis indicated 6 predictors of prehospital death, including OHCA without the presence of witnesses (odds ratio (OR) = 4.2), OHCA occurring in a public place (OR = 3.1), no bystander CPR (OR = 9.7), no bystander cardiac massage (OR = 13.1), initial diagnosis of non-shockable cardiac rhythm (OR = 7.0), and the amount of drugs used for CPR (OR = 0.4), logistic regression confirmed that only the lack of bystander cardiac massage (OR = 6.5) and non-shockable rhythm (OR = 4.6) were independent determinants of prehospital death (area under ROC curve = 0.801).

CONCLUSIONS

Non-shockable rhythm of cardiac arrest and lack of bystander cardiac massage are independent determinants of prehospital death in Bielsko-Biala inhabitants suffering from OHCA.

Cardiopulmonary arrest is the most frequent cause of the unresponsive wakefulness syndrome: A prospective population-based cohort study in Austria

BACKGROUND

The "Unresponsive wakefulness syndrome" (UWS) or previously termed vegetative state is a possible consequence of severe brain damage where individuals just open their eyes but show no conscious behavioural reaction. While head trauma has previously been considered the prevailing cause, clinical experience suggests shows that cardiopulmonary arrest plays an increasingly important role. We therefore attempted to study this hypothesis in a well-defined region of Austria.

METHODS

Prospective population-based cohort study to calculate the incidence and aetiologies of the UWS. All facilities in the state of Styria (n=38), which are involved in the medical care of patients with brain damage, participated. Among the adult population of Styria (n=1010,164) we identified all individuals who developed UWS over a one year period. The diagnosis was based on a formal neurologic evaluation at least 4 weeks after the brain damage and had to be in line with the criteria of the "Multi-society Task Force on Persistent Vegetative State".

RESULTS

We identified 19 individual with UWS which correspond to an annual incidence of 1.88/100,000 people. Male gender predominated (78.9%) and the mean age was 57.8 years (age range 18-78 years). The most frequent cause of UWS was cerebral hypoxia in the wake of cardiopulmonary resuscitation (63%), cerebral bleeding (21%) and brain trauma (16%).

CONCLUSIONS

Cardiopulmonary resuscitation has become the major cause of UWS which leads to an increasing incidence with age. These aspects may become even more prominent with the ageing of our population and need to be considered in the organisation of care.

Where no guideline has gone before: retrospective analysis of resuscitation in the 24th century

AIM OF THE STUDY

Evaluation of the treatment, epidemiology and outcome of cardiac arrest in the television franchise Star Trek.

METHODS

Retrospective cohort study of prospective events. Screening of all episodes of Star Trek: The Next Generation, Star Trek: Deep Space Nine and Star Trek: Voyager for cardiac arrest events. Documentation was performed according to the Utstein guidelines for cardiac arrest documentation. All adult, single person cardiac arrests were included. Patients were excluded if cardiac arrest occurred during mass casualties, if the victims were annihilated by energy weapons or were murdered and nobody besides the assassin could provide first aid. Epidemiological data, treatment and outcome of cardiac arrest victims in the 24th century were studied.

RESULTS

Ninety-six cardiac arrests were included. Twenty-three individuals were female (24%). Cardiac arrest was witnessed in 91 cases (95%), trauma was the leading cause (n = 38; 40%). Resuscitation was initiated in 17 cases (18%) and 12 patients (13%) had return of spontaneous circulation. Favorable neurological outcome and long-term survival was documented in nine patients (9%). Technically diagnosed cardiac arrest was associated with higher rates of favorable neurological outcome and long-term survival. Neurological outcome and survival did not depend on cardiac arrest location.

CONCLUSION

Cardiac arrest remains a critical event in the 24th century. We observed a change of etiology from cardiac toward traumatic origin. Quick access to medical help and new prognostic tools were established to treat cardiac arrest.

Better management of out-of-hospital cardiac arrest increases survival rate and improves neurological outcome in the Swiss Canton Ticino

Aim

To determine the incidence of out-of-hospital cardiac arrest (OHCA) fulfilling Utstein criteria in the Canton Ticino, Switzerland, the survival rate of OHCA patients and their neurological outcome.

