1
|
Winters ME, Hu K, Martinez JP, Mallemat H, Brady WJ. The critical care literature 2022. Am J Emerg Med 2024; 80:123-131. [PMID: 38574434 DOI: 10.1016/j.ajem.2024.03.028] [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: 02/14/2024] [Accepted: 03/31/2024] [Indexed: 04/06/2024] Open
Abstract
The number of critically ill patients that present to emergency departments across the world has risen steadily for nearly two decades. Despite a decrease in initial emergency department (ED) volumes early in the COVID-19 pandemic, the proportion of critically ill patients is now higher than pre-pandemic levels [1]. The emergency physician (EP) is often the first physician to evaluate and resuscitate a critically ill patient. In addition, EPs are frequently tasked with providing critical care long beyond the initial resuscitation. Prolonged boarding of critically ill patients in the ED is associated with increased duration of mechanical ventilation, increased intensive care unit (ICU) length of stay, increased hospital length of stay, increased medication-related adverse events, and increased in-hospital, 30-day, and 90-day mortality [2-4]. Given the continued increase in critically ill patients along with the increases in boarding critically ill patients in the ED, it is imperative for the EP to be knowledgeable about recent literature in resuscitation and critical care medicine, so that critically ill patients continue to receive evidence-based care. This review summarizes important articles published in 2022 that pertain to the resuscitation and management of select critically ill ED patients. These articles have been selected based on the authors review of key critical care, resuscitation, emergency medicine, and medicine journals and their opinion of the importance of study findings as it pertains to the care of the critically ill ED patient. Topics covered in this article include cardiac arrest, post-cardiac arrest care, rapid sequence intubation, mechanical ventilation, fluid resuscitation, and sepsis.
Collapse
Affiliation(s)
- Michael E Winters
- Departments of Emergency Medicine and Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Kami Hu
- Departments of Emergency Medicine and Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Joseph P Martinez
- Departments of Emergency Medicine and Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Haney Mallemat
- Internal Medicine and Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - William J Brady
- Departments of Emergency Medicine and Medicine, University of Virginia School of Medicine, Charlottesville, VA 22908, USA
| |
Collapse
|
2
|
Rahadian RE, Okada Y, Shahidah N, Hong D, Ng YY, Chia MY, Gan HN, Leong BS, Mao DR, Ng WM, Doctor NE, Ong MEH. Machine learning prediction of refractory ventricular fibrillation in out-of-hospital cardiac arrest using features available to EMS. Resusc Plus 2024; 18:100606. [PMID: 38533482 PMCID: PMC10963854 DOI: 10.1016/j.resplu.2024.100606] [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: 12/15/2023] [Revised: 02/22/2024] [Accepted: 03/04/2024] [Indexed: 03/28/2024] Open
Abstract
Background Shock-refractory ventricular fibrillation (VF) or ventricular tachycardia (VT) is a treatment challenge in out-of-hospital cardiac arrest (OHCA). This study aimed to develop and validate machine learning models that could be implemented by emergency medical services (EMS) to predict refractory VF/VT in OHCA patients. Methods This was a retrospective study examining adult non-traumatic OHCA patients brought into the emergency department by Singapore EMS from the Pan-Asian Resuscitation Outcomes Study (PAROS) registry. Data from April 2010 to March 2020 were extracted for this study. Refractory VF/VT was defined as VF/VT persisting or recurring after at least one shock. Features were selected based on expert clinical opinion and availability to dispatch prior to arrival at scene. Multivariable logistic regression (MVR), LASSO and random forest (RF) models were investigated. Model performance was evaluated using receiver operator characteristic (ROC) area under curve (AUC) analysis and calibration plots. Results 20,713 patients were included in this study, of which 860 (4.1%) fulfilled the criteria for refractory VF/VT. All models performed comparably and were moderately well-calibrated. ROC-AUC were 0.732 (95% CI, 0.695 - 0.769) for MVR, 0.738 (95% CI, 0.701 - 0.774) for LASSO, and 0.731 (95% CI, 0.690 - 0.773) for RF. The shared important predictors across all models included male gender and public location. Conclusion The machine learning models developed have potential clinical utility to improve outcomes in cases of refractory VF/VT OHCA. Prediction of refractory VF/VT prior to arrival at patient's side may allow for increased options for intervention both by EMS and tertiary care centres.
Collapse
Affiliation(s)
| | - Yohei Okada
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Department of Preventive Services, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Nur Shahidah
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
- Pre-hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore
| | - Dehan Hong
- Emergency Medical Services Department, Singapore Civil Defence Force, Singapore
| | - Yih Yng Ng
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Department of Preventive and Population Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Han Nee Gan
- Accident & Emergency, Changi General Hospital, Singapore, Singapore
| | - Benjamin S.H. Leong
- Emergency Medicine Department, National University Hospital, Singapore, Singapore
| | - Desmond R. Mao
- Department of Acute and Emergency Care, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Wei Ming Ng
- Emergency Medicine Department, Ng Teng Fong General Hospital, Singapore, Singapore
| | | | - Marcus Eng Hock Ong
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| |
Collapse
|
3
|
Tarchione AR, Vempati A. Electrical Storm/Refractory Ventricular Tachycardia. JOURNAL OF EDUCATION & TEACHING IN EMERGENCY MEDICINE 2024; 9:S27-S54. [PMID: 38707938 PMCID: PMC11068320 DOI: 10.21980/j8ts80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 01/16/2024] [Indexed: 05/07/2024]
Abstract
Audience This simulation case was created for emergency medicine (EM) residents at all levels of training. Background Cardiac electrical storm (ES) is commonly defined as three or more episodes of sustained ventricular tachycardia, ventricular fibrillation, or three shocks from an implantable defibrillator within a 24 hour period.1 This can occur in up to 30-40% of patients with implantable defibrillators; however, it may also present in a wide variety of patients, including those with structural heart disease, myocardial infarction, electrolyte disturbances, and channelopathies.2,3 With each subsequent episode of ventricular arrhythmia, the arrhythmogenic potential of the heart may increase secondary to increased intracellular calcium dysregulation, myocardial injury, and increased endogenous release of catecholamines. The increased pain and catecholamine release from cardioversion/defibrillation and exogenous epinephrine during cardiac arrest further exacerbates ES.2 This carries a significant mortality risk of up to 12% in the first 48 hours.3This case involves a basic knowledge of the Advanced Cardiac Life Support (ACLS) for ventricular tachycardia, both with and without a pulse, and the application of Sgarbossa criteria in a patient with an ST elevation myocardial infarction (STEMI) which makes it ideal for the PGY-1. However, the case quickly becomes refractory to the basic management prescribed in ACLS, requiring trouble shooting and quick thinking about deeper pathophysiology, a skill that is crucial for all emergency medicine physicians. There are multiple ways to troubleshoot this case, making for a good variety of discussion and recent literature review on the complexities of a relatively common arrhythmia, ventricular tachycardia. Educational Objectives By the end of this simulation, learners should be able to: 1) recognize unstable ventricular tachycardia and initiate ACLS protocol, 2) practice dynamic decision making by switching between various ACLS algorithms, 3) create a thoughtful approach for further management of refractory ventricular tachycardia, 4) interpret electrocardiogram (ECG) with ST-segment elevation (STE) and left bundle branch block (LBBB), 5) appropriately disposition the patient and provide care after return of spontaneous circulation (ROSC), 6) navigate a difficult conversation with the patient's husband when she reveals that the patient's wishes were to not be resuscitated. Educational Methods This simulation was performed using high-fidelity simulation followed by an immediate debriefing with nine learners who directly participated in the SIM and twenty-three residents, who were online observers via Zoom. This case was done during our conference day, and there were a total of approximately forty total learners comprised of medical students, PGY-1, PGY-2 and PGY-3 residents. There were several medical students who also observed via Zoom but were not surveyed, and the survey was sent to 32 learners. The case was run three separate times with each session consisting of three-four learners at the same level of training, with other learners in the same level of training observing via Zoom™ video platform. Since we can only have a team of three-four learners participate per group during simulation, the rest of the learners were observing the case and the debrief. There was one simulation instructor and one technician. Research Methods We sent an online survey to all the participants and the observers after the debrief via surveymonkey.com. The survey collected responses to the following statements: (1) the case was believable, (2) the case had right amount of complexity, (3) the case helped in improving medical knowledge and patient care, (4) the simulation environment gave me a real-life experience and, (5) the debriefing session after simulation helped improve my knowledge. Likert scale was used to collect the responses. Results A total of thirteen participants responded to the survey. One hundred percent of them either strongly agreed or agreed that the case was believable and that it helped in improving medical knowledge and patient care. Fifty-four percent strongly agreed, 38 percent agreed, and eight percent were neutral about the case having the right amount of complexity. Thirty one percent strongly agreed, 61 percent agreed, and eight percent were neutral about the case giving them real-life experience. All of them agreed that the debriefing session helped them improve their knowledge. Discussion The high-fidelity simulation case was helpful with educating learners with ventricular tachycardia and fibrillation. Learners learned how to switch between various ACLS algorithms and how to manage a patient with refractory ventricular fibrillation. Learners enforced their knowledge in how to communicate with patient's family members when the patient does not want resuscitation. Topics Stable ventricular tachycardia, unstable ventricular tachycardia, refractory ventricular tachycardia, electrical storm, STEMI equivalents, medical simulation.
