Causes of in-hospital cardiac arrest – Incidences and rate of recognition

Aetiology and predictors of outcome in non-shockable in-hospital cardiac arrest: A retrospective cohort study from the Swedish Registry for Cardiopulmonary Resuscitation

BACKGROUND

Non-shockable in-hospital cardiac arrest (IHCA) is a condition with diverse aetiology, predictive factors, and outcome. This study aimed to compare IHCA with initial asystole or pulseless electrical activity (PEA), focusing specifically on their aetiologies and the significance of predictive factors.

METHODS

Using the Swedish Registry of Cardiopulmonary Resuscitation, adult non-shockable IHCA cases from 2018 to 2022 (n = 5788) were analysed. Exposure was initial rhythm, while survival to hospital discharge was the primary outcome. A random forest model with 28 variables was used to generate permutation-based variable importance for outcome prediction.

RESULTS

Overall, 60% of patients (n = 3486) were male and the median age was 75 years (IQR 67-81). The most frequent arrest location (46%) was on general wards. Comorbidities were present in 79% of cases and the most prevalent comorbidity was heart failure (33%). Initial rhythm was PEA in 47% (n = 2702) of patients, and asystole in 53% (n = 3086). The most frequent aetiologies in both PEA and asystole were cardiac ischemia (24% vs. 19%, absolute difference [AD]: 5.4%; 95% confidence interval [CI] 3.0% to 7.7%), and respiratory failure (14% vs. 13%, no significant difference). Survival was higher in asystole (24%) than in PEA (17%) (AD: 7.3%; 95% CI 5.2% to 9.4%). Cardiopulmonary resuscitation (CPR) durations were longer in PEA, 18 vs 15 min (AD 4.9 min, 95% CI 4.0-5.9 min). The duration of CPR was the single most important predictor of survival across all subgroup and sensitivity analyses. Aetiology ranked as the second most important predictor in most analyses, except in the asystole subgroup where responsiveness at cardiac arrest team arrival took precedence.

CONCLUSIONS

In this nationwide registry study of non-shockable IHCA comparing asystole to PEA, cardiac ischemia and respiratory failure were the predominant aetiologies. Duration of CPR was the most important predictor of survival, followed by aetiology. Asystole was associated with higher survival compared to PEA, possibly due to shorter CPR durations and a larger proportion of reversible aetiologies.

Mechanical versus manual cardiopulmonary resuscitation (CPR): an umbrella review of contemporary systematic reviews and more

BACKGROUND

High-quality cardiopulmonary resuscitation (CPR) can restore spontaneous circulation (ROSC) and neurological function and save lives. We conducted an umbrella review, including previously published systematic reviews (SRs), that compared mechanical and manual CPR; after that, we performed a new SR of the original studies that were not included after the last published SR to provide a panoramic view of the existing evidence on the effectiveness of CPR methods.

METHODS

PubMed, EMBASE, and Medline were searched, including English in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA) SRs, and comparing mechanical versus manual CPR. A Measurement Tool to Assess Systematic Reviews (AMSTAR-2) and GRADE were used to assess the quality of included SRs/studies. We included both IHCA and OHCA, which compared mechanical and manual CPR. We analyzed at least one of the outcomes of interest, including ROSC, survival to hospital admission, survival to hospital discharge, 30-day survival, and survival to hospital discharge with good neurological function. Furthermore, subgroup analyses were performed for age, gender, initial rhythm, arrest location, and type of CPR devices.

RESULTS

We identified 249 potentially relevant records, of which 238 were excluded. Eleven SRs were analyzed in the Umbrella review (January 2014-March 2022). Furthermore, for a new, additional SR, we identified eight eligible studies (not included in any prior SR) for an in-depth analysis between April 1, 2021, and February 15, 2024. The higher chances of using mechanical CPR for male patients were significantly observed in three studies. Two studies showed that younger patients received more mechanical treatment than older patients. However, studies did not comment on the outcomes based on the patient's gender or age. Most SRs and studies were of low to moderate quality. The pooled findings did not show the superiority of mechanical compared to manual CPR except in a few selected subgroups.

CONCLUSIONS

Given the significant heterogeneity and methodological limitations of the included studies and SRs, our findings do not provide definitive evidence to support the superiority of mechanical CPR over manual CPR. However, mechanical CPR can serve better where high-quality manual CPR cannot be performed in selected situations.

[Quality of life after in-hospital cardiac arrest : An 11-year experience from an university center]

BACKGROUND

Cardiac arrest is a life-threatening condition requiring urgent medical care and is one of the leading causes of death worldwide. Given that in-hospital cardiac arrest (IHCA) is still poorly investigated, data on health-associated quality of life thereafter remains scarce. The available evidence is mostly transferred from out-of-hospital cardiac arrest studies, but the epidemiology and determinants of success might be different. The aim of the study was to investigate the change in the quality of life after in-hospital cardiac arrest and to identify potential risk factors for a poor outcome.

MATERIAL AND METHODS

This retrospective analysis of data and prospective evaluation of quality of life included all patients surviving an IHCA and being treated by the emergency medical team between 2010 and 2020. The primary endpoint of the study was the quality of life after IHCA at the reference date. Secondary endpoints covered determination of risk factors and predictors of poor outcome after in-hospital cardiopulmonary resuscitation.

RESULTS

In total 604 patients were resuscitated within the period of 11 years and 61 (10%) patients survived until the interview took place. Finally, 48 (79%) patients fulfilled the inclusion criteria and 31 (65%) were included in the study. There was no significant difference in the quality of life before and after cardiac arrest (EQ-5D-5L utility 0.79 vs. 0.78, p = 0.567) and in the EQ-5D-5L visual analogue scale (VAS) score.

CONCLUSION

The quality of life before and after IHCA in survivors was good and comparable. The quality of life was mostly affected by reduced mobility and anxiety/depression. Future studies with larger patient samples should focus on potentially modifiable factors that could prevent, warn, and limit the consequences of in-hospital cardiac arrest. Moreover, research on outcomes of IHCA should include available tools for the quality of life assessment.

Survey of hospital practitioners: common understanding of cardiopulmonary resuscitation definition and outcomes

BACKGROUND

Cardiopulmonary resuscitation (CPR) is internationally defined as chest compressions and rescue breaths, and is a subset of resuscitation. First used for out-of-hospital cardiac arrest, CPR is now frequently used for in-hospital cardiac arrest (IHCA) with different causes and outcomes.

AIMS

This paper aims to describe clinical understanding of the role of in-hospital CPR and perceived outcomes for IHCA.

METHODS

An online survey of a secondary care staff involved in resuscitation was conducted, focussing on definitions of CPR, features of do-not-attempt-CPR conversations with patients and clinical case scenarios. Data were analysed using a simple descriptive approach.

RESULTS

Of 652 responses, 500 were complete and used for analysis. Two hundred eleven respondents were senior medical staff covering acute medical disciplines. Ninety-one percent of respondents agreed or strongly agreed that defibrillation is part of CPR, and 96% believed CPR for IHCA included defibrillation. Responses to clinical scenarios were dissonant, with nearly half of respondents demonstrating a pattern of underestimating survival and subsequently showing a desire to offer CPR in similar scenarios with poor outcomes. This was unaffected by seniority and level of resuscitation training.

CONCLUSIONS

The common use of CPR in hospital reflects the broader definition of resuscitation. Recapturing the CPR definition for clinicians and patients as only chest compressions and rescue breaths may allow clinicians to better discuss individualised resuscitation care to aide meaningful shared decision-making around patient deterioration. This may involve reframing current in-hospital algorithms and uncoupling CPR from wider resuscitative measures.

Effect of averaging time and respiratory pause time on the measurement of acoustic respiration rate monitoring

BACKGROUND

Acoustic respiration rate (RRa) monitoring is a method of continuously measuring respiratory rate using a signal from an acoustic transducer placed over the airway. The purpose of the present study is to examine how the averaging time and respiratory pause time settings of an RRa monitor affect the detection time of sudden respiratory rate changes.

