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Berrigan W, Tao F, Kopcow J, Park AL, Allen I, Tahir P, Reddy A, Bailowitz Z. The Effect of Platelet Dose on Outcomes after Platelet Rich Plasma Injections for Musculoskeletal Conditions: A Systematic Review and Meta-Analysis. Curr Rev Musculoskelet Med 2024:10.1007/s12178-024-09922-x. [PMID: 39331322 DOI: 10.1007/s12178-024-09922-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/23/2024] [Indexed: 09/28/2024]
Abstract
PURPOSE OF REVIEW This study aims to systematically review platelet dosage in platelet rich plasma (PRP) injections for common musculoskeletal conditions. RECENT FINDINGS Notable heterogeneity exists in the literature regarding platelet dosage. Clinical studies indicate that a higher dosage may lead to improved outcomes concerning pain relief, functional improvement, and chondroprotection in knee osteoarthritis (OA). However, the impact of dosing on other musculoskeletal pathologies remains uncertain. Our investigation identifies a potential dose-response relationship between platelet dose and PRP effectiveness for knee OA treatment, pinpointing an optimal threshold of greater than 10 billion platelets for favorable clinical outcomes. Notably, this effect appears more pronounced for functional outcomes than for pain relief. For other conditions, a lower dosage may suffice, although the existing literature lacks clarity on this matter. PRP dosage may significantly influence treatmentoutcomes, particularly in knee OA. Further research is warranted to elucidate optimal dosages for varying conditions.
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Affiliation(s)
- William Berrigan
- Department of Orthopaedic Surgery, University of California, 1500 Owens Street, San Francisco, 94158, USA.
| | - Frances Tao
- Department of Orthopaedic Surgery, University of California, 1500 Owens Street, San Francisco, 94158, USA
- Department of Family & Community Medicine, University of California, San Francisco, USA
| | - Joel Kopcow
- School of Medicine, University of California, San Francisco, USA
| | - Anna L Park
- School of Medicine, University of California, San Francisco, USA
| | - Isabel Allen
- Department of Epidemiology and Biostatistics, University of California, San Francisco, USA
| | - Peggy Tahir
- School of Medicine, University of California, San Francisco, USA
| | | | - Zachary Bailowitz
- Department of Orthopaedic Surgery, University of California, 1500 Owens Street, San Francisco, 94158, USA
- Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
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Shetty P, Ren Y, Dillon D, Mcleod A, Nishijima D, Taylor SL. Derivation of a clinical decision rule for termination of resuscitation in non-traumatic pediatric out-of-hospital cardiac arrest. Resuscitation 2024; 204:110400. [PMID: 39299508 DOI: 10.1016/j.resuscitation.2024.110400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 09/02/2024] [Accepted: 09/14/2024] [Indexed: 09/22/2024]
Abstract
AIM Prehospital termination of resuscitation (ToR) rules are used to predict medical futility in adult out-of-hospital cardiac arrest (OHCA), however, the available evidence for pediatric patients is limited. The primary aim of this study is to derive a Pediatric Termination of Resuscitation (PToR) prediction rule for use in pediatric non-traumatic OHCA patients. METHODS We analyzed a retrospective cohort of pediatric OHCA patients within the CARES database over a 10-year period (2013-2022). We split the dataset into training and test datasets and fit logistic regressions with Least Absolute Shrinkage and Selection Operator (LASSO) to select predictor variables and estimate predictive test characteristics for the primary outcome of death and a secondary composite outcome of death or survival to hospital discharge with unfavorable neurologic status. RESULTS We analyzed a sample of 21,240 children where 2,326 (11.0%) survived to hospital discharge, and 1,894 (8.9%) survived to hospital discharge with favorable neurologic status. We derived a PToR rule for death demonstrating a specificity of 99.1% and a positive predictive value (PPV) of 99.8% and a PToR rule for death or survival with poor neurologic status with a specificity of 99.7% and PPV of 99.9% within the test dataset. CONCLUSION We derived a clinical prediction rule with high specificity and positive predictive value in prehospital settings utilizing Advanced Life Support (ALS) providers which may inform termination of resuscitation considerations in pediatric patients. Further prospective and validation studies will be necessary to define the appropriateness and applicability of these PToR criteria for routine use.
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Affiliation(s)
- Pranav Shetty
- Department of Emergency Medicine, University of California, Davis School of Medicine, 4150 V Street #2100, Sacramento, CA 95817, USA.
| | - Yunyi Ren
- Department of Public Health Sciences, University of California, Davis, Medical Sciences 1-C, One Shield's Ave. Davis, CA 95616, USA
| | - David Dillon
- Department of Emergency Medicine, University of California, Davis School of Medicine, 4150 V Street #2100, Sacramento, CA 95817, USA
| | - Alec Mcleod
- University of California, Davis School of Medicine, 4610 X St, Sacramento, CA 95817, USA
| | - Daniel Nishijima
- Department of Emergency Medicine, University of California, Davis School of Medicine, 4150 V Street #2100, Sacramento, CA 95817, USA
| | - Sandra L Taylor
- Department of Public Health Sciences, University of California, Davis, Medical Sciences 1-C, One Shield's Ave. Davis, CA 95616, USA
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3
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Chocron R, Laurenceau T, Soumagnac T, Beganton F, Jabre P, Jouven X. Potential kidney donors among patients with out-of-hospital cardiac arrest and a termination of resuscitation rule. Resuscitation 2024; 201:110318. [PMID: 39009272 DOI: 10.1016/j.resuscitation.2024.110318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 07/05/2024] [Accepted: 07/08/2024] [Indexed: 07/17/2024]
Abstract
IMPORTANCE Uncontrolled donation after circulatory determination of death (uDCD) has been developed and can serve as a source of kidneys for transplantation, especially when considering patients that meet extended criteria donation (ECD). OBJECTIVE This study assessed the theorical size and characteristics of the potential pool of kidney transplants from uDCD with standard criteria donation (SCD) and ECD among patients who meet Termination of Resuscitation (TOR) criteria following Out of Hospital Cardiac Arrest (OHCA). METHODS AND PARTICIPANTS This study focused on adult patients experiencing unexpected OHCA, who were prospectively enrolled in the Parisian registry from May 16th, 2011, to December 31st, 2020. RESULTS During the study period, EMS attempted resuscitation for 19,976 OHCA patients, of which 64.5% (12,890) had no return of spontaneous circulation. Among them, 47.4% (9,461) had TOR criteria, representing no chance of survival, and from them, 8.8% (1,764) met SCD criteria and could be potential organ donors and 33.6% (6,720) met ECD for kidney donors. The mean potential number per year of uDCD candidates with SCD and ECD remain stable respectively around 98 (±10.8) and 672 (±103.8) cases per year. Elderly patients (≥65 y.o.) represented 61.2% (n = 5,763/9,461) of patients who met TOR and 100% (5763/5763) of patients who could have matched both ECD criteria and TOR. CONCLUSION AND RELEVANCE Implementing uDCD program including SCD and ECD for kidney transplantation among OHCA cases quickly identified by the TOR, holds significant potential to substantially broaden the pool of organ donors. These programs could offer a viable solution to address the pressing burden of kidney shortage, particularly benefiting elderly recipients who may otherwise face prolonged waiting times and limited access to suitable organs.
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Affiliation(s)
- Richard Chocron
- Paris Cité University, Paris Research Cardiovascular Center (PARCC), INSERM, F-75015 Paris, France; Emergency Department, Assistance Publique des Hôpitaux de Paris (AP-HP), Georges Pompidou European Hospital, F-75015 Paris, France.
| | - Thomas Laurenceau
- Paris Cité University, Paris Research Cardiovascular Center (PARCC), INSERM, F-75015 Paris, France; Emergency Department, Assistance Publique des Hôpitaux de Paris (AP-HP), Georges Pompidou European Hospital, F-75015 Paris, France
| | - Tal Soumagnac
- Paris Cité University, Paris Research Cardiovascular Center (PARCC), INSERM, F-75015 Paris, France; Emergency Department, Assistance Publique des Hôpitaux de Paris (AP-HP), Georges Pompidou European Hospital, F-75015 Paris, France
| | - Frankie Beganton
- Paris Research Cardiovascular Center (PARCC), INSERM, F-75015 Paris, France
| | - Patricia Jabre
- Paris Research Cardiovascular Center (PARCC), INSERM, F-75015 Paris, France; EMS Services, SAMU75, AP-HP, Necker Hospital, F-75015 Paris, France
| | - Xavier Jouven
- Paris Cité University, Paris Research Cardiovascular Center (PARCC), INSERM, F-75015 Paris, France; Paris Research Cardiovascular Center (PARCC), INSERM, F-75015 Paris, France; Cardiology Department, AP-HP, Georges Pompidou European Hospital, F-75015 Paris, France
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4
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Smyth MA, Gunson I, Coppola A, Johnson S, Greif R, Lauridsen KG, Taylor-Philips S, Perkins GD. Termination of Resuscitation Rules and Survival Among Patients With Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. JAMA Netw Open 2024; 7:e2420040. [PMID: 38958975 PMCID: PMC11222995 DOI: 10.1001/jamanetworkopen.2024.20040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 05/02/2024] [Indexed: 07/04/2024] Open
Abstract
Importance Termination of resuscitation (TOR) rules may help guide prehospital decisions to stop resuscitation, with potential effects on patient outcomes and health resource use. Rules with high sensitivity risk increasing inappropriate transport of nonsurvivors, while rules without excellent specificity risk missed survivors. Further examination of the performance of TOR rules in estimating survival of out-of-hospital cardiac arrest (OHCA) is needed. Objective To determine whether TOR rules can accurately identify patients who will not survive an OHCA. Data Sources For this systematic review and meta-analysis, the MEDLINE, Embase, CINAHL, Cochrane Library, and Web of Science databases were searched from database inception up to January 11, 2024. There were no restrictions on language, publication date, or time frame of the study. Study Selection Two reviewers independently screened records, first by title and abstract and then by full text. Randomized clinical trials, case-control studies, cohort studies, cross-sectional studies, retrospective analyses, and modeling studies were included. Systematic reviews and meta-analyses were reviewed to identify primary studies. Studies predicting outcomes other than death, in-hospital studies, animal studies, and non-peer-reviewed studies were excluded. Data Extraction and Synthesis Data were extracted by one reviewer and checked by a second. Two reviewers assessed risk of bias using the Revised Quality Assessment Tool for Diagnostic Accuracy Studies. Cochrane Screening and Diagnostic Tests Methods Group recommendations were followed when conducting a bivariate random-effects meta-analysis. This review followed the Preferred Reporting Items for a Systematic Review and Meta-Analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA) statement and is registered with the International Prospective Register of Systematic Reviews (CRD42019131010). Main Outcomes and Measures Sensitivity and specificity tables with 95% CIs and bivariate summary receiver operating characteristic (SROC) curves were produced. Estimates of effects at different prevalence levels were calculated. These estimates were used to evaluate the practical implications of TOR rule use at different prevalence levels. Results This review included 43 nonrandomized studies published between 1993 and 2023, addressing 29 TOR rules and involving 1 125 587 cases. Fifteen studies reported the derivation of 20 TOR rules. Thirty-three studies reported external data validations of 17 TOR rules. Seven TOR rules had data to facilitate meta-analysis. One clinical study was identified. The universal termination of resuscitation rule had the best performance, with pooled sensitivity of 0.62 (95% CI, 0.54-0.71), pooled specificity of 0.88 (95% CI, 0.82-0.94), and a diagnostic odds ratio of 20.45 (95% CI, 13.15-31.83). Conclusions and Relevance In this review, there was insufficient robust evidence to support widespread implementation of TOR rules in clinical practice. These findings suggest that adoption of TOR rules may lead to missed survivors and increased resource utilization.