Collapse
Affiliation(s)
- Ashley R Tarchione
- Kaiser Permanente San Diego Medical Center, Department of Emergency Medicine, San Diego, CA
| | - Amrita Vempati
- Creighton University School of Medicine Phoenix Program, Valleyhealth Medical Center, Department of Emergency Medicine, Phoenix, AZ
| |
Collapse
|
4
|
Berg KM, Bray JE, Ng KC, Liley HG, Greif R, Carlson JN, Morley PT, Drennan IR, Smyth M, Scholefield BR, Weiner GM, Cheng A, Djärv T, Abelairas-Gómez C, Acworth J, Andersen LW, Atkins DL, Berry DC, Bhanji F, Bierens J, Bittencourt Couto T, Borra V, Böttiger BW, Bradley RN, Breckwoldt J, Cassan P, Chang WT, Charlton NP, Chung SP, Considine J, Costa-Nobre DT, Couper K, Dainty KN, Dassanayake V, Davis PG, Dawson JA, Fernanda de Almeida M, De Caen AR, Deakin CD, Dicker B, Douma MJ, Eastwood K, El-Naggar W, Fabres JG, Fawke J, Fijacko N, Finn JC, Flores GE, Foglia EE, Folke F, Gilfoyle E, Goolsby CA, Granfeldt A, Guerguerian AM, Guinsburg R, Hatanaka T, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hsu CH, Ikeyama T, Isayama T, Johnson NJ, Kapadia VS, Daripa Kawakami M, Kim HS, Kleinman ME, Kloeck DA, Kudenchuk P, Kule A, Kurosawa H, Lagina AT, Lauridsen KG, Lavonas EJ, Lee HC, Lin Y, Lockey AS, Macneil F, Maconochie IK, John Madar R, Malta Hansen C, Masterson S, Matsuyama T, McKinlay CJD, Meyran D, Monnelly V, Nadkarni V, Nakwa FL, Nation KJ, Nehme Z, Nemeth M, Neumar RW, Nicholson T, Nikolaou N, Nishiyama C, Norii T, Nuthall GA, Ohshimo S, Olasveengen TM, Gene Ong YK, Orkin AM, Parr MJ, Patocka C, Perkins GD, Perlman JM, Rabi Y, Raitt J, Ramachandran S, Ramaswamy VV, Raymond TT, Reis AG, Reynolds JC, Ristagno G, Rodriguez-Nunez A, Roehr CC, Rüdiger M, Sakamoto T, Sandroni C, Sawyer TL, Schexnayder SM, Schmölzer GM, Schnaubelt S, Semeraro F, Singletary EM, Skrifvars MB, Smith CM, Soar J, Stassen W, Sugiura T, Tijssen JA, Topjian AA, Trevisanuto D, Vaillancourt C, Wyckoff MH, Wyllie JP, Yang CW, Yeung J, Zelop CM, Zideman DA, Nolan JP. 2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Resuscitation 2024; 195:109992. [PMID: 37937881 DOI: 10.1016/j.resuscitation.2023.109992] [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: 11/09/2023]
Abstract
The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.
Collapse
|
5
|
Berg KM, Bray JE, Ng KC, Liley HG, Greif R, Carlson JN, Morley PT, Drennan IR, Smyth M, Scholefield BR, Weiner GM, Cheng A, Djärv T, Abelairas-Gómez C, Acworth J, Andersen LW, Atkins DL, Berry DC, Bhanji F, Bierens J, Bittencourt Couto T, Borra V, Böttiger BW, Bradley RN, Breckwoldt J, Cassan P, Chang WT, Charlton NP, Chung SP, Considine J, Costa-Nobre DT, Couper K, Dainty KN, Dassanayake V, Davis PG, Dawson JA, de Almeida MF, De Caen AR, Deakin CD, Dicker B, Douma MJ, Eastwood K, El-Naggar W, Fabres JG, Fawke J, Fijacko N, Finn JC, Flores GE, Foglia EE, Folke F, Gilfoyle E, Goolsby CA, Granfeldt A, Guerguerian AM, Guinsburg R, Hatanaka T, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hsu CH, Ikeyama T, Isayama T, Johnson NJ, Kapadia VS, Kawakami MD, Kim HS, Kleinman ME, Kloeck DA, Kudenchuk P, Kule A, Kurosawa H, Lagina AT, Lauridsen KG, Lavonas EJ, Lee HC, Lin Y, Lockey AS, Macneil F, Maconochie IK, Madar RJ, Malta Hansen C, Masterson S, Matsuyama T, McKinlay CJD, Meyran D, Monnelly V, Nadkarni V, Nakwa FL, Nation KJ, Nehme Z, Nemeth M, Neumar RW, Nicholson T, Nikolaou N, Nishiyama C, Norii T, Nuthall GA, Ohshimo S, Olasveengen TM, Ong YKG, Orkin AM, Parr MJ, Patocka C, Perkins GD, Perlman JM, Rabi Y, Raitt J, Ramachandran S, Ramaswamy VV, Raymond TT, Reis AG, Reynolds JC, Ristagno G, Rodriguez-Nunez A, Roehr CC, Rüdiger M, Sakamoto T, Sandroni C, Sawyer TL, Schexnayder SM, Schmölzer GM, Schnaubelt S, Semeraro F, Singletary EM, Skrifvars MB, Smith CM, Soar J, Stassen W, Sugiura T, Tijssen JA, Topjian AA, Trevisanuto D, Vaillancourt C, Wyckoff MH, Wyllie JP, Yang CW, Yeung J, Zelop CM, Zideman DA, Nolan JP. 2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation 2023; 148:e187-e280. [PMID: 37942682 PMCID: PMC10713008 DOI: 10.1161/cir.0000000000001179] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.
Collapse
|
6
|
Htet NN, Jafari D, Walker JA, Pourmand A, Shaw A, Dinh K, Tran QK. Trend of Outcome Metrics in Recent Out-of-Hospital-Cardiac-Arrest Research: A Narrative Review of Clinical Trials. J Clin Med 2023; 12:7196. [PMID: 38002808 PMCID: PMC10672249 DOI: 10.3390/jcm12227196] [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: 10/04/2023] [Revised: 11/10/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023] Open
Abstract
Cardiopulmonary resuscitation (CPR) research traditionally focuses on survival. In 2018, the International Liaison Committee on Resuscitation (ILCOR) proposed more patient-centered outcomes. Our narrative review assessed clinical trials after 2018 to identify the trends of outcome metrics in the field OHCA research. We performed a search of the PubMed database from 1 January 2019 to 22 September 2023. Prospective clinical trials involving adult humans were eligible. Studies that did not report any patient-related outcomes or were not available in full-text or English language were excluded. The articles were assessed for demographic information and primary and secondary outcomes. We included 89 studies for analysis. For the primary outcome, 31 (35%) studies assessed neurocognitive functions, and 27 (30%) used survival. For secondary outcomes, neurocognitive function was present in 20 (22%) studies, and survival was present in 10 (11%) studies. Twenty-six (29%) studies used both survival and neurocognitive function. Since the publication of the COSCA guidelines in 2018, there has been an increased focus on neurologic outcomes. Although survival outcomes are used frequently, we observed a trend toward fewer studies with ROSC as a primary outcome. There were no quality-of-life assessments, suggesting a need for more studies with patient-centered outcomes that can inform the guidelines for cardiac-arrest management.