METHODS

A total of 40 healthy adult volunteers were included in the study. First, we measured the apnea detection time (apnea test) by dividing them into two groups (N = 20 each), one with a respiratory pause time setting of 20 s and the other with 40 s. Each group performed two apnea tests with an averaging time setting of 10 and 30 s. Next, we measured the tachypnea detection time (tachypnea test) for half of the subjects (N = 20) with two averaging time settings of 10 and 30 s. For each test, three measurements were taken, and the average of the three measurements was recorded.

RESULTS

There was no significant difference in the apnea detection time between the averaging time set at 10 and 30 s regardless of whether the respiratory pause time was set at 20 or 40 s. However, the apnea detection time was significantly shorter with the respiratory pause time of 20 s than 40 s, regardless of whether the averaging time was set at 10 or 30 s (p < 0.001). The tachypnea detection time was shorter with the averaging time of 10 s than 30 s (p < 0.001). Furthermore, the apnea detection time and tachypnea detection time were much longer than the actual settings.

CONCLUSIONS

The results of the current study show that in the measurement of RRa, the apnea detection time is more affected by the respiratory pause time setting than the averaging time setting; however, the tachypnea detection time is significantly affected by the averaging time setting.

The outcomes of cardiopulmonary resuscitation and their predictors during the coronavirus 2019 pandemic in Iran

BACKGROUND

Coronavirus disease 2019 (COVID-19) can negatively affect different healthcare-related outcomes. Nonetheless, there is limited information about its effects on different healthcare-related outcomes. This study aimed at evaluating the outcomes of cardiopulmonary resuscitation (CPR) and their predictors during the COVID-19 pandemic in Iran.

METHODS

This cross-sectional study was conducted on 1253 patients who had undergone CPR in the emergency wards of teaching hospitals in the west of Iran from the beginning of the first wave to the end of the third epidemic wave of COVID-19 in Iran, between February 20, 2020, and January 20, 2021. Data were collected using the National CPR Documentation Forms developed based on the Utstein Style and routinely used for all patients with cardiac arrest (CA). The SPSS (v. 20.0) program was used to analyze the data through the Chi-square, Fisher's exact, and Mann-Whitney U tests and logistic regression analysis.

RESULTS

Participants' age mean was 64.62 ± 17.54 years. Age mean among participants with COVID-19 was eight years more than other participants. Most participants were male (64.09%) and had at least one underlying disease (64.99%). The total rates of the return of spontaneous circulation (ROSC) and CPR-discharge survival were respectively 15.3% and 3.8% among all participants, 20.25% and 5.17% among participants without COVID-19, and 8.96% and 2.04% among participants with COVID-19. The significant predictors of ROSC were age, affliction by COVID-19, affliction by underlying diseases, baseline rhythm, delay in epinephrine administration, and epinephrine administration time interval, while the significant predictors of CPR-discharge survival were age and baseline rhythm.

CONCLUSIONS

The total rates of ROSC and CPR-discharge survival were respectively 15.3% and 3.8% among all participants. The rates of ROSC and CPR to discharge survival among patients without COVID-19 are respectively 2.26 and 2.53 times more than the rates among patients with COVID-19.

Investigating the outcomes of cardiopulmonary resuscitation and factors affecting it: A cross-sectional study at Dr. Moaven Hospital, Sahneh City from 2014 to 2021

Background and Aims

Cardiopulmonary resuscitation (CPR) is referred to an attempt to maintain the respiratory system and blood circulation active to oxygenate the body's important organs until the heart and blood circulation system return to normal. CPR results are influenced by a variety of circumstances and factors. The purpose of this study was to look into the outcomes of CPR and the factors that influence them at the Dr. Moaven Hospital in Sahneh.

Methods

This cross-sectional descriptive study was carried out retrospectively from the start of 2014 to the start of 2021. Kermanshah University of Medical Sciences provides hospitals with a two-page form for data collection. After entering the data into SPSS24, descriptive and inferential statistical tests were applied to analyze the results.

Results

Out of 497 patients who referred to Dr. Moaven Hospital in Sahne City, 280 were men and 217 were women, with a resuscitation success rate of 22.5% in men and 23.5% in women. CPR was conducted on 63.2% of patients in the emergency department, with 22.2% of them having successful CPR. The existence of the underlying disease had a statistically significant link with the outcomes of CPR (p = 0.007). The most prevalent cause for visit was cardiorespiratory arrest (30.6%), and there was no statistically significant difference between the diagnostic and reason for visit and the outcome of resuscitation, according to the χ 2 test.

Conclusion

According to the findings of this study, increasing age and duration of CPR, the existence of underlying diseases, and the absence of shockable rhythms all reduce the likelihood of success in CPR.

Aetiology and outcome in hospitalized cardiac arrest patients

Aims

To study aetiologies of in-hospital cardiac arrests (IHCAs) and their association with 30-day survival.

Methods and results

Observational study with data from national registries. Specific aetiologies (n = 22) of IHCA patients between April 2018 and December 2020 were categorized into cardiac vs. non-cardiac and six main aetiology categories: myocardial ischemia, other cardiac causes, pulmonary causes, infection, haemorrhage, and other non-cardiac causes. Main endpoints were proportions in each aetiology, 30-day survival, and favourable neurological outcome (Cerebral Performance Category scale 1-2) at discharge. Among, 4320 included IHCA patients (median age 74 years, 63.1% were men), approximate 50% had cardiac causes with a 30-day survival of 48.4% compared to 18.7% among non-cardiac causes (P < 0.001). The proportion in each category were: myocardial ischemia 29.9%, pulmonary 21.4%, other cardiac causes 19.6%, other non-cardiac causes 11.6%, infection 9%, and haemorrhage 8.5%. The odds ratio (OR) for 30-day survival compared to myocardial ischemia for each category were: other cardiac causes OR 1.48 (CI 1.24-1.76); pulmonary causes OR 0.36 (CI 0.3-0.44); infection OR 0.25 (CI 0.18-0.33); haemorrhage OR 0.22 (CI 0.16-0.3); and other non-cardiac causes OR 0.56 (CI 0.45-0.69). IHCA caused by myocardial ischemia had the best favourable neurological outcome while those caused by infection had the lowest OR 0.06 (CI 0.03-0.13).

Conclusion

In this nationwide observational study, aetiologies with cardiac and non-cardiac causes of IHCA were evenly distributed. IHCA caused by myocardial ischemia and other cardiac causes had the strongest associations with 30-day survival and neurological outcome.

Outcomes of Cardiopulmonary Resuscitation and Predictors of Its Outcomes in the Emergency Department in King Saud Medical City, Saudi Arabia

BACKGROUND

Cardiac arrest is a medical emergency marked by the cessation of cardiac mechanical activity and insufficient blood flow. CPR (cardiopulmonary resuscitation) is a life-saving method that involves restoring the essential functions of two vital organs: the heart and lungs. This study was conducted to identify the outcome of CPR in cardiac arrest patients presented to the emergency department (ED) and to identify predictors of CPR outcomes.

METHODOLOGY

This was a retrospective, descriptive study. All in-hospital cardiac arrest patients who underwent CPR in the King Saud Medical City (KSMC) ED between January 2017 and January 2020 were analyzed, with a sample size of 351 patients.

RESULTS

Overall return of spontaneous circulation (ROSC) and survival to discharge (STD) were achieved in 106 (30.2%) and 40 (11.39%) patients, respectively. When assessing the predictors of ROSC, the analyses showed that patient age, pre-arrest intubation, the method used to deliver oxygen, and CPR duration were all statistically significant predictors for ROSC. Similarly, when assessing predictors associated with STD, the analyses showed that patient age, pre-arrest intubation, the method used to deliver oxygen, and CPR duration were positively associated with STD.

CONCLUSION

Comparing the study's findings to those of similar studies, it shows a CPR outcome rate within the range of similar studies. It also highlights that CPR outcomes are highly associated with CPR duration (a maximum of 30 minutes), younger age, and endotracheal intubation.

Pulmonary embolism management in the emergency department: part 2

Pulmonary embolism (PE) can present with a range of severity. Prognostic risk stratification is important for efficacious and safe management. This second of two review articles discusses the management of high-, intermediate- and low-risk PE. We discuss strategies to identify patients suitable for urgent outpatient care in addition to identification of patients who would benefit from thrombolysis. We discuss specific subgroups of patients where optimal treatment differs from the usual approach and identify emerging management paradigms exploring new therapies and subgroups.