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Affiliation(s)
- Michael A. Smyth
- Medical School, University of Warwick, Coventry, England
- University Hospital Coventry and Warwickshire NHS Trust, Coventry, England
| | - Imogen Gunson
- West Midlands Ambulance Service University NHS Foundation Trust, Brierly Hill, England
| | - Alison Coppola
- University Hospitals Plymouth NHS Trust, Plymouth, England
| | | | - Robert Greif
- Department of Anesthesiology and Pain Therapy, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
- School of Medicine, Sigmund Freud University, Vienna, Austria
| | - Kasper G. Lauridsen
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Medicine, Randers Regional Hospital, Randers, Denmark
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Gavin D. Perkins
- Medical School, University of Warwick, Coventry, England
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, England
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5
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Kajino K, Daya MR, Onoe A, Nakamura F, Nakajima M, Sakuramoto K, Ong MEH, Kuwagata Y. Development and validation of a prehospital termination of resuscitation (TOR) rule for out - of hospital cardiac arrest (OHCA) cases using general purpose artificial intelligence (AI). Resuscitation 2024; 197:110165. [PMID: 38452995 DOI: 10.1016/j.resuscitation.2024.110165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Prehospital identification of futile resuscitation efforts (defined as a predicted probability of survival lower than 1%) for out-of-hospital cardiac arrest (OHCA) may reduce unnecessary transport. Reliable prediction variables for OHCA 'termination of resuscitation' (TOR) rules are needed to guide treatment decisions. The Universal TOR rule uses only three variables (Absence of Prehospital ROSC, Event not witnessed by EMS and no shock delivered on the scene) has been externally validated and is used by many EMS systems. Deep learning, an artificial intelligence (AI) platform is an attractive model to guide the development of TOR rule for OHCA. The purpose of this study was to assess the feasibility of developing an AI-TOR rule for neurologically favorable outcomes using general purpose AI and compare its performance to the Universal TOR rule. METHODS We identified OHCA cases of presumed cardiac etiology who were 18 years of age or older from 2016 to 2019 in the All-Japan Utstein Registry. We divided the dataset into 2 parts, the first half (2016-2017) was used as a training dataset for rule development and second half (2018-2019) for validation. The AI software (Prediction One®) created the model using the training dataset with internal cross-validation. It also evaluated the prediction accuracy and displayed the ranking of influencing variables. We performed validation using the second half cases and calculated the prediction model AUC. The top four of the 11 variables identified in the model were then selected as prognostic factors to be used in an AI-TOR rule, and sensitivity, specificity, positive predictive value, and negative predictive value were calculated from validation cohort. This was then compared to the performance of the Universal TOR rule using same dataset. RESULTS There were 504,561 OHCA cases, 18 years of age or older, 302,799 cases were presumed cardiac origin. Of these, 149,425 cases were used for the training dataset and 153,374 cases for the validation dataset. The model developed by AI using 11 variables had an AUC of 0.969, and its AUC for the validation dataset was 0.965. The top four influencing variables for neurologically favorable outcome were Prehospital ROSC, witnessed by EMS, Age (68 years old and younger) and nonasystole. The AUC calculated using the 4 variables for the AI-TOR rule was 0.953, and its AUC for the validation dataset was 0.952 (95%CI 0.949 -0.954). Of 80,198 patients in the validation cohort that satisfied all four criteria for the AI-TOR rule, 58 (0.07%) had a neurologically favorable one-month survival. The specificity of AI-TOR rule was 0.990, and the PPV was 0.999 for predicting lack of neurologically favorable survival, both the specificity and PPV were higher than that achieved with the universal TOR (0.959, 0.998). CONCLUSIONS The accuracy of prediction models using AI software to determine outcomes in OHCA was excellent and the AI-TOR rule's variables from prediction model performed better than the Universal TOR rule. External validation of our findings as well as further research into the utility of using AI platforms for TOR prediction in clinical practice is needed.
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Affiliation(s)
- Kentaro Kajino
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan.
| | - Mohamud R Daya
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Atsunori Onoe
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Fumiko Nakamura
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Mari Nakajima
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Kazuhito Sakuramoto
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore; Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Yasuyuki Kuwagata
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan
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Ishii J, Nishikimi M, Ohshimo S, Shime N. The Current Discussion Regarding End-of-Life Care for Patients with Out-of-Hospital Cardiac Arrest with Initial Non-Shockable Rhythm: A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:533. [PMID: 38674179 PMCID: PMC11052369 DOI: 10.3390/medicina60040533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/04/2024] [Accepted: 03/20/2024] [Indexed: 04/28/2024]
Abstract
Despite recent advances in resuscitation science, outcomes in patients with out-of-hospital cardiac arrest (OHCA) with initial non-shockable rhythm remains poor. Those with initial non-shockable rhythm have some epidemiological features, including the proportion of patients with a witnessed arrest, bystander cardiopulmonary resuscitation (CPR), age, and presumed etiology of cardiac arrest have been reported, which differ from those with initial shockable rhythm. The discussion regarding better end-of-life care for patients with OHCA is a major concern among citizens. As one of the efforts to avoid unwanted resuscitation, advance directive is recognized as a key intervention, safeguarding patient autonomy. However, several difficulties remain in enhancing the effective use of advance directives for patients with OHCA, including local regulation of their use, insufficient utilization of advance directives by emergency medical services at the scene, and a lack of established tools for discussing futility of resuscitation in advance care planning. In addition, prehospital termination of resuscitation is a common practice in many emergency medical service systems to assist clinicians in deciding whether to discontinue resuscitation. However, there are also several unresolved problems, including the feasibility of implementing the rules for several regions and potential missed survivors among candidates for prehospital termination of resuscitation. Further investigation to address these difficulties is warranted for better end-of-life care of patients with OHCA.
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Affiliation(s)
| | - Mitsuaki Nishikimi
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8551, Japan; (J.I.); (S.O.); (N.S.)
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Morrison LJ, Sandroni C, Grunau B, Parr M, Macneil F, Perkins GD, Aibiki M, Censullo E, Lin S, Neumar RW, Brooks SC. Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation. Circulation 2023; 148:e120-e146. [PMID: 37551611 DOI: 10.1161/cir.0000000000001125] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
AIM OF THE REVIEW Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries. METHODS The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section. RESULTS There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness. CONCLUSIONS All health systems should develop, implement, and evaluate protocols designed to optimize organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.
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Morrison LJ, Sandroni C, Grunau B, Parr M, Macneil F, Perkins GD, Aibiki M, Censullo E, Lin S, Neumar RW, Brooks SC. Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation. Resuscitation 2023; 190:109864. [PMID: 37548950 DOI: 10.1016/j.resuscitation.2023.109864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
AIM OF THE REVIEW Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries. METHODS The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section. RESULTS There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness. CONCLUSIONS All health systems should develop, implement, and evaluate protocols designed to optimise organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.
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Park SY, Lim D, Ryu JH, Kim YH, Choi B, Kim SH. Modification of termination of resuscitation rule with compression time interval in South Korea. Sci Rep 2023; 13:1403. [PMID: 36697453 PMCID: PMC9876889 DOI: 10.1038/s41598-023-28789-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 01/24/2023] [Indexed: 01/26/2023] Open
Abstract
This study aimed to validate the predictive performance of the termination of resuscitation (TOR) rule and examine the compression time interval (CTI) as a criterion for modifying the rule. This retrospective observational study analyzed adult out-of-hospital cardiac arrest (OHCA) patients attended by emergency medical service (EMS) providers in mixed urban-rural areas in Korea in 2020 and 2021. We evaluated the predictive performance of basic life support (BLS) and the Korean Cardiac Arrest Research Consortium (KoCARC) TOR rule using the false-positive rate (FPR) and positive predictive value (PPV). We modified the age cutoff criterion and examined the CTI as a new criterion. According to the TOR rule, 1827 OHCA patients were classified into two groups. The predictive performance of the BLS TOR rule had an FPR of 11.7% (95% confidence interval (CI): 5.9-17.5) and PPV of 98.4% (97.6-99.2) for mortality, and an FPR of 3.6% (0.0-7.8) and PPV of 78.6% (75.9-81.3) for poor neurological outcomes at hospital discharge. The predictive performance of the KoCARC TOR rule had an FPR of 5.0% (1.1-8.9) and PPV of 98.9% (98.0-99.8) for mortality, and an FPR of 3.7% (0.0-7.8) and PPV of 50.0% (45.7-54.3) for poor neurological outcomes at hospital discharge. The modified cutoff value for age was 68 years, with an area under the receiver operating characteristic curve over 0.7. In the group that met the BLS TOR rule, the cutoff of the CTI for death was not determined and was 21 min for poor neurological outcomes. In the group that met the KoCARC TOR rule, the cutoff of the CTI for death and poor neurological outcomes at the time of hospital discharge was 25 min and 21 min, respectively. The BLS TOR and KoCARC TOR rules showed inappropriate predictive performance for mortality and poor neurological outcomes. However, the predictive performance of the TOR rule could be supplemented by modifying the age criterion and adding the CTI criterion of the KoCARC.
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Affiliation(s)
- Song Yi Park
- Department of Emergency Medicine, Dong-A University College of Medicine, Dong-A University Hospital, Busan, 49201, South Korea
| | - Daesung Lim
- Department of Emergency Medicine, Seoul Medical Center, Seoul, 02053, South Korea
| | - Ji Ho Ryu
- Department of Emergency Medicine, Pusan National University College of Medicine, Pusan National University Yangsan Hospital, Busan, 50612, South Korea
| | - Yong Hwan Kim
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, 51353, South Korea
| | - Byungho Choi
- Department of Emergency Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, 44033, South Korea
| | - Sun Hyu Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, 44033, South Korea.