Collapse
Affiliation(s)
- Natalie N. Htet
- Department of Emergency Medicine, Stanford University, Stanford, CA 94305, USA;
| | - Daniel Jafari
- Donald and Barbara Zucker School of Medicine Hofstra Northwell, Hempstead, NY 11549, USA;
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY 11030, USA
| | - Jennifer A. Walker
- Department of Emergency Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth, TX 76104, USA;
- Department of Emergency Medicine, Burnett School of Medicine, Texas Christian University, Fort Worth, TX 76109, USA
| | - Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC 20037, USA;
| | - Anna Shaw
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Khai Dinh
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Quincy K. Tran
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| |
Collapse
|
7
|
Abuelazm MT, Ghanem A, Katamesh BE, Hassan AR, Abdalshafy H, Seri AR, Awad AK, Abdelnabi M, Abdelazeem B. Defibrillation strategies for refractory ventricular fibrillation out-of-hospital cardiac arrest: A systematic review and network meta-analysis. Ann Noninvasive Electrocardiol 2023; 28:e13075. [PMID: 37482919 PMCID: PMC10475889 DOI: 10.1111/anec.13075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/10/2023] [Accepted: 07/10/2023] [Indexed: 07/25/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Double sequential external defibrillation (DSED) and vector-change defibrillation (VCD) have been suggested to enhance clinical outcomes for patients with ventricular fibrillation (VF) refractory of standard defibrillation (SD). Therefore, this network meta-analysis aims to evaluate the comparative efficacy of DSED, VCD, and SD for refractory VF. METHODS A systematic review and network meta-analysis synthesizing randomized controlled trials (RCTs) and comparative observational studies retrieved from PubMed, EMBASE, WOS, SCOPUS, and Cochrane through November 15th, 2022. R software netmeta and netrank package (R version 4.2.0) and meta-insight software were used to pool dichotomous outcomes using odds ratio (OR) presented with the corresponding confidence interval (CI). Our protocol was prospectively published in PROSPERO with ID: CRD42022378533. RESULTS We included seven studies with a total of 1632 participants. DSED was similar to SD in survival to hospital discharge (OR: 1.14 with 95% CI [0.55, 2.83]), favorable neurological outcome (modified Rankin scale ≤2 or cerebral performance category ≤2) (OR: 1.35 with 95% CI [0.46, 3.99]), and return of spontaneous circulation (ROSC) (OR: 0.81 with 95% CI [0.43; 1.5]). In addition, VCD was similar to SD in survival to hospital discharge (OR: 1.12 with 95% CI [0.27, 4.57]), favorable neurological outcome (OR: 1.01 with 95% CI [0.18, 5.75]), and ROSC (OR: 0.88 with 95% CI [0.24; 3.15]). CONCLUSION Double sequential external defibrillation and VCD were not associated with enhanced outcomes in patients with refractory VF out-of-hospital cardiac arrest, compared to SD. However, the current evidence is still inconclusive, warranting further large-scale RCTs.
Collapse
Affiliation(s)
| | - Ahmed Ghanem
- Cardiology DepartmentThe Lundquist InstituteTorranceCaliforniaUSA
| | | | | | | | - Amith Reddy Seri
- Department of Internal MedicineMcLaren Health CareFlintMichiganUSA
- Department of Internal MedicineMichigan State UniversityEast LansingMichiganUSA
| | | | - Mohamed Abdelnabi
- Department of Clinical PharmacyUniversity of MichiganAnn ArborMichiganUSA
| | - Basel Abdelazeem
- Department of Internal MedicineMcLaren Health CareFlintMichiganUSA
- Department of Internal MedicineMichigan State UniversityEast LansingMichiganUSA
| |
Collapse
|
8
|
Lupton JR, Neth MR, Sahni R, Jui J, Wittwer L, Newgard CD, Daya MR. Survival by time-to-administration of amiodarone, lidocaine, or placebo in shock-refractory out-of-hospital cardiac arrest. Acad Emerg Med 2023; 30:906-917. [PMID: 36869657 DOI: 10.1111/acem.14716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/24/2023] [Accepted: 03/01/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Amiodarone and lidocaine have not been shown to have a clear survival benefit compared to placebo for out-of-hospital cardiac arrest (OHCA). However, randomized trials may have been impacted by delayed administration of the study drugs. We sought to evaluate how timing from emergency medical services (EMS) arrival on scene to drug administration affects the efficacy of amiodarone and lidocaine compared to placebo. METHOD This is a secondary analysis of the 10-site, 55-EMS-agency double-blind randomized controlled amiodarone, lidocaine, or placebo in OHCA study. We included patients with initial shockable rhythms who received the study drugs of amiodarone, lidocaine, or placebo before achieving return of spontaneous circulation. We performed logistic regression analyses evaluating survival to hospital discharge and secondary outcomes of survival to admission and functional survival (modified Rankin scale score ≤ 3). We evaluated the samples stratified by early (<8 min) and late administration groups (≥8 min). We compared outcomes for amiodarone and lidocaine compared to placebo and adjust for potential confounders. RESULTS There were 2802 patients meeting inclusion criteria, with 879 (31.4%) in the early (<8 min) and 1923 (68.6%) in the late (≥8 min) groups. In the early group, patients receiving amiodarone, compared to placebo, had significantly higher survival to admission (62.0% vs. 48.5%, p = 0.001; adjusted OR [95% CI] 1.76 [1.24-2.50]), survival to discharge (37.1% vs. 28.0%, p = 0.021; 1.56 [1.07-2.29]), and functional survival (31.6% vs. 23.3%, p = 0.029; 1.55 [1.04-2.32]). There were no significant differences with early lidocaine compared to early placebo (p > 0.05). Patients in the late group who received amiodarone or lidocaine had no significant differences in outcomes at discharge compared to placebo (p > 0.05). CONCLUSIONS The early administration of amiodarone, particularly within 8 min, is associated with greater survival to admission, survival to discharge, and functional survival compared to placebo in patients with an initial shockable rhythm.
Collapse
Affiliation(s)
- Joshua R Lupton
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Matthew R Neth
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Ritu Sahni
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Jonathan Jui
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Lynn Wittwer
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Craig D Newgard
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Mohamud R Daya
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| |
Collapse
|
9
|
Dreyfuss A, Carlson GK. Defibrillation in the Cardiac Arrest Patient. Emerg Med Clin North Am 2023; 41:529-542. [PMID: 37391248 DOI: 10.1016/j.emc.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
Defibrillation is one of the few interventions known to favorably impact survival in cardiac arrest. In witnessed arrest, survival improves with defibrillation as early as possible, whereas it may improve outcomes to administer high-quality chest compressions for 90 seconds before defibrillation in unwitnessed arrest. Minimizing pre-, peri-, and post-shock pauses has been shown to have mortality benefits. Refractory ventricular fibrillation has high mortality rates, and there is ongoing research into promising adjunctive treatment modalities. There remains no consensus on optimal pad positioning and defibrillation energy level, however, recent data suggest anteroposterior pad placement may be superior to anterolateral placement.
Collapse
Affiliation(s)
- Andrea Dreyfuss
- Department of Emergency Medicine, Hennepin Hospital, 701 Park Avenue, Minneapolis, MN 55415, USA.
| | | |
Collapse
|
10
|
Ao CV, Ho MP. Double sequential defibrillation for refractory ventricular fibrillation. Am J Emerg Med 2023:S0735-6757(23)00342-X. [PMID: 37414677 DOI: 10.1016/j.ajem.2023.06.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 06/27/2023] [Indexed: 07/08/2023] Open
Affiliation(s)
- Chi-Va Ao
- Cardiovascular Intensive Care Unit, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Min-Po Ho
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.
| |
Collapse
|
11
|
Bloom JE, Partovi A, Bernard S, Okyere D, Heritier S, Mahony E, Eliakundu AL, Dawson LP, Voskoboinik A, Anderson D, Ball J, Chan W, Kaye DM, Nehme Z, Stub D. Use of a novel smartphone-based application tool for enrolment and randomisation in pre-hospital clinical trials. Resuscitation 2023; 187:109787. [PMID: 37028747 DOI: 10.1016/j.resuscitation.2023.109787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/11/2023] [Accepted: 03/25/2023] [Indexed: 04/08/2023]
Abstract
The effective recruitment and randomisation of patients in pre-hospital clinical trials presents unique challenges. Owing to the time critical nature of many pre-hospital emergencies and limited resourcing, the use of traditional methods of randomisation that may include centralised telephone or web-based systems are often not practicable or feasible. Previous technological limitations have necessitated that pre-hospital trialists strike a compromise between implementing pragmatic, deliverable study designs, and robust enrolment and randomisation methodologies. In this commentary piece, we present a novel smartphone-based solution that has the potential to align pre-hospital clinical trial recruitment processes to that of best-in-practice in-hospital and ambulatory care setting studies. Running title: Smartphone application based randomisation in pre-hospital clinical trials.
Collapse
Affiliation(s)
- Jason E Bloom
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia; School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia; Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | | | - Stephen Bernard
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Daniel Okyere
- Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | - Stephane Heritier
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Emily Mahony
- Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | - Amminadab L Eliakundu
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Luke P Dawson
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Aleksandr Voskoboinik
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - David Anderson
- Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia; Department of Paramedicine, Monash University, McMahons Road, Frankston, VIC 3199, Australia
| | - Jocasta Ball
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - Ziad Nehme
- Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia; Department of Paramedicine, Monash University, McMahons Road, Frankston, VIC 3199, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia; Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia; Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia.
| |
Collapse
|
12
|
Bhat C, Yadav K, Rosenberg H. Defibrillation strategies for refractory ventricular fibrillation. CAN J EMERG MED 2023; 25:297-298. [PMID: 36966437 DOI: 10.1007/s43678-023-00486-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 02/28/2023] [Indexed: 03/27/2023]
Affiliation(s)
- Chirag Bhat
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Hans Rosenberg
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| |
Collapse
|
13
|
Nolan JP, Berg KM, Bray JE. Out-of-hospital cardiac arrest. Intensive Care Med 2023; 49:447-450. [PMID: 36912966 PMCID: PMC10010215 DOI: 10.1007/s00134-023-07028-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 03/01/2023] [Indexed: 03/14/2023]
Affiliation(s)
- Jerry P Nolan
- Warwick Medical School, University of Warwick, Coventry, UK.