In-hospital cardiac arrest rhythm analysis by anesthesiologists: a diagnostic performance study

PURPOSE

In-hospital cardiac arrest is associated with high morbidity and mortality, with an overall survival rate at one year of approximately 13%. The first cardiac rhythm is often analyzed by anesthesiologist-intensivists. We aimed to determine the diagnostic performance of anesthesiologist-intensivists when distinguishing between shockable and nonshockable rhythms.

METHODS

We conducted a simulation-based, multicentre, prospective, observational study between May 2019 and March 2020. The responses of the participants were used to calculate individual sensitivity (defined as the proportion of decisions to shock for shockable rhythms) and individual specificity (defined as the proportion of decisions not to shock for nonshockable rhythms). The main outcome measure was the overall diagnostic performance, defined as the overall sensitivity and specificity. Secondary outcome measures were the sensitivity and specificity of participants' decisions for each type of cardiac arrest rhythm and their decision-making times.

RESULTS

Among the 267 physicians contacted, 179 (67%) completed the test. The median [interquartile range (IQR)] overall sensitivity was 88 [79-95]% and the median overall specificity was 86 [77-92]%. Among shockable rhythms, the median [IQR] sensitivity was 100 [100-100]% for ventricular tachycardia (VT), 100 [100-100]% for coarse ventricular fibrillation (VF), and 60 [20-100]% for fine VF. The median [IQR] specificities for nonshockable rhythms were 93 [86-100]% for asystole and 83 [72-86]% for pulseless electrical activity. The median decision times ranged from 2.0 to 3.5 sec.

CONCLUSION

Anesthesiologist-intensivists were quickly and effectively able to analyze rhythms in this simulation-based study. Participants' sensitivity in deciding to deliver shocks for VT and coarse VF was excellent, while specificity of their decisions for pulseless electrical activity was insufficient.

Right heart thrombus in transit: Raising bar in the management of cardiac arrest

Right heart thrombus represents medical emergency as it is associated with acute pulmonary embolism. Right heart thrombus can manifest acutely in a dramatic fashion as cardiac arrest. Bedside echocardiography is a key to rapid diagnosis and allow early intervention. We report a case of elderly female who was admitted to our hospital after a mechanical fall and found to have hip fracture. Despite an initial uncomplicated course, she experienced cardiopulmonary arrest with right heart clot in transit identified on transesophageal echocardiography (TEE). We highlight the utility of point-of-care ultrasound as well as use of TEE to establish cause of cardiopulmonary arrest.

Factors Associated With In-Hospital Post-Cardiac Arrest Survival in a Referral Level Hospital in Uganda

BACKGROUND

Cardiac arrest (CA) is still associated with high mortality and morbidity across all practice settings despite resuscitation attempts and advancements in its management. Patient outcomes vary and are affected by multiple factors. Nonetheless, there is a paucity of information on survival after CA and associated factors in low-resource settings such as East Africa where Uganda is located. This study set out to describe post-CA survival, associated factors, and neurological outcome at a hospital in Southwestern Uganda.

METHODS

This was a descriptive study in which we followed up with resuscitated CA patients from any of the selected hospital locations at Mbarara Regional Referral Hospital in Southwestern Uganda. We included all patients who were resuscitated after an index CA in the operating room (OR), intensive care unit (ICU), the pediatric ward, or accident and emergency (A&E) wards. Details of resuscitation were obtained from resuscitation team leader interviews and patient medical records. We followed up with patients with return of spontaneous circulation (ROSC) for up to 7 days after CA when neurological outcomes were measured using the age-appropriate Cerebral Performance Category (CPC) score. Factors affecting survival were then determined.

RESULTS

A total of 74 participants were enrolled over 8 months. Seven-day survival was 14.86%. Eight of the 11 survivors had a CPC score of 1 seven days after CA. Admission with trauma was associated with increased mortality with an adjusted hazard ratio (HR) of 4.06; 95% confidence interval (CI), 1.19-13.82. Compared to the A&E ward, HR for index CA in OR, ICU, and pediatric ward was 0.15; 95% CI, 0.05-0.45; 0.67; 95% CI, 0.32-1.40, and 0.65; 95% CI, 0.25-1.69, respectively. Compared to cardiopulmonary resuscitation (CPR) <10 minutes, the HR for CPR duration between 10 and 20 minutes was 2.26; 95% CI, 0.78-3.24 and for >20 minutes was 2.26; 95% CI, 1.12-4.56. Prevention of hypotension after ROSC was associated with decreased mortality with an HR of 0.23; 95% CI, 0.08-0.58.

CONCLUSIONS

Whereas 7-day survival of resuscitated CA patients at Mbarara Regional Referral Hospital (MRRH) was low, survivors had a good neurologic outcome. CA in the OR, CPR <20 minutes, and prevention of hypotension postarrest seemed to be associated with survival.

Electrocardiogram interpretation competency among undergraduate nursing students: A quasi-experimental study

BACKGROUND

Cardiac diseases are highly prevalent. Electrocardiogram (ECG) is a noninvasive, rapid, safe, and low-cost procedure that is commonly used by nurses in clinical settings to diagnose a variety of cardiac arrhythmia. However, there is a limited number of studies that have assessed nursing students' competencies in electrocardiogram interpretation in Saudi Arabia. This study aimed to assess the electrocardiogram interpretation competency among undergraduate nursing students and to evaluate the effectiveness of the electrocardiogram interpretation educational program.

METHODS

A quasi-experimental pre-post-test design was conducted. A pre-post-test self-administered standardized questionnaire was completed by a convenient sample of 79 nursing students who enrolled in an educational program. Data were analyzed using descriptive and inferential statistics with p < .05 was assumed. The study hypothesized that ECG competency scores of nursing students who are enrolled in an educational program will be higher in post-test than their pre-test scores.

RESULTS

The vast majority of students (96.2%) expressed their interest to enroll in more ECG training sessions. The study results showed that students' mean ECG interpretation competency was 4.16 (1.88) and 7.43 (2.38) in pre- and post-tests, respectively, with a statistical significance of p < .001.

CONCLUSION

Overall performance of nursing students was limited. Study results confirm the primary hypothesis that the educational program was effective in improving students' ECG interpretation competencies. More ECG contents and programs should be integrated into nursing curricula and more follow-up studies are recommended. This study highlighted the significance of equipping nursing students with ECG interpretation competencies through education and training to ensure safe practice.

Effect of Digital Learning With an Interactive eBook on Electrocardiogram Interpretation Among Clinical Nurses: A Repeated-Measures Analysis

In digital learning, the use of an interactive eBook is perceived as helpful for students. However, the effect of interactive eBooks on learning among clinical nurses has not been explored yet. This study used an interactive electrocardiogram eBook to explore the effect of digital learning on the promotion of electrocardiogram interpretation competence, confidence, knowledge retention, and learning satisfaction among clinical nurses. A single-group quasi-experimental study with three repeated measures was conducted. A total of 80 nurses from the emergency room, critical units, and medical-surgical units completed the measures. The results showed that digital learning is an effective method that significantly improved nurses' electrocardiogram competence, learning retention, confidence, and learning satisfaction. Most nurses were satisfied with the convenience and content design of this eBook. Few nurses reported drawbacks regarding loading speed and individual learning habits. It is recommended that more preset learning exercise questions should be created for trial and error so that nurses can have repeated practice for self-assessment. Specific feedback mechanisms should be established to promote motivation for digital self-learning.