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Milling L, Lassen AT, Mikkelsen S. Transparency in out-of-hospital cardiac arrest resuscitation: decision-making when patients are in the grey area between treatment and futility. Eur J Emerg Med 2021; 28:414-415. [PMID: 34560702 DOI: 10.1097/mej.0000000000000880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Louise Milling
- Prehospital Research Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital
- Department of Regional Health Research, University of Southern Denmark
| | - Annmarie T Lassen
- Emergency Medicine Research Unit, Odense University Hospital, Odense, Denmark
| | - Søren Mikkelsen
- Prehospital Research Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital
- Department of Regional Health Research, University of Southern Denmark
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Schröder AS, Sperhake JP, Ondruschka B, Hoedtke J, Anders S. Todesfeststellung und Leichenschau in der Notfallmedizin. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00902-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
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12
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A point of entry into paediatric termination of resuscitation research. Resuscitation 2021; 169:182-184. [PMID: 34718081 DOI: 10.1016/j.resuscitation.2021.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 11/22/2022]
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13
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Berry CL, Olaf MF, Kupas DF, Berger A, Knorr AC. EMS agencies with high rates of field termination of resuscitation and longer scene times also have high rates of survival. Resuscitation 2021; 169:205-213. [PMID: 34666123 DOI: 10.1016/j.resuscitation.2021.09.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/16/2021] [Accepted: 09/20/2021] [Indexed: 11/30/2022]
Abstract
AIM Out-of-hospital cardiac arrest (OOHCA) management dichotomizes strategies to (1) "scoop-and-run" to a higher level of care or (2) "treat on the X" with the goal of return of spontaneous circulation (ROSC) before transport, with field termination of resuscitation (FTOR) of unsuccessful resuscitations. We hypothesized that EMS agencies with greater average time on-scene and higher rates of field termination of resuscitation would have more favorable outcomes. METHODS The Cardiac Arrest Registry to Enhance Survival (CARES) was used to identify OOHCA cases from 2013 to 2018. Agencies in the top and bottom quartiles of on-scene time were categorized as high (HiOST) and low (LoOST); in the top and bottom quartiles of field termination rate were categorized as high (HiTOR) and low (LoTOR). Generalized estimating equation models compared top and bottom quartiles. RESULTS We classified 95 agencies as HiOST (average > 25.1 min) or LoOST (average < 19.3 min). We classified 95 agencies as HiTOR (average > 46.5% FTOR) or LoTOR (average < 23.5% FTOR). Controlling for agency characteristics, HiOST had a higher survival to discharge for transported patients (28.1% vs 23.1%, OR = 2.8, 95 %CI 2.1-3.6, p < 0.001), ROSC on emergency department arrival, and favorable neurologic outcome than LoOST. HiTOR had a higher survival to discharge for transported patients (25.6% vs 19.3%, OR = 3.3, 95 %CI 2.5-4.4, p < 0.001), ROSC on emergency department arrival, and favorable neurologic outcome than LoTOR. CONCLUSION EMS agencies with higher rates of FTOR and longer on-scene times for patients with OOHCA have higher overall patient survival, ROSC, and favorable neurologic function.
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Affiliation(s)
- Christopher L Berry
- Geisinger Commonwealth School of Medicine, 1 Guthrie Square, Sayre, PA 18840, United States.
| | - Mark F Olaf
- Geisinger Commonwealth School of Medicine, 100 North Academy Ave., Danville, PA 17822-2005, United States
| | - Douglas F Kupas
- Geisinger Health System, 100 North Academy Ave., Danville, PA 17822-2005, United States
| | - Andrea Berger
- Department of Population Health Sciences, Biostatistics Core, Geisinger, 100 North Academy Ave., Danville, PA 17822-2005, United States
| | - Anne C Knorr
- Geisinger Health System, 100 North Academy Ave., Danville, PA 17822-2005, United States
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14
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Harris MI, Crowe RP, Anders J, D'Acunto S, Adelgais KM, Fishe J. Applying a set of termination of resuscitation criteria to paediatric out-of-hospital cardiac arrest. Resuscitation 2021; 169:175-181. [PMID: 34555488 DOI: 10.1016/j.resuscitation.2021.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 09/08/2021] [Accepted: 09/13/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Prehospital Termination of Resuscitation (TOR) protocols for adults can reduce the number of futile transports of patients in cardiac arrest, yet similar protocols are not widely available for paediatric out-of-hospital cardiac arrest (POHCA). The objective of this study was to apply a set of criteria for paediatric TOR (pTOR) from the Maryland Institute for Emergency Medical Services Systems (MIEMSS) to a large national cohort and determine its association with return of spontaneous circulation (ROSC) after POHCA. METHODS We identified patients ages 0-17 treated by Emergency Medical Services (EMS) with cardiac arrest in 2019 from the ESO dataset and and applied the applicable pTOR certeria for medical or traumatic arrests. We calculated predictive test characteristics for the outcome of prehospital ROSC, stratified by medical and traumatic cause of arrest. RESULTS We analyzed records for 1595 POHCA patients. Eighty-eight percent (n = 1395) were classified as medical. ROSC rates were 23% among medical POHCA and 27% among traumatic POHCA. The medical criteria correctly classified >99% (322/323) of patients who achieved ROSC as ineligible for TOR. The trauma criteria correctly classified 93% (50/54) of patients with ROSC as ineligible for TOR. Of the five misclassified patients, three were involved in drowning incidents. CONCLUSIONS The Maryland pTOR criteria identified eligible patients who did not achieve prehospital ROSC, while reliably excluding those who did achieve prehospital ROSC. As most misclassified patients were victims of drowning, we recommend considering the exclusion of drowning patients from future pTOR guidelines. Further studies are needed to evaluate the long-term survival and neurologic outcome of patients misclassified by pTOR criteria.
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Affiliation(s)
- Matthew I Harris
- Northwell Hofstra School of Medicine, Departments of Paediatrics and Emergency, Medicine, New Hyde Park, NY, United States.
| | | | - Jennifer Anders
- Johns Hopkins School of Medicine, Department of Paediatrics, Baltimore, MD, United States
| | - Salvatore D'Acunto
- University of Florida College of Medicine - Jacksonville, Center for Data Solutions, Jacksonville, FL United States
| | - Kathleen M Adelgais
- University of Colorado School of Medicine, Department of Paediatrics, Section of Paediatric Emergency Medicine, Aurora, CO, United States
| | - Jennifer Fishe
- University of Florida College of Medicine - Jacksonville, Center for Data Solutions, Jacksonville, FL United States; University of Florida College of Medicine - Jacksonville, Department of Emergency Medicine, Jacksonville, FL, United States
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15
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Milling L, Binderup LG, de Muckadell CS, Christensen EF, Lassen A, Christensen HC, Nielsen DS, Mikkelsen S. Documentation of ethically relevant information in out-of-hospital resuscitation is rare: a Danish nationwide observational study of 16,495 out-of-hospital cardiac arrests. BMC Med Ethics 2021; 22:82. [PMID: 34193147 PMCID: PMC8247191 DOI: 10.1186/s12910-021-00654-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/16/2021] [Indexed: 01/04/2023] Open
Abstract
Background Decision-making in out-of-hospital cardiac arrest should ideally include clinical and ethical factors. Little is known about the extent of ethical considerations and their influence on prehospital resuscitation. We aimed to determine the transparency in medical records regarding decision-making in prehospital resuscitation with a specific focus on ethically relevant information and consideration in resuscitation providers’ documentation. Methods This was a Danish nationwide retrospective observational study of out-of-hospital cardiac arrests from 2016 through 2018. After an initial screening using broadly defined inclusion criteria, two experienced philosophers performed a qualitative content analysis of the included medical records according to a preliminary codebook. We identified ethically relevant content in free-text fields and categorised the information according to Beauchamp and Childress’ four basic bioethical principles: autonomy, non-maleficence, beneficence, and justice.
Results Of 16,495 medical records, we identified 759 (4.6%) with potentially relevant information; 710 records (4.3%) contained ethically relevant information, whereas 49 did not. In general, the documentation was vague and unclear. We identified four kinds of ethically relevant information: patients’ wishes and perspectives on life; relatives’ wishes and perspectives on patients’ life; healthcare professionals’ opinions and perspectives on resuscitation; and do-not-resuscitate orders. We identified some “best practice” examples that included all perspectives of decision-making.
Conclusions There is sparse and unclear evidence on ethically relevant information in the medical records documenting resuscitation after out-of-hospital cardiac arrests. However, the “best practice” examples show that providing sufficient documentation of decision-making is, in fact, feasible. To ensure transparency surrounding prehospital decisions in cardiac arrests, we believe that it is necessary to ensure more systematic documentation of decision-making in prehospital resuscitation. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-021-00654-y.
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Affiliation(s)
- Louise Milling
- Prehospital Research Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Kildemosevej 15, 5000, Odense C, Denmark. .,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.
| | - Lars Grassmé Binderup
- Philosophy, Department for the Study of Culture, University of Southern Denmark, Odense, Denmark
| | | | | | - Annmarie Lassen
- Emergency Medicine Research Unit, Odense University Hospital, Odense, Denmark
| | | | - Dorthe Susanne Nielsen
- Department of Infectious Diseases, Sub-department of Immigrant Medicine, Odense University Hospital, Odense, Denmark.,Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
| | - Søren Mikkelsen
- Prehospital Research Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Kildemosevej 15, 5000, Odense C, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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16
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Lee MJ, Shin TY, Lee CH, Moon JD, Roh SG, Kim CW, Park HE, Woo SH, Lee SJ, Shin SL, Oh YT, Lim YS, Choe JY, Na SH, Hwang SO. 2020 Korean Guidelines for Cardiopulmonary Resuscitation. Part 9. Education and system implementation for enhanced chain of survival. Clin Exp Emerg Med 2021; 8:S116-S124. [PMID: 34034453 PMCID: PMC8171173 DOI: 10.15441/ceem.21.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 03/28/2021] [Indexed: 02/07/2023] Open
Affiliation(s)
- Mi Jin Lee
- Department of Emergency Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Tae-Yong Shin
- Department of Emergency Medicine, Asan Chungmu General Hospital, Asan, Korea
| | - Chang Hee Lee
- Department of Emergency Medical Technician, Namseoul University, Cheonan, Korea
| | - Jun Dong Moon
- Department of Emergency Medical Service, College of Health & Nursing, Kongju National University, Gongju, Korea
| | - Sang Gyun Roh
- Department of Emergency Medical Services, Sun Moon University, Asan, Korea
| | - Chan Woong Kim
- Department of Emergency Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hyo Eun Park
- Division of Cardiology, Department of Internal Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Seon Hee Woo
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Seung Joon Lee
- National Medical Emergency Center, National Medical Center, Seoul, Korea
| | - Seung Lyul Shin
- Department of Emergency Medicine, Inha University College of Medicine, Incheon, Korea
| | - Young Taeck Oh
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yong Su Lim
- Department of Emergency Medicine, Gachon University College of Medicine, Incheon, Korea
| | - Jae Young Choe
- Department of Emergency Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Sang-Hoon Na
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Oh Hwang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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17
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Onoe A, Kajino K, Daya MR, Ong MEH, Nakamura F, Nakajima M, Takahashi H, Kishimoto M, Sakuramoto K, Muroya T, Ikegawa H, Kuwagata Y. Outcomes of patients with OHCA of presumed cardiac etiology that did not achieve prehospital restoration of spontaneous circulation: The All-Japan Utstein Registry experience. Resuscitation 2021; 162:245-250. [PMID: 33766662 DOI: 10.1016/j.resuscitation.2021.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/18/2020] [Accepted: 03/08/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Correct identification of futile prehospital resuscitation for out-of-hospital cardiac arrest (OHCA) may reduce unnecessary transports. Prehospital return of spontaneous circulation (ROSC) is considered by many to be an important predictor of outcome. The purpose of this study was to evaluate OHCA victims without prehospital ROSC characteristics and their outcomes in relation to the universal Termination of Resuscitation (TOR) rule. METHODS A retrospective, population-based review of OHCA victims without prehospital ROSC from January 1, 2010 to December 31, 2017 in the All-Japan Utstein Registry. We compared those that met the universal TOR rule and those that did not for the primary outcome: one-month survival with neurologically favorable Cerebral Performance Category (CPC) 1 or 2. RESULTS 989,929 OHCA cases, 18 years of age or older, were registered in the All-Japan Utstein Registry and 525,801 cases were of presumed cardiac origin and had no prehospital ROSC. Of these, the one-month CPC was 1 or 2 for 3957 cases (0.8%). In the 'no ROSC' group who also met the TOR rule, the number of cases was 433,571 with a one-month survival of 0.9% (3799 cases), and the proportion with a CPC 1or 2 was 0.2% (699 cases). CONCLUSIONS Continued resuscitation and transport of cases with no field ROSC who fulfill the TOR rule is futile and could be considered for adoption in Japan.