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, BA1 3NG, UK.
| | - Katherine M Berg
- Harvard Medical School, Boston, MA, USA
- Division of Pulmonary and Critical Care, Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Janet E Bray
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Alfred Hospital, Melbourne, VIC, Australia
- Prehospital, Resuscitation and Emergency Care Research Unit, Curtin University, Perth, WA, Australia
| |
Collapse
|
14
|
Keep shocking: Double sequential defibrillation for refractory ventricular fibrillation. Am J Emerg Med 2023; 63:178.e5-178.e6. [PMID: 36210231 DOI: 10.1016/j.ajem.2022.09.036] [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: 09/17/2022] [Accepted: 09/25/2022] [Indexed: 12/13/2022] Open
Abstract
Double sequential defibrillation is proposed as a novel modality of managing refractory ventricular fibrillation (VF). However, existing evidence has not been enough to support this. Here, we report an interesting case of a 54-year-old male who suffered from cardiac arrest with VF rhythm. The patient did not respond to 11 consecutive shocks along with antiarrhythmic medications. However, double sequential defibrillation terminated the VF. He had another episode of VF unresponsive to thirty minutes of standard defibrillation on his way to the catheterization laboratory. Again, the VF was terminated by double sequential defibrillation. Five days later, the patient was discharged home without neurological sequels.
Collapse
|
15
|
Lupton JR, Jui J, Neth MR, Sahni R, Daya MR, Newgard CD. Development of a clinical decision rule for the early prediction of Shock-Refractory Out-of-Hospital cardiac arrest. Resuscitation 2022; 181:60-67. [PMID: 36280216 DOI: 10.1016/j.resuscitation.2022.10.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/16/2022] [Accepted: 10/08/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Nearly half of ventricular fibrillation or ventricular tachycardia (VF/VT) out-of-hospital cardiac arrest (OHCA) patients receive three or more shocks, often referred to as refractory VF/VT. Our objective was to derive a clinical decision rule (CDR) for the early stratification of patients into risk categories for refractory VF/VT. METHODS We included adults with non-traumatic OHCA in the Resuscitation Outcomes Consortium Epistry (2011-2015) with ≥ 1 EMS shock. We used Classification and Regression Tree analysis for CDR building using variables known at initial EMS rhythm analysis including age, sex, witness, location, bystander interventions, initial EMS rhythm, obvious non-cardiac etiology, and dispatch to arrival times. The outcome was refractory VF/VT (≥3 shocks). We calculated sensitivity, specificity, area under the receiver operating curve (AUROC), and odds ratios (OR). The rule was validated using the Portland Cardiac Arrest Epidemiologic Registry (2018-2020). RESULTS There were 17,140 eligible patients and 8,146 (47.5%) had refractory VF/VT. The optimal CDR (AUROC = 0.671) defined three groups: high-risk were any patients requiring an EMS shock after a bystander AED shock; moderate-risk were any non-EMS witnessed arrests with shockable initial EMS rhythms; and the remainder were low-risk. Refractory VF/VT increased across the low (30.7%), moderate (58.5%) and high-risk (84.8%) groups. Compared to low-risk, being moderate-risk or higher (OR [95% CI]:3.37 [3.16-3.59]; sensitivity 72.7%; specificity 55.9%) or high-risk (OR:12.63 [9.89-16.13]; sensitivity 5.4%; specificity 99.1%) had higher odds of refractory VF/VT. Results was similar in the validation cohort (n = 765, AUROC = 0.672). CONCLUSIONS Patients at higher risk for refractory VF/VT can be identified early in EMS care.
Collapse
Affiliation(s)
- Joshua R Lupton
- Department of Emergency Medicine, Oregon Health and Science University, United States.
| | - Jonathan Jui
- Department of Emergency Medicine, Oregon Health and Science University, United States
| | - Matthew R Neth
- Department of Emergency Medicine, Oregon Health and Science University, United States
| | - Ritu Sahni
- Department of Emergency Medicine, Oregon Health and Science University, United States
| | - Mohamud R Daya
- Department of Emergency Medicine, Oregon Health and Science University, United States
| | - Craig D Newgard
- Department of Emergency Medicine, Oregon Health and Science University, United States
| |
Collapse
|
16
|
Cheskes S, Verbeek PR, Drennan IR, McLeod SL, Turner L, Pinto R, Feldman M, Davis M, Vaillancourt C, Morrison LJ, Dorian P, Scales DC. Defibrillation Strategies for Refractory Ventricular Fibrillation. N Engl J Med 2022; 387:1947-1956. [PMID: 36342151 DOI: 10.1056/nejmoa2207304] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Despite advances in defibrillation technology, shock-refractory ventricular fibrillation remains common during out-of-hospital cardiac arrest. Double sequential external defibrillation (DSED; rapid sequential shocks from two defibrillators) and vector-change (VC) defibrillation (switching defibrillation pads to an anterior-posterior position) have been proposed as defibrillation strategies to improve outcomes in patients with refractory ventricular fibrillation. METHODS We conducted a cluster-randomized trial with crossover among six Canadian paramedic services to evaluate DSED and VC defibrillation as compared with standard defibrillation in adult patients with refractory ventricular fibrillation during out-of-hospital cardiac arrest. Patients were treated with one of these three techniques according to the strategy that was randomly assigned to the paramedic service. The primary outcome was survival to hospital discharge. Secondary outcomes included termination of ventricular fibrillation, return of spontaneous circulation, and a good neurologic outcome, defined as a modified Rankin scale score of 2 or lower (indicating no symptoms to slight disability) at hospital discharge. RESULTS A total of 405 patients were enrolled before the data and safety monitoring board stopped the trial because of the coronavirus disease 2019 pandemic. A total of 136 patients (33.6%) were assigned to receive standard defibrillation, 144 (35.6%) to receive VC defibrillation, and 125 (30.9%) to receive DSED. Survival to hospital discharge was more common in the DSED group than in the standard group (30.4% vs. 13.3%; relative risk, 2.21; 95% confidence interval [CI], 1.33 to 3.67) and more common in the VC group than in the standard group (21.7% vs. 13.3%; relative risk, 1.71; 95% CI, 1.01 to 2.88). DSED but not VC defibrillation was associated with a higher percentage of patients having a good neurologic outcome than standard defibrillation (relative risk, 2.21 [95% CI, 1.26 to 3.88] and 1.48 [95% CI, 0.81 to 2.71], respectively). CONCLUSIONS Among patients with refractory ventricular fibrillation, survival to hospital discharge occurred more frequently among those who received DSED or VC defibrillation than among those who received standard defibrillation. (Funded by the Heart and Stroke Foundation of Canada; DOSE VF ClinicalTrials.gov number, NCT04080986.).