Joint British Societies' guideline on management of cardiac arrest in the cardiac catheter laboratory

More than 300 000 procedures are performed in cardiac catheter laboratories in the UK each year. The variety and complexity of percutaneous cardiovascular procedures have both increased substantially since the early days of invasive cardiology, when it was largely focused on elective coronary angiography and single chamber (right ventricular) permanent pacemaker implantation. Modern-day invasive cardiology encompasses primary percutaneous coronary intervention, cardiac resynchronisation therapy, complex arrhythmia ablation and structural heart interventions. These procedures all carry the risk of cardiac arrest.We have developed evidence-based guidelines for the management of cardiac arrest in adult patients in the catheter laboratory. The guidelines include recommendations which were developed by collaboration between nine professional and patient societies that are involved in promoting high-quality care for patients with cardiovascular conditions. We present a set of protocols which use the skills of the whole catheter laboratory team and which are aimed at achieving the best possible outcomes for patients who suffer a cardiac arrest in this setting. We identified six roles and developed a treatment algorithm which should be adopted during cardiac arrest in the catheter laboratory. We recommend that all catheter laboratory staff undergo regular training for these emergency situations which they will inevitably face.

[Hemodynamic Monitoring 2.0 - What is Possible on Normal Wards?]

Life threatening events after surgery often occur on the ward. These events could be prevented by early detection of clinical deterioration of patients' health status during ward care. Therefore, an adequate monitoring could help to identify patients at risk, since there is an imbalance of monitoring intensity and the occurrence of life-threatening events during hospital stay.Additional monitoring on the general ward could lead to more patient safety. The practicability of additional monitoring needs to be considered, and therefore the use of available monitoring systems on the ward is limited. Capillary refill time (CRT) and the passive leg raise test (PLR) seem to be usable intermittent monitoring techniques.Continuous monitoring systems ensure a better detection of unwanted events and hemodynamic trends. However, the increased workload for the nursing staff and tethered monitors are unfavorable. Future trends of developing wireless monitoring systems are of paramount importance in this respect. Controlling artefacts is crucial for the successful balance between false alarms and "missed events". An adequate reaction is needed when detecting adverse events to avoid a "failure to rescue".

Clinical update on COVID-19 for the emergency clinician: Cardiac arrest in the out-of-hospital and in-hospital settings

Introduction

Coronavirus disease of 2019 (COVID-19) has resulted in millions of cases worldwide. As the pandemic has progressed, the understanding of this disease has evolved. Its impact on the health and welfare of the human population is significant; its impact on the delivery of healthcare is also considerable.

Objective

This article is another paper in a series addressing COVID-19-related updates to emergency clinicians on the management of COVID-19 patients with cardiac arrest.

Discussion

COVID-19 has resulted in significant morbidity and mortality worldwide. From a global perspective, as of February 23, 2022, 435 million infections have been noted with 5.9 million deaths (1.4%). Current data suggest an increase in the occurrence of cardiac arrest, both in the outpatient and inpatient settings, with corresponding reductions in most survival metrics. The frequency of out-of-hospital lay provider initial care has decreased while non-shockable initial cardiac arrest rhythms have increased. While many interventions, including chest compressions, are aerosol-generating procedures, the risk of contagion to healthcare personnel is low, assuming appropriate personal protective equipment is used; vaccination with boosting provides further protection against contagion for the healthcare personnel involved in cardiac arrest resuscitation. The burden of the COVID-19 pandemic on the delivery of cardiac arrest care is considerable and, despite multiple efforts, has adversely impacted the chain of survival.

Conclusion

This review provides a focused update of cardiac arrest in the setting of COVID-19 for emergency clinicians.

Etiologies of In-hospital cardiac arrest: a systematic review and meta-analysis

BACKGROUND

Etiologies of in-hospital cardiac arrest (IHCA) in general wards may differ from etiologies of out-of-hospital cardiac arrest (OHCA) given the different clinical characteristics of these patient populations. An appreciation for the causes of IHCA may allow the clinician to appropriately target root causes of arrest.

METHODS

MEDLINE/PubMed, EMBASE, and Google Scholar were queried from inception until May 31, 2021. Studies reporting etiologies of IHCA were included. A random effects meta-analysis of extracted data was performed using Review Manager 5.4.

RESULTS

Of 12,451 citations retrieved from the initial literature search, 9 were included in the meta-analysis. The most frequent etiologies of cardiac arrest were hypoxia (26.46%, 95% confidence interval [CI] 14.19% to 38.74%), acute coronary syndrome (ACS) (18.23%, 95% CI 13.91% to 22.55%), arrhythmias (14.95%, 95% CI 0% to 34.92%), hypovolemia (14.81%, 95% CI 6.98% to 22.65%), infection (14.36%, 95% CI 9.46% to 19.25%), and heart failure (12.64%, 95% CI 6.47% to 18.80%). Cardiac tamponade, electrolyte disturbances, pulmonary embolism, neurological causes, toxins, and pneumothorax were less frequent causes of IHCA. Initial rhythm was unshockable (pulseless electrical activity or asystole) in 69.83% of cases and shockable (ventricular tachycardia or ventricular fibrillation) in 21.75%.

CONCLUSION

The most prevalent causes of IHCA among the general wards population are hypoxia, ACS, hypovolemia, arrythmias, infection, heart failure, three of which (arrhythmia, infection, heart failure) are not part of the traditional "H's and T's" of cardiac arrest. Other causes noted in the "H's and T's" of advanced cardiac life support do not appear to be important causes of IHCA.

Changes in the incidence of cardiopulmonary resuscitation before and after implementation of the Life-Sustaining Treatment Decisions Act

Background

Methods

Results

Conclusions

Outcomes of Early versus Late Endotracheal Intubation in Patients with Initial Non-Shockable Rhythm Cardiopulmonary Arrest in the Emergency Department

Background

Sudden cardiac arrest is a critical condition in the emergency department (ED). Currently, there is no considerable evidence supporting the best time to complete advanced airway management (AAM) with endotracheal intubation in cardiac arrest patients presented with initial non-shockable cardiac rhythm.

Objectives

To compare survival to hospital discharge and discharge with favorable neurological outcome between the ED cardiac arrest patients who have received AAM with endotracheal intubation within 2 minutes (early AAM group) and those over 2 minutes (late AAM group) after the start of chest compression in ED.

Methods

We conducted a retrospective cohort study involving the ED cardiac arrest patients who presented with initial non-shockable rhythm in ED. Multivariable logistic regression analysis was used to evaluate the independent effect of early AAM on outcomes. The outcomes included the survival to hospital discharge and discharge with favorable neurological outcome.

Results

There were 416 eligible participants: 209 in the early AAM group and 207 participants in the late AAM group. The early AAM group showed higher survival to hospital discharge compared with the late AAM group, but no statistically significant difference (adjusted odds ratio (aOR): 1.28, 95% confidence interval (CI): 0.59 -2.76, p = 0.524). Discharge with favorable neurological outcome is also higher in the early AAM group (aOR: 1.68, 95% CI, 0.52 -5.45, p = 0.387).

Conclusion

This study did not demonstrate a significant improvement of survival to hospital discharge and discharge with favorable neurological outcome in the ED cardiac arrest patients with initial non-shockable cardiac arrest who underwent early AAM within two minutes. More research is needed on the timing of AAM and on airway management strategies to improve survival.

Timing and Identification of the Cause and Treatment of a Cardiac Arrest: A Potential Survival Benefit

OBJECTIVE

The aim of this study was to evaluate how mobile medical teams (MMTs) search for the etiology of a cardiac arrest (CA) and to investigate the association between the discovery of etiology and patient outcome.

SUBJECTS AND METHODS

Resuscitations of all adult patients who experienced an in- or out-of-hospital CA between 2016 and 2018 were video recorded. All video recordings were reviewed. The time to start of "cause analysis" and time to treatment by the MMT were analyzed. Also, investigations performed during etiologic evaluation were examined: heteroanamnesis, medical history-taking, clinical examinations, technical investigations, and the use of the 4Hs and 4Ts method.

RESULTS

Of the 139 CA events included in this study, the MMTs performed etiologic evaluation in only 75% of the resuscitations, and in 20% of the evaluations, they did not use the recommended 4Hs and 4Ts method. Medical history-taking and heteroanamnesis were performed in the large majority, but often without clear cause. A presumptive etiology was found in 46.8% of out-of-hospital CAs and 65.2% of in-hospital CAs. A significant association was found between return of spontaneous circulation and the discovery of presumable etiology for out-of-hospital CAs (p < 0.001). The median time to treatment was 492 s (recommended: 130-250 s) for nonshockable rhythms and 422 s (recommended: 270-390 s) for shockable rhythms, up to twice the time advised according to the guidelines.