Methods and results

All OHCAs treated in Canton Ticino between 1 January 2005 and 31 December 2014 were followed until either death or hospital discharge. The survival and neurological outcome of those OHCA fulfilling Utstein criteria are reported. A total of 3367 OHCAs occurred in the Canton Ticino over a 10-year period. Resuscitation was attempted in 2298 patients; of those 1492 (65%) were of presumed cardiac origin, 454 fulfilling the Utstein comparator criteria. About 69% [95% confidence interval (CI), 66.6–71.4%] of the patients had a bystander-witnessed arrest; a dispatched cardiopulmonary resuscitation (CPR) steadily and significantly increased from 2005 to 2014. Out-of-hospital cardiac arrest occurred prevalently home (67%), in men (71%) of a mean age of 71 ± 13 years. There were no statistically significant differences either in demographic characteristics of OHCA victims over these years or in presenting rhythm. There was a progressive increase in the survival at discharge from 15% in 2005 to 55% in 2014; overall 96% (95% CI, 93.3–99.9%) of the survivors had a good neurological outcome.

Conclusion

The significant increase in Utstein comparator survival rates and improved neurological outcome in OHCA victims in Canton Ticino are the result of an effective OHCA management programme which includes large-scale public education, a coordinated fast EMS response, high density of external defibrillators, and advances in clinical interventions for OHCAs.

Mechanical chest compression does not seem to improve outcome after out-of hospital cardiac arrest. A single center observational trial

AIM

Recently three large post product placement studies, comparing mechanical chest compression (cc) devices to those who received manual cc, found equivalent outcome results for both groups. Thus the question arises whether those results could be replicated using the devices on a daily routine.

METHODS

We prospectively enrolled 948 patients over a 12 months period. Chi-Square test and Mann-Whitney-U test were used to assess differences between "manual" and "mechanical" cc subgroups. Uni- and multivariate Cox regression hazard analysis were used to assess the influence of cc type on survival.

RESULTS

A mechanical cc device was used in 30.1% (n=283) cases. Patients who received mechanical cc had a significantly worse neurological outcome - measured in cerebral performance category (CPC) - than the manual cc group (56.8% vs. 78.6%, p=0.009). Patients receiving mechanical cc were significantly younger, more were male and were more likely to have bystander CPR and an initially shock-able ECG rhythm. There was no difference in the quality of CPR that might explain the worse outcome in mechanical cc patients.

CONCLUSION

Even with high quality CPR in both, manual and mechanical cc groups, outcome in patients who received mechanical cc was significantly worse. The anticipated benefits of a higher compression ratio and a steadier compression depth of a mechanical cc device remain uncertain. In this study selection for mechanical cc was not standardized, and was non-random. This merits further investigation. Further research on how mechanical cc is chosen and used should be considered.

CLINICAL TRIAL REGISTRATION

https://ekmeduniwien.at/core/catalog/2013/ (EK-Nr:1221/2013).

[An urban EMS at the start of a cross-sectoral quality management system: prioritized implementation of the 2010 ERC recommendations and long-term survival after cardiac arrest]

INTRODUCTION

Due to limited resources, the 2010 European Resuscitation Council (ERC) guidelines could not be fully implemented in the Emergency Medical Services (EMS) of Brunswick, Germany. This is why implementation was prioritized according to local conditions. Thus, prehospital therapeutic hypothermia, mechanical chest compression and feedback systems were not established. Clinical data and long-term results were assessed by a QM system and room for improvement was identified.

METHODS

All attempted resuscitations from 2011 until 2014 were recorded and compared against the German Resuscitation Registry. Outcomes of adult patients following non-traumatic cardiac arrest were analyzed by year.

RESULTS

812 resuscitations were attempted (incidence 81.2/100,000 inhabitants/year). In the two years following full implementation since 2013 the discharge rate from hospital was 16.4 %, the discharge rate with a favorable neurologic outcome was 14.1 %, the 1-year survival rate was 14.4 % in 2013. A significant improvement of risk-adjusted ROSC rate during the investigation period was demonstrated. The discharge rates remained unchanged; the increase in the discharge rates paralleled the increase in CPR incidence. EMS response times were remarkably shorter.

CONCLUSION

The implementation of the ERC guidelines chosen appears to be generally safe. Fast EMS response contributed to superior results. All links of the chain of survival showed room for improvement, especially the proportion of lay rescuer CPR and telephone-assisted CPR. The high CPR incidence might indicate room for improvement in prevention. Access to resuscitation care can hardly be evaluated. Age-related access to pre-hospital resuscitation seems to be appropriate.