Collapse
Affiliation(s)
- Sheldon Cheskes
- From the Division of Emergency Medicine, Department of Family and Community Medicine (S.C., I.R.D., S.L.M.), the Division of Emergency Medicine, Department of Medicine, (P.R.V., L.J.M.), the Interdepartmental Division of Critical Care Medicine (R.P., D.C.S.), and the Department of Medicine (R.P., P.D., D.C.S.), Temerty Faculty of Medicine, University of Toronto, the Sunnybrook Centre for Prehospital Medicine (S.C., P.R.V., L.T., M.F.), the Departments of Emergency Services (I.R.D., L.J.M.) and Critical Care Medicine (R.P., D.C.S.), Sunnybrook Health Sciences Centre, the Schwartz/Reisman Emergency Medicine Institute, Sinai Health (S.L.M.), and the Division of Cardiology, Unity Health Toronto (P.D.), Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Medicine, University of Western Ontario, London (M.D.), and the Department of Emergency Medicine, Ottawa Hospital Research Institute, Ottawa (C.V.) - all in Canada
| | - P Richard Verbeek
- From the Division of Emergency Medicine, Department of Family and Community Medicine (S.C., I.R.D., S.L.M.), the Division of Emergency Medicine, Department of Medicine, (P.R.V., L.J.M.), the Interdepartmental Division of Critical Care Medicine (R.P., D.C.S.), and the Department of Medicine (R.P., P.D., D.C.S.), Temerty Faculty of Medicine, University of Toronto, the Sunnybrook Centre for Prehospital Medicine (S.C., P.R.V., L.T., M.F.), the Departments of Emergency Services (I.R.D., L.J.M.) and Critical Care Medicine (R.P., D.C.S.), Sunnybrook Health Sciences Centre, the Schwartz/Reisman Emergency Medicine Institute, Sinai Health (S.L.M.), and the Division of Cardiology, Unity Health Toronto (P.D.), Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Medicine, University of Western Ontario, London (M.D.), and the Department of Emergency Medicine, Ottawa Hospital Research Institute, Ottawa (C.V.) - all in Canada
| | - Ian R Drennan
- From the Division of Emergency Medicine, Department of Family and Community Medicine (S.C., I.R.D., S.L.M.), the Division of Emergency Medicine, Department of Medicine, (P.R.V., L.J.M.), the Interdepartmental Division of Critical Care Medicine (R.P., D.C.S.), and the Department of Medicine (R.P., P.D., D.C.S.), Temerty Faculty of Medicine, University of Toronto, the Sunnybrook Centre for Prehospital Medicine (S.C., P.R.V., L.T., M.F.), the Departments of Emergency Services (I.R.D., L.J.M.) and Critical Care Medicine (R.P., D.C.S.), Sunnybrook Health Sciences Centre, the Schwartz/Reisman Emergency Medicine Institute, Sinai Health (S.L.M.), and the Division of Cardiology, Unity Health Toronto (P.D.), Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Medicine, University of Western Ontario, London (M.D.), and the Department of Emergency Medicine, Ottawa Hospital Research Institute, Ottawa (C.V.) - all in Canada
| | - Shelley L McLeod
- From the Division of Emergency Medicine, Department of Family and Community Medicine (S.C., I.R.D., S.L.M.), the Division of Emergency Medicine, Department of Medicine, (P.R.V., L.J.M.), the Interdepartmental Division of Critical Care Medicine (R.P., D.C.S.), and the Department of Medicine (R.P., P.D., D.C.S.), Temerty Faculty of Medicine, University of Toronto, the Sunnybrook Centre for Prehospital Medicine (S.C., P.R.V., L.T., M.F.), the Departments of Emergency Services (I.R.D., L.J.M.) and Critical Care Medicine (R.P., D.C.S.), Sunnybrook Health Sciences Centre, the Schwartz/Reisman Emergency Medicine Institute, Sinai Health (S.L.M.), and the Division of Cardiology, Unity Health Toronto (P.D.), Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Medicine, University of Western Ontario, London (M.D.), and the Department of Emergency Medicine, Ottawa Hospital Research Institute, Ottawa (C.V.) - all in Canada
| | - Linda Turner
- From the Division of Emergency Medicine, Department of Family and Community Medicine (S.C., I.R.D., S.L.M.), the Division of Emergency Medicine, Department of Medicine, (P.R.V., L.J.M.), the Interdepartmental Division of Critical Care Medicine (R.P., D.C.S.), and the Department of Medicine (R.P., P.D., D.C.S.), Temerty Faculty of Medicine, University of Toronto, the Sunnybrook Centre for Prehospital Medicine (S.C., P.R.V., L.T., M.F.), the Departments of Emergency Services (I.R.D., L.J.M.) and Critical Care Medicine (R.P., D.C.S.), Sunnybrook Health Sciences Centre, the Schwartz/Reisman Emergency Medicine Institute, Sinai Health (S.L.M.), and the Division of Cardiology, Unity Health Toronto (P.D.), Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Medicine, University of Western Ontario, London (M.D.), and the Department of Emergency Medicine, Ottawa Hospital Research Institute, Ottawa (C.V.) - all in Canada
| | - Ruxandra Pinto
- From the Division of Emergency Medicine, Department of Family and Community Medicine (S.C., I.R.D., S.L.M.), the Division of Emergency Medicine, Department of Medicine, (P.R.V., L.J.M.), the Interdepartmental Division of Critical Care Medicine (R.P., D.C.S.), and the Department of Medicine (R.P., P.D., D.C.S.), Temerty Faculty of Medicine, University of Toronto, the Sunnybrook Centre for Prehospital Medicine (S.C., P.R.V., L.T., M.F.), the Departments of Emergency Services (I.R.D., L.J.M.) and Critical Care Medicine (R.P., D.C.S.), Sunnybrook Health Sciences Centre, the Schwartz/Reisman Emergency Medicine Institute, Sinai Health (S.L.M.), and the Division of Cardiology, Unity Health Toronto (P.D.), Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Medicine, University of Western Ontario, London (M.D.), and the Department of Emergency Medicine, Ottawa Hospital Research Institute, Ottawa (C.V.) - all in Canada
| | - Michael Feldman
- From the Division of Emergency Medicine, Department of Family and Community Medicine (S.C., I.R.D., S.L.M.), the Division of Emergency Medicine, Department of Medicine, (P.R.V., L.J.M.), the Interdepartmental Division of Critical Care Medicine (R.P., D.C.S.), and the Department of Medicine (R.P., P.D., D.C.S.), Temerty Faculty of Medicine, University of Toronto, the Sunnybrook Centre for Prehospital Medicine (S.C., P.R.V., L.T., M.F.), the Departments of Emergency Services (I.R.D., L.J.M.) and Critical Care Medicine (R.P., D.C.S.), Sunnybrook Health Sciences Centre, the Schwartz/Reisman Emergency Medicine Institute, Sinai Health (S.L.M.), and the Division of Cardiology, Unity Health Toronto (P.D.), Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Medicine, University of Western Ontario, London (M.D.), and the Department of Emergency Medicine, Ottawa Hospital Research Institute, Ottawa (C.V.) - all in Canada
| | - Matthew Davis
- From the Division of Emergency Medicine, Department of Family and Community Medicine (S.C., I.R.D., S.L.M.), the Division of Emergency Medicine, Department of Medicine, (P.R.V., L.J.M.), the Interdepartmental Division of Critical Care Medicine (R.P., D.C.S.), and the Department of Medicine (R.P., P.D., D.C.S.), Temerty Faculty of Medicine, University of Toronto, the Sunnybrook Centre for Prehospital Medicine (S.C., P.R.V., L.T., M.F.), the Departments of Emergency Services (I.R.D., L.J.M.) and Critical Care Medicine (R.P., D.C.S.), Sunnybrook Health Sciences Centre, the Schwartz/Reisman Emergency Medicine Institute, Sinai Health (S.L.M.), and the Division of Cardiology, Unity Health Toronto (P.D.), Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Medicine, University of Western Ontario, London (M.D.), and the Department of Emergency Medicine, Ottawa Hospital Research Institute, Ottawa (C.V.) - all in Canada
| | - Christian Vaillancourt
- From the Division of Emergency Medicine, Department of Family and Community Medicine (S.C., I.R.D., S.L.M.), the Division of Emergency Medicine, Department of Medicine, (P.R.V., L.J.M.), the Interdepartmental Division of Critical Care Medicine (R.P., D.C.S.), and the Department of Medicine (R.P., P.D., D.C.S.), Temerty Faculty of Medicine, University of Toronto, the Sunnybrook Centre for Prehospital Medicine (S.C., P.R.V., L.T., M.F.), the Departments of Emergency Services (I.R.D., L.J.M.) and Critical Care Medicine (R.P., D.C.S.), Sunnybrook Health Sciences Centre, the Schwartz/Reisman Emergency Medicine Institute, Sinai Health (S.L.M.), and the Division of Cardiology, Unity Health Toronto (P.D.), Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Medicine, University of Western Ontario, London (M.D.), and the Department of Emergency Medicine, Ottawa Hospital Research Institute, Ottawa (C.V.) - all in Canada
| | - Laurie J Morrison
- From the Division of Emergency Medicine, Department of Family and Community Medicine (S.C., I.R.D., S.L.M.), the Division of Emergency Medicine, Department of Medicine, (P.R.V., L.J.M.), the Interdepartmental Division of Critical Care Medicine (R.P., D.C.S.), and the Department of Medicine (R.P., P.D., D.C.S.), Temerty Faculty of Medicine, University of Toronto, the Sunnybrook Centre for Prehospital Medicine (S.C., P.R.V., L.T., M.F.), the Departments of Emergency Services (I.R.D., L.J.M.) and Critical Care Medicine (R.P., D.C.S.), Sunnybrook Health Sciences Centre, the Schwartz/Reisman Emergency Medicine Institute, Sinai Health (S.L.M.), and the Division of Cardiology, Unity Health Toronto (P.D.), Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Medicine, University of Western Ontario, London (M.D.), and the Department of Emergency Medicine, Ottawa Hospital Research Institute, Ottawa (C.V.) - all in Canada
| | - Paul Dorian
- From the Division of Emergency Medicine, Department of Family and Community Medicine (S.C., I.R.D., S.L.M.), the Division of Emergency Medicine, Department of Medicine, (P.R.V., L.J.M.), the Interdepartmental Division of Critical Care Medicine (R.P., D.C.S.), and the Department of Medicine (R.P., P.D., D.C.S.), Temerty Faculty of Medicine, University of Toronto, the Sunnybrook Centre for Prehospital Medicine (S.C., P.R.V., L.T., M.F.), the Departments of Emergency Services (I.R.D., L.J.M.) and Critical Care Medicine (R.P., D.C.S.), Sunnybrook Health Sciences Centre, the Schwartz/Reisman Emergency Medicine Institute, Sinai Health (S.L.M.), and the Division of Cardiology, Unity Health Toronto (P.D.), Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Medicine, University of Western Ontario, London (M.D.), and the Department of Emergency Medicine, Ottawa Hospital Research Institute, Ottawa (C.V.) - all in Canada