CONCLUSION

The current approach for etiologic evaluation is not ideal. Further research is needed to establish a more structured and simplified approach.

In-hospital cardiac arrest due to pulmonary embolism - Treatment and outcomes in a Swedish cohort study

Objectives

Pulmonary embolism (PE) constitutes one of the reversible causes of cardiac arrest. The prognosis for PE-related cardiac arrest is poor. Some previous studies have suggested a higher survival rate in patients with PE-related cardiac arrest who receive thrombolysis. No such study has focused on in-hospital cardiac arrests (IHCA).

Aim

To describe the prevalence of PE-related IHCA and the characteristics of those patients, as well as to describe favourable and adverse outcomes after thrombolysis.

Material and methods

All patients ≥ 18 years who experienced an IHCA at Karolinska University Hospital between 2007 and 2020 with PE as the primary cause of IHCA were included. Patients were identified from the Swedish Registry for Cardiopulmonary Resuscitation (SRCR). Data was collected from the SRCR and medical records. The primary outcome was survival to discharge. Secondary outcomes were alive at the end of CPR, major bleeding, and minor bleeding.

Results

Out of 2,128 IHCA patients, 64 (3%) had a PE-related IHCA of whom 16 (25%) had thrombolysis. A significant association was seen between thrombolysis and survival to discharge (44 % vs 8 %, p-value < 0.01). Major bleeding was not seen in any patient.

Conclusion

Pulmonary embolism is an uncommon cause of IHCA, and thrombolysis is often not administered in such patients. Thrombolysis may increase survival to hospital discharge, and among the selected patients treated with thrombolysis in our study, there was no apparent major bleeding.

Airway management during in-hospital cardiac arrest in adults: UK national survey and interview study with anaesthetic and intensive care trainees

BACKGROUND

The optimal airway management strategy for in-hospital cardiac arrest is unknown.

METHODS

An online survey and telephone interviews with anaesthetic and intensive care trainee doctors identified by the United Kingdom Research and Audit Federation of Trainees. Questions explored in-hospital cardiac arrest frequency, grade and specialty of those attending, proportion of patients receiving advanced airway management, airway strategies immediately available, and views on a randomised trial of airway management strategies during in-hospital cardiac arrest.

RESULTS

Completed surveys were received from 128 hospital sites (76% response rate). Adult in-hospital cardiac arrests were attended by anaesthesia staff at 40 sites (31%), intensive care staff at 37 sites (29%) and a combination of specialties at 51 sites (40%). The majority (123/128, 96%) of respondents reported immediate access to both tracheal intubation and supraglottic airways. A bag-mask technique was used 'very frequently' or 'frequently' during in-hospital cardiac arrest by 111/128 (87%) of respondents, followed by supraglottic airways (101/128, 79%) and tracheal intubation (69/128, 54%). The majority (60/100, 60%) of respondents estimated that ≤30% of in-hospital cardiac arrest patients undergo tracheal intubation, while 34 (34%) estimated this to be between 31% and 70%. Most respondents (102/128, 80%) would be 'likely' or 'very likely' to recruit future patients to a trial of alternative airway management strategies during in-hospital cardiac arrest. Interview data identified several barriers and facilitators to conducting research on airway management in in-hospital cardiac arrest.

CONCLUSIONS

There is variation in airway management strategies for adult in-hospital cardiac arrest across the UK. Most respondents would be willing to take part in a randomised trial of airway management during in-hospital cardiac arrest.

Long-Term Functional Outcome and Quality of Life Following In-Hospital Cardiac Arrest-A Longitudinal Cohort Study

OBJECTIVES

To evaluate the functional outcome and health-related quality of life of in-hospital cardiac arrest survivors at 6 and 12 months.

DESIGN

A longitudinal cohort study.

SETTING

Seven metropolitan hospitals in Australia.

PATIENTS

Data were collected for hospitalized adults (≥ 18 yr) who experienced in-hospital cardiac arrest, defined as "a period of unresponsiveness, with no observed respiratory effort and the commencement of external cardiac compressions."

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Prior to hospital discharge, patients were approached for consent to participate in 6-month and 12-month telephone interviews. Outcomes included the modified Rankin Scale, Barthel Index, Euro-Quality of Life 5 Dimension 5 Level, return to work and hospital readmissions. Forty-eight patients (80%) consented to follow-up interviews. The mean age of participants was 67.2 (± 15.3) years, and 33 of 48 (68.8%) were male. Good functional outcome (modified Rankin Scale score ≤ 3) was reported by 31 of 37 participants (83.8%) at 6 months and 30 of 33 (90.9%) at 12 months. The median Euro-Quality of Life-5D index value was 0.73 (0.33-0.84) at 6 months and 0.76 (0.47-0.88) at 12 months. The median Euro-Quality of Life-Visual Analogue Scale score at 6 months was 70 (55-80) and 75 (50-87.5) at 12 months. Problems in all Euro-Quality of Life-5D-5 L dimension were reported frequently at both time points. Hospital readmission was reported by 23 of 37 patients (62.2%) at 6 months and 16 of 33 (48.5%) at 12 months. Less than half of previously working participants had returned to work by 12 months.

CONCLUSIONS

The majority of in-hospital cardiac arrest survivors had a good functional outcome and health-related quality of life at 6 months, and this was largely unchanged at 12 months. Despite this, many reported problems with mobility, self-care, usual activities, pain, and anxiety/depression. Return to work rates was low, and hospital readmissions were common.

Pulseless electrical activity vs. asystole in adult in-hospital cardiac arrest: Predictors and outcomes

AIM

This observational cohort study aimed to identify factors associated with pulseless electrical activity (PEA) and asystole in in-hospital cardiac arrest (IHCA) patients and to determine whether differences in outcome based on the initial rhythm were explained by patient- and cardiac arrest characteristics.

METHODS

Adults with IHCA from 2017 to 2018 were included from the Danish IHCA Registry (DANARREST). Additional data came from population-based registries. Unadjusted (RRs) and adjusted risk ratios (aRRs) were estimated for predictors of initial rhythm, return of spontaneous circulation (ROSC), and survival.

RESULTS

We included 1495 PEA and 1285 asystole patients. The patients did not differ substantially in patient characteristics. Female sex, age>90 years, pulmonary disease, and obesity were associated with initial asystole. Ischemic heart disease and witnessed and monitored cardiac arrest were associated with initial PEA. In unadjusted and adjusted analyses, PEA was associated with increased ROSC (aRR = 1.21, 95% confidence interval [CI] 1.10; 1.33). PEA was also associated with increased 30-day and 1-year survival in the unadjusted analysis, while there was no clear association between the initial rhythm and 30-day (aRR = 0.88, 95% CI 0.71; 1.11) and 1-year (aRR = 0.85, 95% CI 0.69; 1.04) survival when patient- and cardiac arrest characteristics were adjusted for.

CONCLUSION

In patients with IHCA presenting with PEA or asystole, there were no major differences in patient demographics and comorbidities. The patients differed substantially in cardiac arrest characteristics. Initial PEA was associated with higher risk of ROSC, but there was no difference in 30-day and 1-year survival.

[Cardiac arrest under special circumstances]

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

European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances

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

European Resuscitation Council Guidelines 2021: Epidemiology of cardiac arrest in Europe

In this section of the European Resuscitation Council Guidelines 2021, key information on the epidemiology and outcome of in and out of hospital cardiac arrest are presented. Key contributions from the European Registry of Cardiac Arrest (EuReCa) collaboration are highlighted. Recommendations are presented to enable health systems to develop registries as a platform for quality improvement and to inform health system planning and responses to cardiac arrest.

Association between wide QRS pulseless electrical activity and hyperkalemia in cardiac arrest patients

AIM

We evaluated the relationship between hyperkalemia and wide QRS complex in patients with pulseless electrical activity (PEA) cardiac arrest.

METHODS

This was a single-center, retrospective observational study of patients over the age of 18 treated for cardiac arrest at a tertiary referral hospital whose initial electrocardiogram rhythm was PEA from February 2010 to December 2019. Wide QRS PEA was defined as a QRS interval of 120 ms or more. Hyperkalemia was defined as serum potassium level > 5.5 mmol/L. The primary outcome was hyperkalemia. Multivariable logistic regression analysis was used to evaluate the relationship between wide QRS and hyperkalemia.