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Affiliation(s)
- Atsunori Onoe
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan.
| | - Kentaro Kajino
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Mohamud R Daya
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore; Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Fumiko Nakamura
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Mari Nakajima
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Hiroki Takahashi
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Masanobu Kishimoto
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Kazuhito Sakuramoto
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Takashi Muroya
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Hitoshi Ikegawa
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Yasuyuki Kuwagata
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan
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18
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Greif R, Bhanji F, Bigham BL, Bray J, Breckwoldt J, Cheng A, Duff JP, Gilfoyle E, Hsieh MJ, Iwami T, Lauridsen KG, Lockey AS, Ma MHM, Monsieurs KG, Okamoto D, Pellegrino JL, Yeung J, Finn JC. Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2020; 142:S222-S283. [PMID: 33084395 DOI: 10.1161/cir.0000000000000896] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.
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19
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Greif R, Bhanji F, Bigham BL, Bray J, Breckwoldt J, Cheng A, Duff JP, Gilfoyle E, Hsieh MJ, Iwami T, Lauridsen KG, Lockey AS, Ma MHM, Monsieurs KG, Okamoto D, Pellegrino JL, Yeung J, Finn JC, Baldi E, Beck S, Beckers SK, Blewer AL, Boulton A, Cheng-Heng L, Yang CW, Coppola A, Dainty KN, Damjanovic D, Djärv T, Donoghue A, Georgiou M, Gunson I, Krob JL, Kuzovlev A, Ko YC, Leary M, Lin Y, Mancini ME, Matsuyama T, Navarro K, Nehme Z, Orkin AM, Pellis T, Pflanzl-Knizacek L, Pisapia L, Saviani M, Sawyer T, Scapigliati A, Schnaubelt S, Scholefield B, Semeraro F, Shammet S, Smyth MA, Ward A, Zace D. Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2020; 156:A188-A239. [PMID: 33098918 DOI: 10.1016/j.resuscitation.2020.09.014] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.
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20
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Lupton JR, Kurz MC, Daya MR. Neurologic prognostication after resuscitation from cardiac arrest. J Am Coll Emerg Physicians Open 2020; 1:333-341. [PMID: 33000056 PMCID: PMC7493528 DOI: 10.1002/emp2.12109] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/28/2020] [Accepted: 05/01/2020] [Indexed: 12/11/2022] Open
Abstract
Out-of-hospital cardiac arrest remains a leading cause of mortality in the United States, and the majority of patients who die after achieving return of spontaneous circulation die from withdrawal of care due to a perceived poor neurologic prognosis. Unfortunately, withdrawal of care often occurs during the first day of admission and research suggests this early withdrawal of care may be premature and result in unnecessary deaths for patients who would have made a full neurologic recovery. In this review, we explore the evidence for neurologic prognostication in the emergency department for patients who achieve return of spontaneous circulation after an out-of-hospital cardiac arrest.
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Affiliation(s)
| | | | - Mohamud R Daya
- Oregon Health and Science University Portland Oregon USA
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21
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Lee XJ, Farrington A, Carter H, Shield C, Graves N, McPhail SM, Harvey G, White BP, Willmott L, Cardona M, Hillman K, Callaway L, Barnett AG. A stepped-wedge randomised-controlled trial assessing the implementation, impact and costs of a prospective feedback loop to promote appropriate care and treatment for older patients in acute hospitals at the end of life: study protocol. BMC Geriatr 2020; 20:262. [PMID: 32727393 PMCID: PMC7392836 DOI: 10.1186/s12877-020-01660-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 07/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hospitalisation rates for the older population have been increasing with end-of-life care becoming a more medicalised and costly experience. There is evidence that some of these patients received non-beneficial treatment during their final hospitalisation with a third of the non-beneficial treatment duration spent in intensive care units. This study aims to increase appropriate care and treatment decisions and pathways for older patients at the end of life in Australia. This study will implement and evaluate a prospective feedback loop and tailored clinical response intervention at three hospitals in Queensland, Australia. METHODS A stepped-wedge cluster randomised trial will be conducted with up to 21 clinical teams in three acute hospitals over 70 weeks. The study involves clinical teams providing care to patients aged 75 years or older, who are prospectively identified to be at risk of non-beneficial treatment using two validated tools for detecting death and deterioration risks. The intervention's feedback loop will provide the teams with a summary of these patients' risk profiles as a stimulus for a tailored clinical response in the intervention phase. The Consolidated Framework for Implementation Research will be used to inform the intervention's implementation and process evaluation. The study will determine the impact of the intervention on patient outcomes related to appropriate care and treatment at the end of life in hospitals, as well as the associated healthcare resource use and costs. The primary outcome is the proportion of patients who are admitted to intensive care units. A process evaluation will be carried out to assess the implementation, mechanisms of impact, and contextual barriers and enablers of the intervention. DISCUSSION This intervention is expected to have a positive impact on the care of older patients near the end of life, specifically to improve clinical decision-making about treatment pathways and what constitutes appropriate care for these patients. These will reduce the incidence of non-beneficial treatment, and improve the efficiency of hospital resources and quality of care. The process evaluation results will be useful to inform subsequent intervention implementation at other hospitals. TRIAL REGISTRATION Australia New Zealand Clinical Trial Registry (ANZCTR), ACTRN12619000675123p (approved 6 May 2019).
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Affiliation(s)
- Xing J Lee
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia. .,Australian Centre for Health Services Innovation, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia.
| | - Alison Farrington
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia.,Australian Centre for Health Services Innovation, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia
| | - Hannah Carter
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia.,Australian Centre for Health Services Innovation, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia
| | - Carla Shield
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia.,Australian Centre for Health Services Innovation, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia
| | - Nicholas Graves
- Duke-NUS Postgraduate Medical School, National University of Singapore, Singapore, Singapore
| | - Steven M McPhail
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia.,Australian Centre for Health Services Innovation, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia
| | - Gillian Harvey
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia.,Australian Centre for Health Services Innovation, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia.,Adelaide Nursing School, University of Adelaide, Adelaide, South Australia, Australia
| | - Ben P White
- Australia Centre for Heath Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Lindy Willmott
- Australia Centre for Heath Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Magnolia Cardona
- Gold Coast University Hospital, Southport, Queensland, Australia.,Institute for Evidence-Based Health Care, Bond University, Robina, Queensland, Australia
| | - Ken Hillman
- Simpson Centre for Health Services Research, South West Sydney Clinical School, University of New South Wales, Liverpool, New South Wales, Australia
| | - Leonie Callaway
- Faculty of Health, Queensland University of Technology, Kelvin Grove, Queensland, Australia.,Faculty of Medicine, University of Queensland, Herston, Queensland, Australia.,Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Adrian G Barnett
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia.,Australian Centre for Health Services Innovation, Queensland University of Technology (QUT), Kelvin Grove, Queensland, Australia
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22
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Campos A, Ernest EV, Cash RE, Rivard MK, Panchal AR, Clemency BM, Swor RA, Crowe RP. The Association of Death Notification and Related Training with Burnout among Emergency Medical Services Professionals. PREHOSP EMERG CARE 2020; 25:539-548. [PMID: 32584686 DOI: 10.1080/10903127.2020.1785599] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Death notification is a difficult task commonly encountered during prehospital care and may lead to burnout among EMS professionals. Lack of training could potentiate the relationship between death notification and burnout. The first objective of this study was to describe EMS professionals' experience with death notification and related training. The secondary objective was to assess the associations between death notification delivery, training, and burnout. Methods: We administered an electronic questionnaire to a random sample of nationally-certified EMS professionals. Work-related burnout was measured using the validated Copenhagen Burnout Inventory. Analysis was stratified by certification level to basic life support (BLS) and advanced life support (ALS). The association between the number of adult (≥18 years) patient death notifications delivered in the prior 12 months and burnout was assessed using multivariable logistic regression to adjust for confounding variables. Multivariable logistic regression modeling was used to assess the adjusted association between training and burnout among those who reported delivering at least one death notification in the prior 12 months. Adjusted odds ratios (aOR) and 95% confidence intervals are reported (95% CI). Results: We received 2,333/19,330 (12%) responses and 1,514 were included in the analysis. Most ALS respondents (77%) and one-third of BLS respondents (33%) reported at least one adult death notification in the past year. Approximately half of respondents reported receiving death notification training as part of their initial EMS education program (51% BLS; 52% ALS) and fewer reported receiving continuing education (30% BLS; 44% ALS). Delivering a greater number of death notifications was associated with increased odds of burnout. Among those who delivered at least one death notification, continuing education was associated with reduced odds of burnout. Conclusion: Many EMS professionals reported delivering at least one death notification within the past year. Yet, fewer than half reported training related to death notification during initial EMS education and even fewer reported receiving continuing education. More of those who delivered death notifications experienced burnout, while continuing education was associated with reduced odds of burnout. Future work is needed to develop and evaluate death notification training specifically for EMS professionals.