| | - Damon C Scales
- From the Division of Emergency Medicine, Department of Family and Community Medicine (S.C., I.R.D., S.L.M.), the Division of Emergency Medicine, Department of Medicine, (P.R.V., L.J.M.), the Interdepartmental Division of Critical Care Medicine (R.P., D.C.S.), and the Department of Medicine (R.P., P.D., D.C.S.), Temerty Faculty of Medicine, University of Toronto, the Sunnybrook Centre for Prehospital Medicine (S.C., P.R.V., L.T., M.F.), the Departments of Emergency Services (I.R.D., L.J.M.) and Critical Care Medicine (R.P., D.C.S.), Sunnybrook Health Sciences Centre, the Schwartz/Reisman Emergency Medicine Institute, Sinai Health (S.L.M.), and the Division of Cardiology, Unity Health Toronto (P.D.), Toronto, the Division of Emergency Medicine, London Health Sciences Centre, Department of Medicine, University of Western Ontario, London (M.D.), and the Department of Emergency Medicine, Ottawa Hospital Research Institute, Ottawa (C.V.) - all in Canada
| |
Collapse
|
17
|
Li Y, He X, Li Z, Li D, Yuan X, Yang J. Double sequential external defibrillation versus standard defibrillation in refractory ventricular fibrillation: A systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:1017935. [PMID: 36505388 PMCID: PMC9729543 DOI: 10.3389/fcvm.2022.1017935] [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: 08/12/2022] [Accepted: 11/10/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Double sequential external defibrillation (DSED) in cardiopulmonary resuscitation has shown different results in comparison with standard defibrillation in the treatment of refractory ventricular fibrillation (RVF). This review aims to compare the advantages of DSED with standard defibrillation in the treatment of refractory ventricular fibrillation. Materials and methods PubMed, Embase, Web of Science, and Cochrane Library were searched from inception to May 1, 2022. Studies included adult patients who developed RVF. The study used random-effects and fixed-effects models for meta-analysis, which was reported by risk ratio (RR) with 95% confidence interval (CI), mean difference (MD), or standardized mean difference (SMD). The risk of bias in individual studies was assessed using the Robins-I tool for observational studies and the Cochrane Risk of Bias 2 (ROB-2) tool for clinical trials. Primary outcomes included the termination of RVF, prehospital return of spontaneous circulation (ROSC), survival to hospital admission, survival to hospital discharge, and good neurological recovery. Secondary outcomes included age, total defibrillation attempts, emergency medical system arrival time, and dose of epinephrine and amiodarone used. Results In this systematic review and meta-analysis, 10 studies containing 1347 patients with available data on treatment outcomes were included. The pooled estimate was (RR 1.03, 95% CI, 0.89 to 1.19; Z = 0.42, P = 0.678 > 0.05) for Termination of RVF, (RR 0.84, 95% CI, 0.63 to 1.11; Z = 1.23, P = 0.219 > 0.05) for ROSC, (RR 0.86, 95% CI, 0.69 to 1.06; Z = 1.4, P = 0.162 > 0.05) for survival to hospital admission, (RR 0.77, 95%CI, 0.52 to 1.15; Z = 1.26, P = 0.206 > 0.05) for survival to hospital discharge, (RR 0.65, 95%CI, 0.35 to 1.22; Z = 1.33, P = 0.184 > 0.05) for good neurologic recovery, (MD -1.01, 95%CI, -3.07 to 1.06; Z = 0.96, P = 0.34 > 0.05) for age, (MD 2.27, 95%CI, 1.80 to 2.73; Z = 9.50, P = 0.001 < 0.05) for total defibrillation attempts, (MD 1.10, 95%CI, -0.45 to 66; Z = 1.39, P = 0.16 > 0.05) for emergency medical system arrival time, (SMD 0.34, 95%CI, 0.17 to 0.50; Z = 4.04, P = 0.001 < 0.05) for epinephrine, and (SMD -0.30, 95%CI, -0.65 to -0.05; Z = 1.66, P = 0.1 > 0.05) for amiodarone. Conclusion We discovered no differences between DSED and standard defibrillation in termination of RVF, prehospital return of spontaneous circulation, survival to hospital admission, survival to hospital discharge, good neurological outcome, emergency medical system arrival time, and amiodarone doses in patients with RVF. There were some differences in the number of defibrillations and epinephrine doses utilized during resuscitation. Systematic review registration [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=329354], identifier [CRD42022329354].
Collapse
Affiliation(s)
- Yongkai Li
- Emergency Trauma Center, The First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Xiaojing He
- Seven Section of Department of Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Zhuanyun Li
- Department of Emergency Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dandan Li
- Emergency Trauma Center, The First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Xin Yuan
- Emergency Trauma Center, The First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Jianzhong Yang
- Emergency Trauma Center, The First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China,*Correspondence: Jianzhong Yang,
| |
Collapse
|
18
|
Owyang CG, Abualsaud R, Agarwal S, Del Rios M, Grossestreuer AV, Horowitz JM, Johnson NJ, Kotini-Shah P, Mitchell OJL, Morgan RW, Moskowitz A, Perman SM, Rittenberger JC, Sawyer KN, Yuriditsky E, Abella BS, Teran F. Latest in Resuscitation Research: Highlights From the 2021 American Heart Association's Resuscitation Science Symposium. J Am Heart Assoc 2022; 11:e026191. [PMID: 36172932 DOI: 10.1161/jaha.122.026191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Clark G Owyang
- Division of Pulmonary and Critical Care Medicine Weill Cornell Medicine/New York Presbyterian Hospital New York NY.,Department of Emergency Medicine Weill Cornell Medicine/New York Presbyterian Hospital New York NY
| | - Rana Abualsaud
- Department of Emergency Medicine Weill Cornell Medicine/New York Presbyterian Hospital New York NY
| | - Sachin Agarwal
- Division of Neurocritical Care & Hospitalist Neurology Columbia University Irving Medical Center New York NY
| | - Marina Del Rios
- Department of Emergency Medicine University of Iowa Iowa City IA
| | | | - James M Horowitz
- Division of Cardiology, Department of Medicine NYU Langone Health New York NY
| | - Nicholas J Johnson
- Department of Emergency Medicine and Division of Pulmonary, Critical Care, and Sleep Medicine University of Washington Seattle WA
| | - Pavitra Kotini-Shah
- Department of Emergency Medicine University of Illinois at Chicago Chicago IL
| | - Oscar J L Mitchell
- Division of Pulmonary, Allergy, and Critical Care Medicine University of Pennsylvania Philadelphia PA
| | - Ryan W Morgan
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia Philadelphia PA
| | - Ari Moskowitz
- Division of Critical Care Medicine Montefiore Medical Center New York NY
| | - Sarah M Perman
- Department of Emergency Medicine University of Colorado School of Medicine Aurora CO
| | - Jon C Rittenberger
- Department of Emergency Medicine Guthrie-Robert Packer Hospital, Geisinger Commonwealth Medical College Scranton PA
| | - Kelly N Sawyer
- Department of Emergency Medicine University of Pittsburgh Pittsburgh PA
| | - Eugene Yuriditsky
- Division of Cardiology, Department of Medicine NYU Langone Health New York NY
| | - Benjamin S Abella
- Department of Emergency Medicine Center for Resuscitation Science, University of Pennsylvania Philadelphia PA
| | - Felipe Teran
- Department of Emergency Medicine Weill Cornell Medicine/New York Presbyterian Hospital New York NY
| |
Collapse
|
19
|
Drennan IR, Seidler D, Cheskes S. A survey of the incidence of defibrillator damage during double sequential external defibrillation for refractory ventricular fibrillation. Resusc Plus 2022; 11:100287. [PMID: 36105412 PMCID: PMC9464949 DOI: 10.1016/j.resplu.2022.100287] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/10/2022] [Accepted: 07/26/2022] [Indexed: 11/21/2022] Open
Abstract
Background Double Sequential External Defibrillation (DSED) is a proposed treatment strategy for patients in refractory VF (RVF) during out-of-hospital cardiac arrest (OHCA). Defibrillator damage employing DSED is a theoretical concern expressed by defibrillator manufacturers yet the incidence of damage during resuscitation remains unknown. Objective We sought to explore the incidence of defibrillator damage employing DSED for RVF during OHCA. Methods We conducted a survey of EMS agencies, authors of previous publications, EMS medical directors, base hospital medical oversight groups, and defibrillator manufacturers to assess the incidence of defibrillator damage during DSED. Our survey focused on the frequency of DSED use, number of shocks used during DSED, technique used to employ DSED (simultaneous or sequential), and the incidence of defibrillator damage during DSED. We specifically targeted groups that were known to be using DSED in clinical practice. Results Our survey response rate was 50% (65/129): 61% (34/56) EMS medical directors, 60% (6/10) authors, 100% (8/8) base hospitals, 33% (1/3) defibrillator manufacturers, 31% (16/52) paramedic services. In our case-based analysis the overall incidence of defibrillator damage was 0.4%. The incidence of defibrillator damage based on total number of DSED shocks was estimated between 0.11% and 0.22%. All reported cases of defibrillator damage occurred using a simultaneous defibrillation technique. Conclusion When DSED is employed using either a sequential or simultaneous technique the rate of defibrillator damage appears to be exceedingly low. Further high-quality evidence is required to determine the impact of DSED on patient centered outcomes, but the incidence of defibrillator damage should not limit it use. Defibrillator damage should continue to be monitored in future trials and clinical practice.