RESULTS

Among 617 patients, we analyzed 111 episodes in the wide QRS group and 506 episodes in the narrow QRS group. The potassium level in the wide QRS group was significantly higher than in the narrow QRS group (5.4 mmol/L, IQR 4.4-6.7 vs. 4.6 mmol/L, IQR 4.0-5.6, P < 0.001). Among all patients, 49.6% (n = 55/111) in the wide QRS group had hyperkalemia, which was significantly higher than the 26.7% (n = 135/506) in the narrow QRS group (P < 0.001). In multivariable logistic regression analysis, wide QRS PEA was significantly associated with hyperkalemia (odds ratio = 2.86, 95% confidence interval: 1.80-4.53, P < 0.001).

CONCLUSIONS

Wide QRS PEA as an initial cardiac rhythm was significantly associated with hyperkalemia in cardiac arrest patients.

Final-year nursing students' foundational knowledge and self-assessed confidence in interpreting cardiac arrhythmias: A cross-sectional study

BACKGROUND

Graduating nurses should possess knowledge and understanding of cardiac arrhythmia interpretation, so they can assess abnormal and life-threatening arrhythmias. However, literature around nursing students' foundational knowledge in cardiac arrhythmia interpretation remains scarce.

OBJECTIVES

To examine final-year nursing students' foundational knowledge and self-assessed confidence in interpreting cardiac arrhythmias.

DESIGN

Cross-sectional study design.

SETTINGS

Two Australian universities (one regional and the other large metropolitan).

PARTICIPANTS

Nursing students in the final year of a program of study leading to initial registration as a registered nurse.

METHODS

An online survey was adopted to examine final-year nursing students' foundational knowledge and their self-assessed confidence when interpreting cardiac rhythms.

RESULTS

A total of 114 participants completed surveys, representing a response rate of 22%. More than 70% of the participants were able to interpret asystole, sinus rhythm, and sinus bradycardia. Over 50% correctly identified ventricular tachycardia, atrial flutter, sinus tachycardia, atrial fibrillation, and ventricular fibrillation. Under 15% of the participants were able to interpret junctional rhythm, paced rhythm, and unifocal/multifocal premature ventricular contractions. Self-assessed confidence levels were generally lower than the accuracy rates of arrhythmia interpretation. Although many participants acknowledged that learning arrhythmia interpretation was difficult and challenging, most of them had positive perceptions and wanted to learn more.

CONCLUSION

Nursing curricula need to be supported and strategies need to be implemented to standardise educational electrocardiogram interpretation programs, which are critical to improving final-year nursing students' foundational knowledge and confidence in interpreting cardiac arrhythmias and enhancing patient safety.

Factors associated with shockable versus non-shockable rhythms in patients with in-hospital cardiac arrest

AIM

To identify factors associated with the initial rhythm in patients with in-hospital cardiac arrest and to assess whether potential differences in outcomes based on the initial rhythm can be explained by patient and event characteristics.

METHODS

Adult patients (≥18 years old) with in-hospital cardiac arrest in 2017 and 2018 were included from the Danish In-Hospital Cardiac Arrest Registry (DANARREST). We used population-based registries to obtain data on comorbidities, cardiac procedures, and medications. Unadjusted and adjusted risk ratios (RRs) for initial rhythm, return of spontaneous circulation (ROSC), and survival were estimated in separate models including an incremental number of prespecified variables.

RESULTS

A total of 3422 patients with in-hospital cardiac arrest were included, of which 639 (19%) had an initial shockable rhythm. Monitored cardiac arrest, witnessed cardiac arrest, and specific cardiac diseases (i.e. ischemic heart disease, dysrhythmias, and valvular heart disease) were associated with initial shockable rhythm. Conversely, higher age, female sex, and specific non-cardiovascular comorbidities (e.g. overweight and obesity, renal disease, and pulmonary cancer) were associated with an initial non-shockable rhythm. Initial shockable rhythm remained strongly associated with increased ROSC (RR = 1.63, 95%CI 1.51-1.76), 30-day survival (RR = 2.31, 95%CI 2.02-2.64), and 1-year survival (RR = 2.36, 95%CI 2.02-2.76) compared to initial non-shockable rhythm in the adjusted analyses.

CONCLUSION

In this study, specific patient and cardiac arrest characteristics were associated with initial rhythm in patients with in-hospital cardiac arrest. However, differences in patient and cardiac arrest characteristics did not fully explain the association with survival for initial shockable rhythm compared to a non-shockable rhythm.

Association between the frequency of admission for pneumonia and the incidence of in-hospital cardiac arrest: A population-based case–control study

Objective:

To examine the association between the frequency of admission for pneumonia and the incidence of in-hospital cardiac arrest.

Methods:

We enrolled 1739 patients with in-hospital cardiac arrest and 6956 randomly selected age- and sex-matched control patients using a longitudinal claims sub-dataset from 1996 to 2011 for 1 million people randomly selected from the population covered by the Taiwan National Health Insurance program. The odds ratio of in-hospital cardiac arrest associated with the number of hospital admissions for pneumonia was calculated.

Results:

During the 15-year study period, the in-hospital cardiac arrest group had a higher frequency (28.4% vs 8.1%, p < 0.0001) of admission for pneumonia compared to the control group. The comorbidities of heart failure, chronic pulmonary disease, diabetes, renal failure, liver disease, lymphoma, alcohol abuse, and drug abuse were higher in the in-hospital cardiac arrest group than in the control group. In addition, the risk of in-hospital cardiac arrest was 3.37 for the patients admitted for pneumonia, and the risk of in-hospital cardiac arrest increased for patients with multiple admissions for pneumonia (once, 3.03; two times, 3.44; and three times, 4.42). In cross-analysis, the more admissions for pneumonia and the greater the number of comorbidities, the higher the risk of in-hospital cardiac arrest (odds ratio = 21.37, 95% confidence interval = 13.6–33.9 for patients with more than three admissions for pneumonia and more than three comorbidities).

Conclusion:

Higher admission frequency for pneumonia was associated with a higher risk of in-hospital cardiac arrest. Awareness of this risk factor may help clinicians provide early prevention or detection for patients with potential in-hospital cardiac arrest risks immediately after admission.

Assessing the effect of arrival time of physician and cardiopulmonary resuscitation (CPR) team on the outcome of CPR

Introduction

Negligence of proper time and poor performance of resuscitation team can lead to more mortality and negative consequences of cardiac arrest, as well as less survival. This study was conducted with objective of determining the arrival time of physician and resuscitation team to survive the victims of cardiopulmonary arrest.

Materials and methods

In this prospective and descriptive-analytic study, the resuscitation performance and the arrival time of resuscitation team in 143 inpatients who had been diagnosed with witnessed cardiopulmonary arrest were examined using a researcher-made checklist. Data analysis was performed using parametric and non-parametric statistical tests and SPSS.

Results

Initial survival rate was 26.6%. In general, the mean time of physician’s presence after the code announcement in minutes and seconds was 02:31 ± 01:22. It was also 02:24 ± 01:15 in successful cases and 02:34 ± 01:25 in unsuccessful cases. Independent t-test did not show a significant difference between the physician’s presence time and the rate of initial successful resuscitation (p = 0.504). The time of first shock after observing ventricular fibrillation/tachycardia (in minutes and seconds) was 01:30 ± 00:47. According to independent t-test, the aforementioned time was less than the mean time (02:31 ± 01:22) of physician’s presence (p < 0.001).

Conclusions

In this study, the initial survival rate in comparison to other regions in the country was almost more favorable and it was similar to global norms. In this study, the starting time of resuscitation was within the acceptable range. There was no relationship between the presence of physician and the initial survival rate of patients, as well as the use of defibrillator (by physician compared to other team members) and intubation with the initial survival rate. This could indicate the adequate performance of resuscitation team in the absence of physician on the condition of having sufficient knowledge and skill.