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Affiliation(s)
- Abraham Campos
- Received May 7, 2020 from Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, Nebraska (AC, EVE); Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts (REC); South Shore Health, EMS Division, Weymouth, Massachusetts (MKR); National Registry of Emergency Medical Technicians, Columbus, Ohio (ARP); Wexner Medical Center, Department of Emergency Medicine, The Ohio State University, Columbus, Ohio (ARP); Department of Emergency Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York (BMC); Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan (RAS); ESO, Austin, Texas (RPC)
| | - Eric V Ernest
- Received May 7, 2020 from Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, Nebraska (AC, EVE); Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts (REC); South Shore Health, EMS Division, Weymouth, Massachusetts (MKR); National Registry of Emergency Medical Technicians, Columbus, Ohio (ARP); Wexner Medical Center, Department of Emergency Medicine, The Ohio State University, Columbus, Ohio (ARP); Department of Emergency Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York (BMC); Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan (RAS); ESO, Austin, Texas (RPC)
| | - Rebecca E Cash
- Received May 7, 2020 from Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, Nebraska (AC, EVE); Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts (REC); South Shore Health, EMS Division, Weymouth, Massachusetts (MKR); National Registry of Emergency Medical Technicians, Columbus, Ohio (ARP); Wexner Medical Center, Department of Emergency Medicine, The Ohio State University, Columbus, Ohio (ARP); Department of Emergency Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York (BMC); Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan (RAS); ESO, Austin, Texas (RPC)
| | - Madison K Rivard
- Received May 7, 2020 from Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, Nebraska (AC, EVE); Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts (REC); South Shore Health, EMS Division, Weymouth, Massachusetts (MKR); National Registry of Emergency Medical Technicians, Columbus, Ohio (ARP); Wexner Medical Center, Department of Emergency Medicine, The Ohio State University, Columbus, Ohio (ARP); Department of Emergency Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York (BMC); Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan (RAS); ESO, Austin, Texas (RPC)
| | - Ashish R Panchal
- Received May 7, 2020 from Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, Nebraska (AC, EVE); Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts (REC); South Shore Health, EMS Division, Weymouth, Massachusetts (MKR); National Registry of Emergency Medical Technicians, Columbus, Ohio (ARP); Wexner Medical Center, Department of Emergency Medicine, The Ohio State University, Columbus, Ohio (ARP); Department of Emergency Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York (BMC); Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan (RAS); ESO, Austin, Texas (RPC)
| | - Brian M Clemency
- Received May 7, 2020 from Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, Nebraska (AC, EVE); Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts (REC); South Shore Health, EMS Division, Weymouth, Massachusetts (MKR); National Registry of Emergency Medical Technicians, Columbus, Ohio (ARP); Wexner Medical Center, Department of Emergency Medicine, The Ohio State University, Columbus, Ohio (ARP); Department of Emergency Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York (BMC); Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan (RAS); ESO, Austin, Texas (RPC)
| | - Robert A Swor
- Received May 7, 2020 from Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, Nebraska (AC, EVE); Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts (REC); South Shore Health, EMS Division, Weymouth, Massachusetts (MKR); National Registry of Emergency Medical Technicians, Columbus, Ohio (ARP); Wexner Medical Center, Department of Emergency Medicine, The Ohio State University, Columbus, Ohio (ARP); Department of Emergency Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York (BMC); Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan (RAS); ESO, Austin, Texas (RPC)
| | - Remle P Crowe
- Received May 7, 2020 from Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, Nebraska (AC, EVE); Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts (REC); South Shore Health, EMS Division, Weymouth, Massachusetts (MKR); National Registry of Emergency Medical Technicians, Columbus, Ohio (ARP); Wexner Medical Center, Department of Emergency Medicine, The Ohio State University, Columbus, Ohio (ARP); Department of Emergency Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York (BMC); Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan (RAS); ESO, Austin, Texas (RPC)
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Anderson NE, Slark J, Gott M. When resuscitation doesn’t work: A qualitative study examining ambulance personnel preparation and support for termination of resuscitation and patient death. Int Emerg Nurs 2020; 49:100827. [DOI: 10.1016/j.ienj.2019.100827] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 10/01/2019] [Accepted: 11/29/2019] [Indexed: 12/12/2022]
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Gordon L, Pasquier M, Brugger H, Paal P. Autoresuscitation (Lazarus phenomenon) after termination of cardiopulmonary resuscitation - a scoping review. Scand J Trauma Resusc Emerg Med 2020; 28:14. [PMID: 32102671 PMCID: PMC7045737 DOI: 10.1186/s13049-019-0685-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 11/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Autoresuscitation describes the return of spontaneous circulation after termination of resuscitation (TOR) following cardiac arrest (CA). We aimed to identify phenomena that may lead to autoresuscitation and to provide guidance to reduce the likelihood of it occurring. MATERIALS AND METHODS We conducted a literature search (Google Scholar, MEDLINE, PubMed) and a scoping review according to PRISMA-ScR guidelines of autoresuscitation cases where patients undergoing CPR recovered circulation spontaneously after TOR with the following criteria: 1) CA from any cause; 2) CPR for any length of time; 3) A point was reached when it was felt that the patient had died; 4) Staff declared the patient dead and stood back. No further interventions took place; 5) Later, vital signs were observed. 6) Vital signs were sustained for more than a few seconds, such that staff had to resume active care. RESULTS Sixty-five patients with ROSC after TOR were identified in 53 articles (1982-2018), 18 (28%) made a full recovery. CONCLUSIONS Almost a third made a full recovery after autoresuscitation. The following reasons for and recommendations to avoid autoresuscitation can be proposed: 1) In asystole with no reversible causes, resuscitation efforts should be continued for at least 20 min; 2) CPR should not be abandoned immediately after unsuccessful defibrillation, as transient asystole can occur after defibrillation; 3) Excessive ventilation during CPR may cause hyperinflation and should be avoided; 4) In refractory CA, resuscitation should not be terminated in the presence of any potentially-treatable cardiac rhythm; 5) After TOR, the casualty should be observed continuously and ECG monitored for at least 10 min.
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Affiliation(s)
- Les Gordon
- Department of Anaesthesia, University Hospitals Morecambe Bay Trust, Royal Lancaster Infirmary, Lancaster, UK
- International Commission for Mountain Emergency Medicine (ICAR MEDCOM), Zermatt, Switzerland
| | - Mathieu Pasquier
- International Commission for Mountain Emergency Medicine (ICAR MEDCOM), Zermatt, Switzerland
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Hermann Brugger
- International Commission for Mountain Emergency Medicine (ICAR MEDCOM), Zermatt, Switzerland
- Institute of Mountain Emergency Medicine, EURAC research, Bolzano, Italy
| | - Peter Paal
- International Commission for Mountain Emergency Medicine (ICAR MEDCOM), Zermatt, Switzerland.
- Department of Anaesthesiology and Intensive Care, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria.
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Teefy J, Cram N, Van Zyl T, Van Aarsen K, McLeod S, Dukelow A. Evaluation of the Uptake of a Prehospital Cardiac Arrest Termination of Resuscitation Rule. J Emerg Med 2020; 58:254-259. [PMID: 31924467 DOI: 10.1016/j.jemermed.2019.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 10/29/2019] [Accepted: 11/10/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Previous research has focused on creation and validation of a basic life support rule for termination of resuscitation (TOR) in nontraumatic out-of-hospital cardiac arrest (OHCA) to identify patients who will not be successfully resuscitated or will not have a favorable outcome. Although now widely implemented, translational research regarding in-field compliance with TOR criteria and barriers to use is scarce. OBJECTIVES This project aimed to assess compliance rates, barriers to use, and effect on ambulance transport rates after implementing TOR criteria for OHCA. METHODS Retrospective chart review of patients ≥ 18 years with OHCA. Data from regional Emergency Medical Services agencies were collected to determine TOR rule compliance for patients meeting criteria, barriers to use, and effect of a TOR rule on ambulance transport. RESULTS There were 552 patients with OHCAs identified. Ninety-one patients met TOR criteria, with paramedics requesting TOR in 81 (89%) cases and physicians granting requests in 65 (80.2%) cases. Perceived barriers to TOR compliance included distraught families, nearby advanced-care paramedics, and unusual circumstances. Reasons for physician refusal of TOR requests included hospital proximity, patient not receiving epinephrine, and poor communication connection to paramedics. Total high priority transports decreased 15.6% after implementation of a TOR rule. CONCLUSIONS The study found high compliance after implementation of a TOR rule and identified potentially addressable barriers to TOR use. Appropriate application of a TOR rule led to reduction in high-priority ambulance transports, potentially reducing futile use of health care resources and risk of ambulance motor vehicle collisions.
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Affiliation(s)
- John Teefy
- Division of Emergency Medicine, Department of Medicine, Western University, London, Ontario, Canada
| | - Natalie Cram
- Alberta Health Services, Calgary, Alberta, Canada
| | - Theunis Van Zyl
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Kristine Van Aarsen
- Division of Emergency Medicine, Department of Medicine, Western University, London, Ontario, Canada
| | - Shelley McLeod
- Schwartz/Reisman Emergency Medicine Institute, Department of Family & Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Adam Dukelow
- Division of Emergency Medicine, Department of Medicine, Western University, London, Ontario, Canada; Southwest Ontario Regional Base Hospital Program, London Health Sciences Centre, London, Ontario, Canada
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Anderson NE, Slark J, Faasse K, Gott M. Paramedic student confidence, concerns, learning and experience with resuscitation decision-making and patient death: A pilot survey. Australas Emerg Care 2019; 22:156-161. [DOI: 10.1016/j.auec.2019.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/25/2019] [Accepted: 07/01/2019] [Indexed: 11/26/2022]
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Ebell MH, Vellinga A, Masterson S, Yun P. Meta-analysis of the accuracy of termination of resuscitation rules for out-of-hospital cardiac arrest. Emerg Med J 2019; 36:479-484. [PMID: 31142552 DOI: 10.1136/emermed-2018-207833] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 04/21/2019] [Accepted: 04/24/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND Our objective was to perform a systematic review of studies reporting the accuracy of termination of resuscitation rules (TORRs) for out-of-hospital cardiac arrest (OHCA). METHODS We performed a comprehensive search of the literature for studies evaluating the accuracy of TORRs, with two investigators abstracting relevant data from each study regarding study design, study quality and the accuracy of the TORRs. Bivariate meta-analysis was performed using the mada procedure in R. RESULTS We identified 14 studies reporting the performance of 9 separate TORRs. The sensitivity (proportion of eventual survivors for whom the TORR recommends resuscitation and transport) was generally high: 95% for the European Resuscitation Council (ERC) TORR, 97% for the basic life support (BLS) TORR and 99% for the advanced life support (ALS) TORR. The BLS and ERC TORR were more specific, which would lead to fewer futile transports, and all three of these TORRs had a miss rate of ≤0.13% (defined as a case where a patient is recommended for termination but survives). The pooled proportion of patients for whom each rule recommends TOR was much higher for the ERC and BLS TORRs (93.5% and 74.8%, respectively) than for the ALS TORR (29.0%). CONCLUSIONS The BLS and ERC TORRs identify a large proportion of patients who are candidates for termination of resuscitation following OHCA while having a very low rate of misclassifying eventual survivors (<0.1%). Further prospective validation of the ERC TORR and direct comparison with BLS TORR are needed.