Collapse
Affiliation(s)
- Ian R. Drennan
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- University of Toronto, Department of Family and Community Medicine, Division of Emergency Medicine, Toronto, ON, Canada
- Corresponding author at: Sunnybrook Research Institute, 2075 Bayview Ave, Toronto, ON M4N 3M5, Canada.
| | - Dustin Seidler
- Toronto Paramedic Service, Toronto, ON, Canada
- School of Health Services Management, Ryerson University, Toronto, ON, Canada
| | - Sheldon Cheskes
- University of Toronto, Department of Family and Community Medicine, Division of Emergency Medicine, Toronto, ON, Canada
- Sunnybrook Centre for Prehospital Medicine, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michaels Hospital, Toronto, ON, Canada
| |
Collapse
|
20
|
Defibrillator pad placement for shockable rhythms in OHCA. Resuscitation 2022; 175:167-168. [PMID: 35595495 DOI: 10.1016/j.resuscitation.2022.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 03/16/2022] [Indexed: 11/20/2022]
|
21
|
Kulangareth NV, Magtibay K, Massé S, Krishnakumar Nair, Dorian P, Nanthakumar K, Umapathy K. An In-Silico model for evaluating the directional shock vectors in terminating and modulating rotors. Comput Biol Med 2022; 146:105665. [DOI: 10.1016/j.compbiomed.2022.105665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/03/2022] [Accepted: 05/19/2022] [Indexed: 11/27/2022]
|
22
|
Patrick C, Crowe RP, Ward B, Mohammed A, Keene KR, Dickson R. Feasibility of prehospital esmolol for refractory ventricular fibrillation. J Am Coll Emerg Physicians Open 2022; 3:e12700. [PMID: 35425942 PMCID: PMC8994138 DOI: 10.1002/emp2.12700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/16/2022] [Accepted: 02/18/2022] [Indexed: 11/22/2022] Open
Abstract
Background Esmolol may increase survival for patients with refractory ventricular fibrillation (RVF); however, information related to esmolol use in the prehospital environment is limited. We aimed to assess the feasibility of prehospital bolus dose esmolol for patients with RVF treated by a high‐volume, ground‐based emergency medical services (EMS) agency. Methods Esmolol (0.5 mg/kg single bolus) was added to the RVF protocol on December 10, 2018. Feasibility was defined as esmolol administration in >75% of RVF cases. Secondarily, we compared the proportion of patients with prehospital return of spontaneous circulation (ROSC), 24‐hour survival, and survival to hospital discharge during the intervention period (December 10, 2018–June 10, 2020) to a historical control period (June 10, 2017–December 9, 2018) using chi‐square tests. Results Before the protocol change, 63 patients with RVF were identified. After esmolol was added, 70 patients with RVF were identified and 61 (87%) received esmolol. Prehospital ROSC was higher in the esmolol group compared to the historical control group, though statistical significance was not reached (38% versus 24%, P = 0.09). Overall, few patients survived to 24 hours (esmolol n = 15, pre‐esmolol n = 16) and fewer survived to hospital discharge (esmolol n = 5, pre‐esmolol n = 5), precluding stable statistical comparisons. Conclusion Collectively, these findings suggest that EMS clinicians are able to accurately identify RVF and administer esmolol in the prehospital setting and that ROSC may be increased. Further large‐scale studies are needed to determine the effect of prehospital esmolol for RVF as it relates to neurologically intact hospital discharge.
Collapse
Affiliation(s)
- Casey Patrick
- Montgomery County Hospital District EMS Conroe Texas USA
| | | | - Brad Ward
- Montgomery County Hospital District EMS Conroe Texas USA
| | - Ali Mohammed
- Department of Emergency Medicine HCA Houston Healthcare Kingwood Kingwood Texas USA
| | - Kelley Rogers Keene
- Department of Emergency Medicine Baylor College of Medicine Houston Texas USA
| | - Robert Dickson
- Montgomery County Hospital District EMS Conroe Texas USA
- Department of Emergency Medicine Baylor College of Medicine Houston Texas USA
| |
Collapse
|
23
|
Huebinger R, Wang HE. Cardiac arrest systems of care; shining in the spotlight. Resuscitation 2022; 172:159-161. [PMID: 35077858 DOI: 10.1016/j.resuscitation.2022.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 01/14/2022] [Indexed: 10/19/2022]
Affiliation(s)
- Ryan Huebinger
- Department of Emergency Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, United States.
| | - Henry E Wang
- Department of Emergency Medicine, The Ohio State University, Columbus, OH, United States
| |
Collapse
|
24
|
Scaturo N, Shomo E, Frank M. Current and investigational therapies for the treatment of refractory ventricular fibrillation. Am J Health Syst Pharm 2022; 79:935-943. [PMID: 35020803 DOI: 10.1093/ajhp/zxac011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE Esmolol, dual sequential defibrillation, vector change defibrillation, and left stellate ganglion block are presented and reviewed for the treatment of refractory ventricular fibrillation. SUMMARY Although no formal definition has been established for refractory ventricular fibrillation, the literature describes it as a pulseless ventricular arrhythmia that persists despite 3 standard defibrillation attempts, administration of amiodarone 300 mg intravenously, and provision of three 1-mg intravenous doses of epinephrine. Evolving literature surrounding resuscitation in this particular subset of cardiac arrest challenges the efficacy of traditional therapies, such as epinephrine, and suggests that other treatment modalities may improve outcomes. Case reports, case series, and small retrospective studies have pointed to benefit when utilizing a variety of therapies, namely, esmolol, dual sequential defibrillation, vector change defibrillation, or left stellate ganglion block, in patients with refractory ventricular fibrillation arrest. CONCLUSION A mounting, although limited, body of evidence suggests that esmolol, dual sequential defibrillation, vector change defibrillation, or left stellate ganglion block may be effective at terminating refractory ventricular fibrillation and improving patient outcomes. Further evidence is required before these therapies can be adopted as standard practice; however, as key members of the code response team, it is imperative for pharmacists to be familiar with the supporting evidence, safety considerations, and logistical challenges of utilizing these treatments during arrest.
Collapse
Affiliation(s)
- Nicholas Scaturo
- Department of Pharmacy, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Eileen Shomo
- Department of Pharmacy, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Marshall Frank
- Emergency Medicine Program, Florida State University, Sarasota Memorial Hospital, Sarasota, FL, andSarasota County Fire Department, Sarasota, FL, USA
| |
Collapse
|
25
|
Kulangareth NV, Umapathy K. Effect of Shock Vector Orientation in Modulating and Terminating Rotors - a Simulation Study. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2021; 2021:5488-5491. [PMID: 34892367 DOI: 10.1109/embc46164.2021.9630733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The main treatment option for Ventricular Fibrillation (VF), especially in out-of-hospital cardiac arrests (OHCA) is defibrillation. Typically, the survival-to-discharge rates are very poor for OHCA. Existing studies have shown that rotors may be the sources of arrhythmia and ablating them could modulate or terminate VF. However, tracking rotors and ablating them is not a feasible solution in a OHCA scenario. Hence, if the sources (or rotors) can be regionally localized non-invasively and this information can be used to direct the orientation of the shock vectors, it may aid the termination of rotors and defibrillation success. In this work, using computational modeling, we present our initial results on testing the effect of shock vector orientation on modulating (or) terminating rotors. A combination of Sovilj's and Aliev Panfilov's monodomain cardiac models were used in inducing rotors and testing the effect of shock vector magnitude and direction. Based on our simulation results on an average with four experimental trials, a shock vector directed in the perpendicular direction along the axis of the rotor terminated the rotor with 16% lesser magnitude than parallel direction and 38% lesser magnitude than in oblique direction.Clinical Relevance- A rotor localization dependent defibrillation strategy may aid the defibrillation protocol procedures to improve the survival rates. Based on the four experimental trials, the results indicate shock vectors oriented perpendicular to the axis of the rotors were efficient in modulating or terminating rotors with lower magnitude than other directions.