Comparison of in-hospital and out-of-hospital cardiac arrest patients receiving targeted temperature management: A matched case-control study

BACKGROUND

Evidences that support the use of targeted temperature management (TTM) for in-hospital cardiac arrest (IHCA) are lacking. We aimed to investigate the hypothesis that TTM benefits for patients with IHCA are similar to those with out-of-hospital cardiac arrest (OHCA) and to determine the independent predictors of resuscitation outcomes in patients with cardiac arrest receiving subsequent TTM.

METHODS

This is a retrospective, matched, case-control study (ratio 1:1) including 93 patients with IHCA treated with TTM after the return of spontaneous circulation, who were admitted to Partners HealthCare system in Boston from January 2011 to December 2018. Controls were defined as the same number of patients with OHCA, matched for age, Charlson score, and sex. Survival and neurological outcomes upon discharge were the primary outcome measures.

RESULTS

Patients with IHCA were more likely to have experienced a witnessed arrest and receive bystander cardiopulmonary resuscitation, a larger total dosage of epinephrine, and extracorporeal membrane oxygenation. The time duration for ROSC was shorter in patients with IHCA than in those with OHCA. The IHCA group was more likely associated with mild thrombocytopenia during TTM than the OHCA group. Survival after discharge and favorable neurological outcomes did not differ between the two groups. Among all patients who had cardiac arrest treated with TTM, the initial shockable rhythm, time to ROSC, and medical history of heart failure were independent outcome predictors for survival to hospital discharge. The only factor to predict favorable neurological outcomes at discharge was initial shockable rhythm.

CONCLUSION

The beneficial effects of TTM in eligible patients with IHCA were similar with those with OHCA. Initial shockable rhythm was the only independent predictor of both survival and favorable neurological outcomes at discharge in all cardiac arrest survivors receiving TTM.

Single-center In-hospital Cardiac Arrest Outcomes

BACKGROUND

This study was designed to evaluate the patient characteristics and outcomes of in-hospital cardiac arrest (IHCA).

MATERIALS AND METHODS

We carried out a single-center, 5-year, retrospective chart review and analysis of resuscitation data for age, gender, body mass index (BMI), length of stay (LOS) until cardiac arrest, survival of initial IHCA, survival to hospital discharge, primary medical service, and determination of the etiology of cardiac arrest.

RESULTS

A total of 500 cases occurred with a mean LOS of 8.5 days until the initial IHCA. Overall, 79.5% survived the initial IHCA and 32.4% survived to discharge. As LOS increased, there was an increase in the proportion of pulmonary and metabolic etiologies. Logistic regression analysis adjusting for BMI, gender, age, LOS, and primary medical service were on a surgical service significant for survival to discharge (p = 0.0007) and LOS <9 days significant for survival of IHCA (p = 0.018).

CONCLUSION

There are a number of causes of IHCA, and the incidence of death and respiratory related IHCA etiologies increase with LOS. Length of stay carries the highest weight when predicting survival of IHCA. Also, there is a higher rate of survival to discharge when on a primary surgical service.

HOW TO CITE THIS ARTICLE

Riley LE, Mehta HJ, Lascano J. Single-center In-hospital Cardiac Arrest Outcomes. Indian J Crit Care Med 2020;24(1):44-48.

An outcome study of adult in-hospital cardiac arrests in non-monitored areas with resuscitation attempted using AED

OBJECTIVES

To investigate the outcomes of patients with in-hospital cardiac arrest (IHCA) who underwent cardiopulmonary resuscitation (CPR) using an automated external defibrillator (AED) in non-monitored areas. Additionally, to detect correlated factors associated with rate of return of spontaneous circulation (ROSC) and survival rate, among collected data.

METHODS

This study included 109 patients. After investigating patient characteristics and resuscitation-related factors, the correlated factors associated with ROSC rates and survival rate were analyzed using univariate and multivariate analyses.

RESULTS

The rate of survival to hospital discharge was 21.1%. CPR with AED performed since 2013 was associated with a higher ROSC rate (adjusted odds ratio [AOR] 3.24, 95% confidence interval [CI]: 1.21 to 9.52, p < 0.05), but not with the survival rate after ROSC. Tracheal intubation was significantly associated with a higher ROSC rate (AOR 3.62, 95% CI: 1.27 to 11.7, p < 0.05) and a lower survival rate after ROSC (hazard ratio 6.6, 95% CI: 1.2 to 43.3, p < 0.05). Dysrhythmia as the cause of cardiac arrest and intensive care unit (ICU) admission after ROSC were associated with higher survival rates (hazard ratio 0.056, 95% CI: 0.004 to 0.759, p < 0.05, and hazard ratio 0.072, 95% CI: 0.017 to 0.264, p < 0.0001, respectively).

CONCLUSIONS

The factors associated with ROSC rate and those associated with the survival rate after ROSC were different. Although initial shockable rhythms on AED were not associated with the survival rate, dysrhythmia as the etiology of cardiac arrest, and ICU admission were significantly associated with higher survival rates after ROSC.

Usefulness of Trends in Continuous Electrocardiographic Telemetry Monitoring to Predict In-Hospital Cardiac Arrest

Survival from in-hospital cardiac arrest (IHCA) due to pulseless electrical activity/asystole remains poor. We aimed to evaluate whether electrocardiographic changes provide predictive information for risk of IHCA from pulseless electrical activity/asystole. We conducted a retrospective case-control study, utilizing continuous electrocardiographic data from case and control patients. We selected 3 consecutive 3-hour blocks (block 3, 2, and 1 in that order); block 1 immediately preceded cardiac arrest in cases, whereas block 1 was chosen at random in controls. In each block, we measured dominant positive and negative trends in electrocardiographic parameters, evaluated for arrhythmias, and compared these between consecutive blocks. We created random forest and logistic regression models, and tested them on differentiating case versus control patients (case block 1 vs control block 1), and temporal relation to cardiac arrest (case block 2 vs case block 1). Ninety-one cases (age 63.0 ± 17.6, 58% male) and 1,783 control patients (age 63.5 ± 14.8, 67% male) were evaluated. We found significant differences in electrocardiographic trends between case and control block 1, particularly in QRS duration, QTc, RR, and ST. New episodes of atrial fibrillation and bradyarrhythmias were more common before IHCA. The optimal model was the random forest, achieving an area under the curve of 0.829, 63.2% sensitivity, 94.6% specificity at differentiating case versus control block 1 on a validation set, and area under the curve 0.954, 91.2% sensitivity, 83.5% specificity at differentiating case block 1 versus case block 2. In conclusion, trends in electrocardiographic parameters during the 3-hour window immediately preceding IHCA differ significantly from other time periods, and provide robust predictive information.

One-Year Survival after Inhospital Cardiac Arrest-Does Prearrest Sepsis Matter?

AIM

Cardiac arrest is not a common complication of sepsis, although sepsis has been recognized as one condition behind cardiac arrest. Our aim was to evaluate the prevalence of sepsis among patients with inhospital cardiac arrest (IHCA), and to determine if sepsis is associated with inferior outcome after IHCA.

METHODS

All consecutive emergency team dispatches in Turku University Hospital in 2011 to 2014 (n = 607) were retrospectively reviewed to identify the patients undergoing cardiopulmonary resuscitation (CPR) for IHCA (n = 301). The patient records were reviewed for the criteria of severe sepsis, organ dysfunction, and chronic comorbidities before IHCA. Outcome was followed for 1 year.

RESULTS

The criteria for prearrest severe sepsis were met by 83/301 (28%) of the patients, and 93/301 (31%) had multiorgan dysfunction (3 or more organ systems). The patients with severe sepsis had higher mortality than those without severe sepsis, increasing from 30-day mortalities of 63/83 (76%) and 151/218 (69%), respectively (P = 0.256), to 1-year mortalities of 72/83 (87%) and 164/218 (75%), respectively (P = 0.030). Emergency admission, age, immunosuppression, DM, multiorgan dysfunction, and a nonshockable rhythm were independent predictors of 1-year mortality by multivariate logistic regression analysis. Six out of 83 patients with severe sepsis before IHCA (7%) survived 1 year with good neurological outcome (CPC scale 1).

CONCLUSIONS

A high proportion of patients with IHCA have sepsis and multiorgan dysfunction, and their prognosis is worse than the prognosis of patients with IHCA in general.