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Affiliation(s)
- Mark H Ebell
- Department of Epidemiology, College of Public Health, University of Georgia, Athens, Georgia, USA
| | - Akke Vellinga
- Department of General Practice, National University of Ireland, Galway, Galway, Ireland
| | - Siobhan Masterson
- Department of General Practice, National University of Ireland, Galway, Galway, Ireland
| | - Phillip Yun
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Goto Y, Funada A, Maeda T, Okada H, Goto Y. Field termination-of-resuscitation rule for refractory out-of-hospital cardiac arrests in Japan. J Cardiol 2018; 73:240-246. [PMID: 30580892 DOI: 10.1016/j.jjcc.2018.12.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 11/30/2018] [Accepted: 12/08/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Guidelines for cardiopulmonary resuscitation (CPR) recommend using the universal termination-of-resuscitation (TOR) rule to identify out-of-hospital cardiac arrest (OHCA) patients eligible for field termination of resuscitation, thus avoiding medically futile transportation to the hospital. However, in Japan, emergency medical services (EMS) personnel are forbidden from terminating CPR in the field and transport almost all patients with OHCA to hospitals. We aimed to develop and validate a novel TOR rule to identify patients eligible for field termination of CPR. METHODS We analyzed 540,478 patients with OHCA from 2011 to 2015 using a Japanese registry. Main outcome measures were specificity and positive predictive value (PPV) of the newly developed TOR rule in predicting 1-month mortality after OHCA. RESULTS Recursive partitioning analysis in the development group (n=434,208) showed that EMS personnel could consider TOR if patients with OHCA met all of the following five criteria: (1) initial asystole, (2) arrest unwitnessed by a bystander, (3) age ≥81 years, (4) no bystander-administered CPR or automated external defibrillator use before EMS arrival, and (5) no return of spontaneous circulation after EMS-initiated CPR for 14min. For patients meeting these criteria, specificity and PPV for predicting 1-month mortality were 99.2% [95% confidence interval (CI), 99.0-99.3%] and 99.7% (95% CI, 99.6-99.7%), respectively, for the development group and were 99.5% (95% CI, 99.3-99.7%) and 99.8% (95% CI, 99.7-99.9%), respectively, for the validation group. Implementation of this novel rule would reduce patient transports to hospitals by 10.6% in the development group and 10.4% in the validation group. CONCLUSIONS Having both high specificity and PPV of >99% for predicting 1-month mortality, our developed TOR rule may be applied in the field for Japanese patients with OHCA who meet all five criteria. Prospective validation studies and establishment of prehospital EMS protocol are required before implementing this rule.
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Affiliation(s)
- Yoshikazu Goto
- Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Kanazawa, Japan.
| | - Akira Funada
- Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Tetsuo Maeda
- Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Hirofumi Okada
- Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Yumiko Goto
- Department of Cardiology, Yawata Medical Center, Komatsu, Japan
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Escutnaire J, Ducrocq F, Singier A, Baert V, Babykina E, Dumont C, Vilhelm C, Marc JB, Segal N, Wiel E, Mols P, Hubert H. Can We Define Termination Of Resuscitation Criteria In Out-Of-Hospital Hanging? PREHOSP EMERG CARE 2018; 23:1-8. [PMID: 30118612 DOI: 10.1080/10903127.2018.1476635] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 03/01/2018] [Accepted: 05/09/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Survival rate of cardiac arrest due to hanging (H-CA) victims is low. Hence, this leads to the question of the utility of resuscitation in these patients. The objective was to investigate whether there are predictive criteria for survival with a good neurological outcome or predictive criteria for non-survival or survival with a poor neurological outcome enabling us to define the termination of resuscitation rules in these patients. METHODS Between July 1, 2011 and January 1, 2016, we included 1,689 out-of-hospital cardiac arrests due to hanging. We compared the characteristics of survivors with a good neurological outcome at day 30 with the others. RESULTS The study population was mainly composed of males with a median age of 48 [37-60]. The overall survival was 2.1%, among which 48.6% had a good neurological outcome. Survivors benefited more often from immediate basic life support than the rest of the subjects, which was corroborated by the shorter no-flow durations. We did not record any difference in terms of advanced cardiac life support initiation frequency and technique between survivors with a good neurological outcome and the rest. Nevertheless, ACLS duration was longer in survivors with a good neurological outcome than in others. CONCLUSIONS Basic life support (BLS) was the decisive criterion for 15/17 survivors. However, a detailed analysis showed 2 survivors presenting no BLS before the arrival of mobile medical teams and non-shockable rhythms who survived at day 30 with a good neurological outcome. These results lead us to consider that mobile medical team intervention and ACLS attempt are not futile, and the benefit justifies the cost. Thus, we cannot define any rule for the termination of resuscitation.
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Anderson NE, Gott M, Slark J. Grey areas: New Zealand ambulance personnel’s experiences of challenging resuscitation decision-making. Int Emerg Nurs 2018; 39:62-67. [DOI: 10.1016/j.ienj.2017.08.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 07/30/2017] [Accepted: 08/04/2017] [Indexed: 11/24/2022]
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Yates EJ, Schmidbauer S, Smyth AM, Ward M, Dorrian S, Siriwardena AN, Friberg H, Perkins GD. Out-of-hospital cardiac arrest termination of resuscitation with ongoing CPR: An observational study. Resuscitation 2018; 130:21-27. [PMID: 29958956 DOI: 10.1016/j.resuscitation.2018.06.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/10/2018] [Accepted: 06/15/2018] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Termination of resuscitation guidelines for out-of-hospital cardiac arrest can identify patients in whom continuing resuscitation has little chance of success. This study examined the outcomes of patients transferred to hospital with ongoing CPR. It assessed outcomes for those who would have met the universal prehospital termination of resuscitation criteria (no shocks administered, unwitnessed by emergency medical services, no return of spontaneous circulation). METHODS A retrospective cohort study of consecutive adult patients who were transported to hospital with ongoing CPR was conducted at three hospitals in the West Midlands, UK between September 2016 and November 2017. Patient characteristics, interventions and response to treatment (ROSC, survival to discharge) were identified. RESULTS 227 (median age 69 years, 67.8% male) patients were identified. 89 (39.2%) met the universal prehospital termination of resuscitation criteria. Seven (3.1%) were identified with a potentially reversible cause of cardiac arrest. After hospital arrival, patients received few specialist interventions that were not available in the prehospital setting. Most (n = 210, 92.5%) died in the emergency department. 17 were admitted (14 to intensive care), of which 3 (1.3%) survived to hospital discharge. There were no survivors (0%) in those who met the criteria for universal prehospital termination of resuscitation. CONCLUSION Overall survival amongst patients transported to hospital with ongoing CPR was very poor. Application of the universal prehospital termination of resuscitation rule, in patients without obvious reversible causes of cardiac arrest, would have allowed resuscitation to have been discontinued at the scene for 39.2% of patients who did not survive.
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Affiliation(s)
- E J Yates
- Critical Care Unit, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, West Midlands, UK.
| | - S Schmidbauer
- Lund University, Skåne University Hospital, Dept. of Clinical Sciences, Anaesthesiology and Intensive Care, Malmö, Sweden; Center for Cardiac Arrest at Lund University, Lund University, Lund, Sweden
| | - A M Smyth
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK; West Midlands Ambulance Service NHS Foundation Trust, West Midlands, UK
| | - M Ward
- West Midlands Ambulance Service NHS Foundation Trust, West Midlands, UK
| | - S Dorrian
- Department of Emergency Medicine, University Hospitals Birmingham NHS Foundation Trust, West Midlands, UK
| | - A N Siriwardena
- Community and Health Research Unit, School of Health and Social Care, College of Social Science, University of Lincoln, Lincoln, UK
| | - H Friberg
- Lund University, Skåne University Hospital, Dept. of Clinical Sciences, Anaesthesiology and Intensive Care, Malmö, Sweden; Center for Cardiac Arrest at Lund University, Lund University, Lund, Sweden
| | - G D Perkins
- Critical Care Unit, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, West Midlands, UK
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Abstract
AbstractEthical dilemmas can create moral distress in even the most experienced emergency physicians (EPs). Following reasonable and justified approaches can help alleviate such distress. The purpose of this article is to guide EPs providing Emergency Medical Services (EMS) direction to navigate through common ethical issues confronted in the prehospital delivery of care, including protecting privacy and confidentiality, decision-making capacity and refusal of treatment, withholding of treatment, and termination of resuscitation (TOR). This requires a strong foundation in the principles and theories underlying sound ethical decisions that EPs and prehospital providers make every day in good faith, but will now also make with more awareness and conscientiousness.BrennerJM, AsweganAL, VearrierLE, BasfordJB, IsersonKV. The ethics of real-time EMS direction: suggested curricular content. Prehosp Disaster Med. 2018;33(2):201–212.
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How to conduct implementation trials and multicentre studies in the emergency department. CAN J EMERG MED 2018; 20:448-452. [PMID: 29378671 DOI: 10.1017/cem.2017.433] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The objective of Panel 2b was to present an overview of and recommendations for the conduct of implementation trials and multicentre studies in emergency medicine. METHODS Panel members engaged methodologists to discuss the design and conduct of implementation and multicentre studies. We also conducted semi-structured interviews with 37 Canadian adult and pediatric emergency medicine researchers to elicit barriers and facilitators to conducting these kinds of studies. RESULTS Responses were organized by themes, and, based on these responses, recommendations were developed and refined in an iterative fashion by panel members. CONCLUSIONS We offer eight recommendations to facilitate multicentre clinical and implementation studies, along with guidance for conducting implementation research in the emergency department. Recommendations for multicentre studies reflect the importance of local study investigators and champions, requirements for research infrastructure and staffing, and the cooperation and communication between the coordinating centre and participating sites.
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Anderson NE, Gott M, Slark J. Beyond prognostication: ambulance personnel’s lived experiences of cardiac arrest decision-making. Emerg Med J 2018; 35:208-213. [DOI: 10.1136/emermed-2017-206743] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 12/13/2017] [Accepted: 12/18/2017] [Indexed: 11/04/2022]
Abstract
IntroductionThe purpose of this study was to explore ambulance personnel’s decisions to commence, continue, withhold or terminate resuscitation efforts for patients with out-of-hospital cardiac arrest.MethodSemistructured interviews with a purposive sample of 16 demographically diverse ambulance personnel, currently employed in a variety of emergency ambulance response roles, around New Zealand.ResultsParticipants sought and integrated numerous factors, beyond established prognostic indicators, when making resuscitation decisions. Factors appeared to be integrated in four distinct phases, described under four main identified themes: prearrival impressions, immediate on-scene impressions, piecing together the big picture and transition to termination of resuscitation. Commencing or continuing resuscitation was sometimes a default action, particularly where ambulance personnel felt the context was uncertain, unfamiliar or overwhelming. Managing the impact of termination of resuscitation and resulting scene of a death required significant confidence, psychosocial skills and experience.ConclusionThis unique, exploratory study provides new insights into ambulance personnel’s experiences of prehospital resuscitation decision-making. Prognostication in out-of-hospital cardiac arrest is known to be challenging, but results from this study suggest that confidence in a poor prognosis for the cardiac arrested patient is only part of the resuscitation decision-making picture. Results suggest ambulance personnel may benefit from greater educational preparation and mentoring in managing the scene of a death to avoid inappropriate or prolonged resuscitation efforts.