Prevalence and Outcomes of Sudden Cardiac Arrest in a University Hospital in the Western Region, Saudi Arabia

BACKGROUND

Sudden cardiac arrest (SCA) is a major cause of mortality, yet its epidemiological and outcome data in hospitals from Saudi Arabia are limited.

OBJECTIVES

This study aimed to evaluate the prevalence, risk factors and outcomes of SCA in a teaching hospital in Jeddah, Saudi Arabia.

METHODS

This retrospective study included all patients aged ≥18 years with SCA who were resuscitated at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, between January 1 and December 31, 2016. Data were retrieved from the hospital medical records as flow sheets designed in accordance with the Utstein-style recommendations. Factors relating to mortality were analyzed using descriptive analyses and chi-square test.

RESULTS

A total of 429 cases of SCA met the inclusion criteria, and its prevalence was 7.76 cases/1000 adult hospital admission. Of these, 61.3% were male, and the mean age was 58.4 years, with 36.6% aged >65 years. Only 3.5% were outside-hospital cardiac arrests. The most common initial rhythm was pulseless electrical activity/asystole (93.2%), while ventricular tachycardia/ventricular fibrillation was documented in only 29 cases (6.8%). The overall rate of return to spontaneous circulation (ROSC) was 56.2%, and 56.8% in cases of in-hospital cardiac arrest (IHCA). Patients with SCA due to sepsis had significantly increased mortality (P < 0.000; odds ratio [OR] = 0.24 [0.12-0.47 95% confidence interval [CI]]), while those with SCA due to respiratory causes had significantly better survival outcomes (P = 0.001; OR = 2.3 [1.5-3.8 95% CI]). No significant differences in outcomes were found between other risk factors, including cardiac causes.

CONCLUSION

In this population, the prevalence of SCA in adults was higher than reported in many similar studies. Further, sepsis was found to affect the survival rate. Although the rate of ROSC for IHCA patients was favorable compared with other studies, it is relatively poor. This finding signifies the need to identify and control risk factors for SCA to improve survival.

Association of hemoglobin with incidence of in-hospital cardiac arrest in patients with acute coronary syndrome complicated by cardiogenic shock

Objective

This study was performed to investigate the association of the admission hemoglobin level with the incidence of in-hospital cardiac arrest (IHCA) in patients with acute coronary syndrome (ACS) complicated by cardiogenic shock (CS).

Methods

In this retrospective study, we reviewed the medical records of consecutive patients with ACS complicated by CS admitted to the coronary care unit from January 2014 to October 2017. Logistic regression models were carried out to evaluate the association between hemoglobin and the incidence of IHCA. Interaction and subgroup analyses were also performed.

Results

In total, 211 patients were included in the study, and 61 (28.9%) patients developed IHCA. In the multivariable analysis, hemoglobin was a strong independent predictor of IHCA (odds ratio, 0.971; 95% confidence interval, 0.954–0.989). In the fully adjusted model, patients in the higher hemoglobin tertile were less likely to develop IHCA than patients in the lowest hemoglobin tertile (odds ratio, 0.194; 95% confidence interval, 0.071–0.530). The relationship remained stable in most subgroups except patients aged ≥70 years.

Conclusion

In patients with ACS complicated by CS, the incidence of IHCA is related to the hemoglobin concentration, and a high hemoglobin concentration is a protective factor against the development of IHCA.

Early whole-body CT for treatment guidance in patients with return of spontaneous circulation after cardiac arrest

PURPOSE

Non-traumatic cardiac arrest (CA) and return of spontaneous circulation (ROSC) after cardiopulmonary resuscitation (CPR) are often associated with multiple pathologies. Expecting a high prevalence of important findings, a whole-body CT (WBCT) could be of relevance for therapy. The aim of this study is to investigate the feasibility and diagnostic yield of an early WBCT in this setting.

METHODS

This single-center retrospective study included 100 consecutive patients (27 female; 73 male; mean age 68.5± 12.57 years) with non-traumatic, in- and out-of-hospital CA and ROSC following CPR, who underwent a contrast-enhanced WBCT within 6 h after ROSC over 12 months. CT findings were determined corresponding to anatomical region.

RESULTS

Early WBCT was successfully carried out in 100% of the patients with CA and ROSC after CPR. Acute pathologies were found not only in the chest but also in the head (15%) and the abdomen (6%). Early global brain edema (n = 12), acute stroke (n = 3), pulmonary embolism (n = 10), pneumothorax (26%), acute abdominal pathologies (n = 6), iatrogenic bleeding (4%), and CPR-related injuries (93%) were detected by CT right from the beginning of the post-cardiac arrest care.

CONCLUSIONS

An early WBCT is feasible and provides added diagnostic value for patients with ROSC after non-traumatic CA.

Pediatric In-Hospital Cardiac Arrest Secondary to Acute Pulmonary Embolism

OBJECTIVES

Pulmonary embolism is a rarely reported and potentially treatable cause of cardiac arrest in children and adolescents. The objective of this case series is to describe the course of five adolescent patients with in-hospital cardiac arrest secondary to pulmonary embolism.

DESIGN

Case series.

SETTING

Single, large academic children's hospital.

PATIENTS

All patients under the age of 18 years (n = 5) who experienced an in-hospital cardiac arrest due to apparent pulmonary embolism from August 1, 2013, to July 31, 2017.

INTERVENTIONS

All five patients received systemic thrombolytic therapy (IV tissue plasminogen activator) during cardiac arrest or periarrest during ongoing resuscitation efforts.

MEASUREMENTS AND MAIN RESULTS

Five adolescent patients, 15-17 years old, were treated for pulmonary embolism-related cardiac arrests during the study period. These accounted for 6.3% of all children and 25% of adolescents (12-17 yr old) receiving at least 5 minutes of in-hospital cardiopulmonary resuscitation during the study period. All five had venous thromboembolism risk factors. Two patients had known, extensive venous thrombi at the time of cardiac arrest, and one was undergoing angiography at the time of arrest. The diagnoses of pulmonary embolism were based on clinical suspicion, bedside echocardiography (n = 4), and low end-tidal CO2 levels relative to arterial CO2 values (n = 5). IV tissue plasminogen activator was administered during cardiopulmonary resuscitation in three patients and after the return of spontaneous circulation, in the setting of severe hemodynamic instability, in the other two patients. Four of five patients were successfully resuscitated and survived to hospital discharge.

CONCLUSIONS

Pulmonary embolism was recognized as the etiology of multiple adolescent cardiac arrests in this single-center series and may be more common than previously reported. Recognition, high-quality cardiopulmonary resuscitation, and treatment with thrombolytic therapy resulted in survival in four of five patients.

Age-Dependent Myocardial Dysfunction in Critically Ill Patients: Role of Mitochondrial Dysfunction

Myocardial dysfunction is common in septic shock and post-cardiac arrest but manifests differently in pediatric and adult patients. By conventional echocardiographic parameters, biventricular systolic dysfunction is more prevalent in children with septic shock, though strain imaging reveals that myocardial injury may be more common in adults than previously thought. In contrast, diastolic dysfunction in general and post-arrest myocardial systolic dysfunction appear to be more widespread in the adult population. A growing body of evidence suggests that mitochondrial dysfunction mediates myocardial depression in critical illness; alterations in mitochondrial electron transport system function, bioenergetic production, oxidative and nitrosative stress, uncoupling, mitochondrial permeability transition, fusion, fission, biogenesis, and autophagy all may play key pathophysiologic roles. In this review we summarize the epidemiologic and clinical phenotypes of myocardial dysfunction in septic shock and post-cardiac arrest and the multifaceted manifestations of mitochondrial injury in these disease processes. Since neonatal and pediatric-specific data for mitochondrial dysfunction remain sparse, conclusive age-dependent differences are not clear; instead, we highlight what evidence exists and identify gaps in knowledge to guide future research. Finally, since focal ischemic injury (with or without reperfusion) leading to myocardial infarction is predominantly an atherosclerotic disease of the elderly, this review focuses specifically on septic shock and global ischemia-reperfusion injury occurring after resuscitation from cardiac arrest.