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Setälä P, Hoppu S, Virkkunen I, Yli-Hankala A, Kämäräinen A. Assessment of futility in out-of-hospital cardiac arrest. Acta Anaesthesiol Scand 2017; 61:1334-1344. [PMID: 28905989 DOI: 10.1111/aas.12966] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/27/2017] [Accepted: 08/08/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Our aim was to evaluate the impact of futile resuscitation attempts to the outcome calculations of attempted resuscitation in out-of-hospital cardiac arrest (OHCA). Defined as partial resuscitations, we focused on a subgroup of patients in whom cardiopulmonary resuscitation (CPR) was initiated, but further efforts were soon abandoned due to evidence of futility. METHODS We conducted this study using the Utstein template during a 12-month study period. We compared the event characteristics between full and partial resuscitation attempts and determined the incidence, survival and neurological outcome. RESULTS Emergency Medical Services (EMS) attended a total of 314 OHCA cases. In 34 cases, resuscitation was not attempted due to futility. Seventy-four cases were partial resuscitation attempts where resuscitation was soon discontinued due to dismal prognostic factors. Partial attempts were associated with an unwitnessed OHCA, prolonged downtime, end-stage malignant disease, multiple trauma, asystole or pulseless electrical activity as the initial rhythm, and a first responding unit being the first unit on the scene (P < 0.05, respectively). The calculation of survival to hospital discharge rate was 14% and increased 5% when partial resuscitation attempts were excluded from the analysis. Seventy-four percentage had a Cerebral Performance Category 1-2 at hospital discharge. Shockable initial rhythm, public location and bystander CPR had a positive impact on survival. CONCLUSIONS Resuscitative efforts were considered futile in 11% of cases and resuscitation was discontinued due to evidence of futility in additional 24% cases based on additional information. Terminating resuscitation should be identified as a separate subgroup of OHCA cases to better reflect the outcome.
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Affiliation(s)
- P. Setälä
- Emergency Medical Service; Tampere University Hospital; Tampere Finland
- FinnHEMS Research and Development Unit; FinnHEMS Ltd; Vantaa Finland
| | - S. Hoppu
- Emergency Medical Service; Tampere University Hospital; Tampere Finland
- Department of Intensive Care; Tampere University Hospital; Tampere Finland
| | - I. Virkkunen
- Emergency Medical Service; Tampere University Hospital; Tampere Finland
- FinnHEMS Research and Development Unit; FinnHEMS Ltd; Vantaa Finland
| | - A. Yli-Hankala
- Medical School; University of Tampere; Tampere Finland
- Department of Anaesthesia; Tampere University Hospital; Tampere Finland
| | - A. Kämäräinen
- Emergency Medical Service; Tampere University Hospital; Tampere Finland
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Implementation of the universal BLS termination of resuscitation rule in a rural EMS system. Resuscitation 2017; 118:75-81. [DOI: 10.1016/j.resuscitation.2017.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 06/22/2017] [Accepted: 07/05/2017] [Indexed: 11/24/2022]
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Bossaert L, Perkins G, Askitopoulou H, Raffay V, Greif R, Haywood K, Mentzelopoulos S, Nolan J, Van de Voorde P, Xanthos T. Ethik der Reanimation und Entscheidungen am Lebensende. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0329-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Soar J, Nolan J, Böttiger B, Perkins G, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars M, Smith G, Sunde K, Deakin C. Erweiterte Reanimationsmaßnahmen für Erwachsene („adult advanced life support“). Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0330-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
OBJECTIVE The aim of this article was to compare specific characteristics and outcomes among adult and pediatric out-of-hospital cardiac arrest (OHCA) patients to show that the existing literature warrants the design and implementation of pediatric studies that would specifically evaluate termination of resuscitation protocols. We also address the emotional and practical concerns associated with ceasing resuscitation efforts on scene when treating pediatric patients. METHODS Relevant prospective and retrospective studies were used to compare characteristics and outcomes between adult and pediatric OHCA patients. Characteristics analyzed were nonwitnessed arrests, absence of shockable rhythm, no return of spontaneous circulation, and survival to hospital discharge. RESULTS Cases of unwitnessed arrests by emergency medical services providers are substantially the same in pediatric patients (41.0%-96.3%) compared with their adult counterparts (47.4%-97.7%). The adult studies revealed 57.6% to 92.2% of patients without an initial shockable rhythm. The pediatric studies showed a range of 64.0% to 98.0%. The range of adult patients without return of spontaneous circulation was 54.8% to 95.4%, and the range in pediatric patients was 68.2% to 95.6%. Survival rates among the adult studies ranged from 0.8% to 9.3% (mean, 5.0%; median, 5.2%), and in the pediatric studies they were 2.0% to 26.2% (mean, 9.2%; median, 7.7%). CONCLUSIONS The data compared demonstrate that characteristics and outcomes are virtually identical between adult and pediatric OHCA patients. We also found the 3 chief barriers hindering further research to be invalid impediments to moving forward. This review warrants designing pediatric studies that would specifically correlate termination of resuscitation protocols with patient survival and include predictive values.
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Tataris KL, Richards CT, Stein-Spencer L, Ryan S, Lazzara P, Weber JM. EMS Provider Perceptions on Termination of Resuscitation in a Large, Urban EMS System. PREHOSP EMERG CARE 2017; 21:610-615. [PMID: 28481722 DOI: 10.1080/10903127.2017.1317891] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Despite the value of out-of-hospital Termination of Resuscitation (TOR) and the scientific evidence in favor of this practice, TOR has not been uniformly adopted or consistently practiced in EMS systems. Previous focus group studies have identified multiple barriers to implementation of out of hospital TOR but existing literature on EMS provider perceptions is limited. We sought to identify EMS providers' perceived barriers to performing out-of-hospital TOR in a large urban EMS system. METHODS The Chicago EMS System is a regional collaborative of EMS physicians, nurses and provider agencies, including the Chicago Fire Department (CFD), which provides exclusive emergency response for 9-1-1 calls in Chicago. CFD is an urban, fire-based EMS agency with a tiered response, with fire-fighter EMTs and paramedics providing initial care, and single role paramedics providing supplemental care and transport. A 2-page written survey was distributed to understand providers' experiences with managing OHCA and perceived barriers to TOR to inform subsequent improvements in protocol development and education. RESULTS Of 3500 EMS providers that received the survey, 2309 were completed (66%). Survey respondent demographics were fire-fighter/EMTB (69%), fire-fighter/paramedic (14%), and single role paramedic (17%). The most frequent barrier to field TOR was scene safety (86%). The most common safety issue identified was family reaction to TOR (68%) and many providers felt threatened by family when trying to perform TOR (38%). Providers with a higher career numbers of OHCA were more likely to have felt threatened by the family (OR 6.70, 95% CI 2.99-15.00) and single role paramedics were more likely than FF/EMTBs to have felt threatened (OR 3.34, 95% CI 2.65-4.22). Barriers to delivering a death notification after TOR, include being uncomfortable or threatened with possible family reaction (52%) and family asking to continue the resuscitation (45%). There was lack of formal prior death notification training, the majority learned from colleagues through on the job training. CONCLUSIONS Our study identifies scene safety, death notification delivery, and lack of formal training in death notification as barriers that EMS providers face while performing TOR in a large urban EMS system. These findings informed educational and operational initiatives to overcome the identified provider level issues and improve compliance with TOR policies.
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Grunau B, Taylor J, Scheuermeyer FX, Stenstrom R, Dick W, Kawano T, Barbic D, Drennan I, Christenson J. External Validation of the Universal Termination of Resuscitation Rule for Out-of-Hospital Cardiac Arrest in British Columbia. Ann Emerg Med 2017; 70:374-381.e1. [PMID: 28302424 DOI: 10.1016/j.annemergmed.2017.01.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 01/04/2017] [Accepted: 01/19/2017] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE The Universal Termination of Resuscitation Rule (TOR Rule) was developed to identify out-of-hospital cardiac arrests eligible for field termination of resuscitation, avoiding futile transportation to the hospital. The validity of the rule in emergency medical services (EMS) systems that do not routinely transport out-of-hospital cardiac arrest patients to the hospital is unknown. We seek to validate the TOR Rule in British Columbia. METHODS This study included consecutive, nontraumatic, adult, out-of-hospital cardiac arrests treated by EMS in British Columbia from April 2011 to September 2015. We excluded patients with active do-not-resuscitate orders and those with missing data. Following consensus guidelines, we examined the validity of the TOR Rule after 6 minutes of resuscitation (to approximate three 2-minute cycles of resuscitation). To ascertain rule performance at the different time junctures, we recalculated TOR Rule classification accuracy at subsequent 1-minute resuscitation increments. RESULTS Of 6,994 consecutive, adult, EMS-treated, out-of-hospital cardiac arrests, overall survival was 15%. At 6 minutes of resuscitation, rule performance was sensitivity 0.72, specificity 0.91, positive predictive value 0.98, and negative predictive value 0.36. The TOR Rule recommended care termination for 4,367 patients (62%); of these, 92 survived to hospital discharge (false-positive rate 2.1%; 95% confidence interval 1.7% to 2.5%); however, this proportion steadily decreased with later application. The TOR Rule recommended continuation of resuscitation in 2,627 patients (38%); of these, 1,674 died (false-negative rate 64%; 95% confidence interval 62% to 66%). Compared with 6-minute application, test characteristics at 30 minutes demonstrated nearly perfect positive predictive value (1.0) and specificity (1.0) but a lower sensitivity (0.46) and negative predictive value (0.25). CONCLUSION In this cohort of adult out-of-hospital cardiac arrest patients, the TOR Rule applied at 6 minutes falsely recommended care termination for 2.1% of patients; however, this decreased with later application. Systems using the TOR Rule to cease resuscitation in the field should consider rule application at points later than 6 minutes.
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Affiliation(s)
- Brian Grunau
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada; St. Paul's Hospital, Vancouver, British Columbia, Canada; Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada.
| | - John Taylor
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Frank X Scheuermeyer
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada; St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Robert Stenstrom
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada; St. Paul's Hospital, Vancouver, British Columbia, Canada; Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - William Dick
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada; British Columbia Emergency Health Services
| | - Takahisa Kawano
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada; St. Paul's Hospital, Vancouver, British Columbia, Canada; Department of Emergency Medicine, University of Fukui Hospital, Fukui Prefecture, Japan
| | - David Barbic
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada; St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Ian Drennan
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Jim Christenson
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada; St. Paul's Hospital, Vancouver, British Columbia, Canada
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Xiong Y, Zhan H, Lu Y, Guan K, Okoro N, Mitchell D, Dwyer M, Leatham A, Salazar G, Liao X, Idris A. Out-of-hospital cardiac arrest without return of spontaneous circulation in the field: Who are the survivors? Resuscitation 2017; 112:28-33. [DOI: 10.1016/j.resuscitation.2016.12.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 12/06/2016] [Accepted: 12/09/2016] [Indexed: 10/20/2022]
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Mikkelsen S, Lossius HM, Binderup LG, Schaffalitzky de Muckadell C, Toft P, Lassen AT. Termination of pre-hospital resuscitation by anaesthesiologists - causes and consequences. A retrospective study. Acta Anaesthesiol Scand 2017; 61:250-258. [PMID: 27891574 DOI: 10.1111/aas.12838] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 10/28/2016] [Accepted: 11/06/2016] [Indexed: 12/01/2022]
Abstract
AIM Differentiating between a newly deceased patient and the lifeless patient in whom immediate resuscitation is required may be facilitated by a pre-hospital anaesthesiologist. The purpose of our study was to investigate to what extent and why the pre-hospital anaesthesiologist pronounced life extinct in situations where an emergency medical technician (EMT) would have been required to resuscitate. METHODS All lifeless patients seen pre-hospitally by the anaesthesiologist-manned Mobile Emergency Care Unit in Odense, Denmark, from 2010 to 2014 were retrospectively studied. RESULTS Of 17 035 contacts, 1275 patients were lifeless without reliable signs of death. In 642 of these patients (3.8%) resuscitation was initiated (median age 68 years). The remaining 633 patients (3.7%) were declared dead at the scene without any resuscitation attempt (median age 77 years). These latter patients would have been attempted resuscitated, had the anaesthesiologist not been present. In 54.5% of cases where documentation was available in the patient records, reasons for not resuscitating these patients included time elapsed from incident to contact with physician, 'overall assessment', chronic disease, or do-not-resuscitate order. CONCLUSION In one patient in 30, the MECU refrained from futile resuscitation in cases where legislation required an EMT to initiate resuscitation. This practice reduced unethical attempts of resuscitation, reduced unnecessary emergency ambulance transports, and reduced the work load of the hospital resuscitation teams for one unnecessary alarm every third day. Differentiating between lifeless patients and dead patients not exhibiting reliable signs of death, however, is a complex task which is only sparsely documented.
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Affiliation(s)
- S Mikkelsen
- Mobile Emergency Care Unit, Department of Anaesthesiology and Intensive Care Medicine V, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - H M Lossius
- Field of Prehospital Critical Care, Network for Medical Sciences, University of Stavanger, Stavanger, Norway
- Norwegian Air Ambulance Foundation, Drøbak, Norway
| | - L G Binderup
- Philosophy, Department for the Study of Culture, University of Southern Denmark, Odense, Denmark
| | | | - P Toft
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Anaesthesiology and Intensive Care Medicine V, Odense University Hospital, Odense, Denmark
| | - A T Lassen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
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Drennan IR, Case E, Verbeek PR, Reynolds JC, Goldberger ZD, Jasti J, Charleston M, Herren H, Idris AH, Leslie PR, Austin MA, Xiong Y, Schmicker RH, Morrison LJ. A comparison of the universal TOR Guideline to the absence of prehospital ROSC and duration of resuscitation in predicting futility from out-of-hospital cardiac arrest. Resuscitation 2016; 111:96-102. [PMID: 27923115 DOI: 10.1016/j.resuscitation.2016.11.021] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 11/08/2016] [Accepted: 11/21/2016] [Indexed: 01/27/2023]
Abstract
INTRODUCTION The Universal Termination of Resuscitation (TOR) Guideline accurately identifies potential out-of-hospital cardiac arrest (OHCA) survivors. However, implementation is inconsistent with some Emergency Medical Service (EMS) agencies using absence of return of spontaneous circulation (ROSC) as sole criterion for termination. OBJECTIVE To compare the performance of the Universal TOR Guideline with the single criterion of no prehospital ROSC. Second, to determine factors associated with survival for patients transported without a ROSC. Lastly, to compare the impact of time to ROSC as a marker of futility to the Universal TOR Guideline. DESIGN Retrospective, observational cohort study. PARTICIPANTS Non-traumatic, adult (≥18 years) OHCA patients of presumed cardiac etiology treated by EMS providers. SETTING ROC-PRIMED and ROC-Epistry post ROC-PRIMED databases between 2007 and 2011. OUTCOMES Primary outcome was survival to hospital discharge and the secondary outcome was functional survival. We used multivariable regression to evaluate factors associated with survival in patients transported without a ROSC. RESULTS 36,543 treated OHCAs occurred of which 9467 (26%) were transported to hospital without a ROSC. Patients transported without a ROSC who met the Universal TOR Guideline for transport had a survival of 3.0% (95% CI 2.5-3.4%) compared to 0.7% (95% CI 0.4-0.9%) in patients who met the Universal TOR Guideline for termination. The Universal TOR Guideline identified 99% of survivors requiring continued resuscitation and transportation to hospital including early identification of survivors who sustained a ROSC after extended durations of CPR. CONCLUSION Using absence of ROSC as a sole predictor of futility misses potential survivors. The Universal TOR Guideline remains a strong predictor of survival.
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Affiliation(s)
- Ian R Drennan
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, 30 Bond St. Toronto, Ontario M5B 1W8, Canada.
| | - Erin Case
- Clinical Trial Center, University of Washington Department of Biostatistics, Seattle, WA 98103, United States.
| | - P Richard Verbeek
- Sunnybrook Centre for Prehospital Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
| | - Joshua C Reynolds
- Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI, United States.
| | - Zachary D Goldberger
- University of Washington School of Medicine, Department of Internal Medicine, Division of Cardiology, Harborview Medical Center, Seattle, WA, United States.
| | - Jamie Jasti
- Resuscitation Research Centre, Department of Emergency Medicine, Medical College of Wisconsin, WI, United States.
| | | | - Heather Herren
- ROC Clinical Trial Center, University of Washington, Seattle, WA, United States.
| | - Ahamed H Idris
- Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center, United States.
| | - Paul R Leslie
- British Columbia Emergency Health Services, British Columbia, Canada.
| | - Michael A Austin
- The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.
| | - Yan Xiong
- Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center, United States.
| | - Robert H Schmicker
- Clinical Trial Center, University of Washington Department of Biostatistics, Seattle, WA 98103, United States.
| | - Laurie J Morrison
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Division of Emergency Medicine, Department of Medicine, University of Toronto, Ontario, Canada.
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Aelen P, Noordergraaf GJ. Dynamic prediction of ROSC: Is the art of prognostication in Resuscitation becoming science? Resuscitation 2016; 111:A3-A4. [PMID: 27855274 DOI: 10.1016/j.resuscitation.2016.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 11/06/2016] [Indexed: 11/18/2022]
Affiliation(s)
- Paul Aelen
- Patient Care & Measurements, Philips Research, High Tech Campus, Eindhoven, The Netherlands; CPRLab, Elisabeth-Tweesteden Ziekenhuis, Tilburg, The Netherlands
| | - Gerrit J Noordergraaf
- Departments of Anesthesiology, Resuscitation & Pain management/CPRLab, Elisabeth-Tweesteden Ziekenhuis, Tilburg, The Netherlands.
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Funada A, Goto Y, Maeda T, Tada H, Teramoto R, Tanaka Y, Hayashi K, Yamagishi M. Prehospital predictors of neurological outcomes in out-of-hospital cardiac arrest patients aged 95 years and older: A nationwide population-based observational study. J Cardiol 2016; 69:340-344. [PMID: 27727087 DOI: 10.1016/j.jjcc.2016.07.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 07/04/2016] [Accepted: 07/13/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Population aging has rapidly progressed in Japan. However, few data exist regarding the characteristics of extremely elderly patients with out-of-hospital cardiac arrest (OHCA). We aimed to determine the prehospital predictors of one-month survival with favorable neurological outcomes (Cerebral Performance Category scale, category 1 or 2; CPC 1-2) in this population. METHODS We investigated 23,520 OHCA patients aged ≥95 years from a prospectively recorded, nationwide, Utstein-style Japanese database between 2008 and 2012. The primary study endpoint was one-month CPC 1-2 after OHCA. RESULTS The one-month CPC 1-2 rate was 0.27% (63/23,520). Only two variables were significantly associated with one-month CPC 1-2 in a multivariate logistic regression model: prehospital return of spontaneous circulation (ROSC) [adjusted odds ratio (aOR), 94.4; 95% confidential interval (CI), 50.1-191.7] and emergency medical service (EMS)-witnessed arrest (aOR, 5.1; 95% CI, 2.6-10.2). When stratified by these two predictors, the one-month CPC 1-2 rates were 20.2% (18/89) for patients who had both prehospital ROSC and EMS-witnessed arrest, 4.2% (33/783) for those who had prehospital ROSC without EMS-witnessed arrest, 0.28% (3/1065) for those who had EMS-witnessed arrest without prehospital ROSC, and 0.04% (9/21,583) for those who had neither predictor, respectively. CONCLUSIONS The crucial prehospital predictors for one-month CPC 1-2 in elderly OHCA patients aged ≥95 years in Japan were prehospital ROSC and EMS-witnessed arrest and the former was the predominant predictor.
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Affiliation(s)
- Akira Funada
- Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Kanazawa, Japan; Division of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Yoshikazu Goto
- Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Kanazawa, Japan.
| | - Tetsuo Maeda
- Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Hayato Tada
- Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Kanazawa, Japan; Division of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Ryota Teramoto
- Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Kanazawa, Japan; Division of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Yoshihiro Tanaka
- Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Kanazawa, Japan; Division of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Kenshi Hayashi
- Division of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Masakazu Yamagishi
- Division of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
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Soar J, Nolan JP, Böttiger BW, Perkins GD, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars MB, Smith GB, Sunde K, Deakin CD. European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support. Resuscitation 2016; 95:100-47. [PMID: 26477701 DOI: 10.1016/j.resuscitation.2015.07.016] [Citation(s) in RCA: 926] [Impact Index Per Article: 115.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK.
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Germany
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Heart of England NHS Foundation Trust, Birmingham, UK
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University, Mainz, Germany
| | - Pierre Carli
- SAMU de Paris, Department of Anaesthesiology and Intensive Care, Necker University Hospital, Paris, France
| | - Tommaso Pellis
- Anaesthesia, Intensive Care and Emergency Medical Service, Santa Maria degli Angeli Hospital, Pordenone, Italy
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | - Markus B Skrifvars
- Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Gary B Smith
- Centre of Postgraduate Medical Research & Education, Bournemouth University, Bournemouth, UK
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care, NIHR Southampton Respiratory Biomedical Research Unit, University Hospital Southampton, Southampton, UK
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