Collapse
|
26
|
Kim S, Jung WJ, Roh YI, Kim TY, Hwang SO, Cha K. Comparison of Resuscitation Outcomes Between 2- or 3-Stacked Defibrillation Strategies With Minimally Interrupted Chest Compression and the Single Defibrillation Strategy: A Swine Cardiac Arrest Model. J Am Heart Assoc 2021; 10:e021250. [PMID: 34533046 PMCID: PMC8649549 DOI: 10.1161/jaha.121.021250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 08/03/2021] [Indexed: 11/16/2022]
Abstract
Background There is controversy over whether the number and mode of electrical shock are optimal for successful defibrillation. Methods and Results Fifty-four pigs were randomly assigned to 3 groups. After inducing ventricular fibrillation and a 2-minute downtime, basic life support was initiated with a 30:2 compression/ventilation ratio for 8 minutes. Subsequently, 20 minutes of advanced life support, including asynchronous ventilation, every 10 chest compressions with 15 L/min of oxygen, was delivered. Animals of the single shock group received a single shock, animals of the 2-stacked shock group received 2 consecutive shocks, and animals of the 3-stacked shock group received 3 consecutive shocks. Animals with the return of spontaneous circulation underwent post-cardiac arrest care for 12 hours. The rates of successful defibrillation, return of spontaneous circulation, 24-hour survival, and 48-hour survival and neurological deficit score were compared between the groups. Hemodynamic parameters, arterial blood gas profiles, troponin I, and cardiac output were not different between the groups. There was a significant difference in chest compression fraction between the single and 3-stacked shock groups (P<0.001), although there was no difference between the single and 2-stacked shock groups (P=0.022) or the 2-stacked and 3-stacked shock groups (P=0.040). The rates of successful defibrillation, return of spontaneous circulation, 24-hour survival, and 48-hour survival were higher in the 2- and 3-stacked shock groups than in the single shock group (P=0.021, P=0.015, and P=0.021, respectively). Neurological deficit score at 48 hours was not different between the groups. Conclusions A stacked shock strategy was superior to a single shock strategy for successful defibrillation and better resuscitation outcomes in treating ventricular fibrillation.
Collapse
Affiliation(s)
- Soyeong Kim
- Department of Emergency MedicineYonsei University Wonju College of MedicineWonjuRepublic of Korea
| | - Woo Jin Jung
- Department of Emergency MedicineYonsei University Wonju College of MedicineWonjuRepublic of Korea
| | - Young Il Roh
- Department of Emergency MedicineYonsei University Wonju College of MedicineWonjuRepublic of Korea
| | - Tae Youn Kim
- Department of Emergency MedicineDongguk University Ilsan Hospital, Dongguk University College of MedicineGoyangRepublic of Korea
| | - Sung Oh Hwang
- Department of Emergency MedicineYonsei University Wonju College of MedicineWonjuRepublic of Korea
| | - Kyoung‐Chul Cha
- Department of Emergency MedicineYonsei University Wonju College of MedicineWonjuRepublic of Korea
| |
Collapse
|
27
|
Horowitz JM, Owyang C, Perman SM, Mitchell OJL, Yuriditsky E, Sawyer KN, Blewer AL, Rittenberger JC, Ciullo A, Hsu CH, Kotini-Shah P, Johnson N, Morgan RW, Moskowitz A, Dainty KN, Fleitman J, Uzendu AI, Abella BS, Teran F. The Latest in Resuscitation Research: Highlights From the 2020 American Heart Association's Resuscitation Science Symposium. J Am Heart Assoc 2021; 10:e021575. [PMID: 34369175 PMCID: PMC8475047 DOI: 10.1161/jaha.121.021575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Clark Owyang
- Department of Emergency Medicine and Division of Pulmonary and Critical Care Medicine Weill Cornell Medicine New York City NY
| | - Sarah M Perman
- Department of Emergency Medicine University of Colorado School of Medicine Aurora CO
| | - Oscar J L Mitchell
- Division of Pulmonary and Critical Care Department of Medicine University of Pennsylvania Philadelphia PA
| | | | - Kelly N Sawyer
- Department of Emergency Medicine University of Pittsburgh School of Medicine Pittsburgh PA
| | - Audrey L Blewer
- Department of Family Medicine and Community Health Duke University Durham NC
| | - Jon C Rittenberger
- Guthrie-Robert Packer Hospital Emergency Medicine Residency Geisinger Commonwealth Medical College Sayre PA
| | - Anna Ciullo
- Division of Emergency Medicine Department of Surgery University of Utah Health Salt Lake City UT
| | - Cindy H Hsu
- Department of Emergency Medicine Department of Surgery Michigan Center for Integrative Research in Critical Care Michigan Medicine University of Michigan Ann Arbor MI
| | - Pavitra Kotini-Shah
- Department of Emergency Medicine University of Illinois College of Medicine at Chicago Chicago IL
| | - Nicholas Johnson
- Division of Pulmonary, Critical Care, & Sleep Medicine Department of Emergency Medicine University of Washington Seattle WA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine at Children's Hospital of Philadelphia Philadelphia PA
| | - Ari Moskowitz
- Division of Critical Care Medicine Montefiore Medical Center Bronx, New York NY
| | - Katie N Dainty
- North York General Hospital University of Toronto Toronto Canada
| | - Jessica Fleitman
- Division of Cardiology University of Pennsylvania Philadelphia PA
| | - Anezi I Uzendu
- Division of Cardiology Massachusetts General Hospital Boston MA
| | - Benjamin S Abella
- Department of Emergency Medicine Center for Resuscitation Science University of Pennsylvania Philadelphia PA
| | - Felipe Teran
- Department of Emergency Medicine Center for Resuscitation Science University of Pennsylvania Philadelphia PA
| |
Collapse
|
28
|
Soar J, Böttiger BW, Carli P, Couper K, Deakin CD, Djärv T, Lott C, Olasveengen T, Paal P, Pellis T, Perkins GD, Sandroni C, Nolan JP. [Adult advanced life support]. Notf Rett Med 2021; 24:406-446. [PMID: 34121923 PMCID: PMC8185697 DOI: 10.1007/s10049-021-00893-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2021] [Indexed: 12/19/2022]
Abstract
These European Resuscitation Council Advanced Life Support guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.
Collapse
Affiliation(s)
- Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, Großbritannien
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, Universitätsklinikum Köln, Köln, Deutschland
| | - Pierre Carli
- SAMU de Paris, Center Hospitalier Universitaire Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, and Université Paris Descartes, Paris, Frankreich
| | - Keith Couper
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
- Warwick Medical School, University of Warwick, Coventry, Großbritannien
| | - Charles D. Deakin
- University Hospital Southampton NHS Foundation Trust, Southampton, Großbritannien
- South Central Ambulance Service NHS Foundation Trust, Otterbourne, Großbritannien
| | - Therese Djärv
- Dept of Acute and Reparative Medicine, Karolinska University Hospital, Stockholm, Schweden
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Schweden
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - Theresa Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norwegen
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Österreich
| | - Tommaso Pellis
- Department of Anaesthesia and Intensive Care, Azienda Sanitaria Friuli Occidentale, Pordenone, Italien
| | - Gavin D. Perkins
- Warwick Medical School and University Hospitals Birmingham NHS Foundation Trust, University of Warwick, Coventry, Großbritannien
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rom, Italien
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rom, Italien
| | - Jerry P. Nolan
- Warwick Medical School, Coventry, Großbritannien, Consultant in Anaesthesia and Intensive Care Medicine Royal United Hospital, University of Warwick, Bath, Großbritannien
| |
Collapse
|
29
|
Oh J, Cha KC, Lee JH, Park S, Kim DH, Lee BK, Park JS, Jung WJ, Lee DK, Roh YI, Kim TY, Chung SP, Kim YM, Park JD, Kim HS, Lee MJ, Na SH, Cho GC, Kim ARE, Hwang SO. 2020 Korean Guidelines for Cardiopulmonary Resuscitation. Part 4. Adult advanced life support. Clin Exp Emerg Med 2021; 8:S26-S40. [PMID: 34034448 PMCID: PMC8171171 DOI: 10.15441/ceem.21.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 03/19/2021] [Indexed: 11/23/2022] Open
Affiliation(s)
- Jaehoon Oh
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Kyoung-Chul Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Seungmin Park
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Dong-Hyeok Kim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Woo Jin Jung
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Dong Keon Lee
- Department of Anesthesiology and Pain Medicine, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Young Il Roh
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Tae Youn Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Min Kim
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - June Dong Park
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Mi Jin Lee
- Department of Emergency Medicine, Kyungpook National University College of Medicine, Daegu, Korea
| | - Sang-Hoon Na
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Gyu Chong Cho
- Department of Emergency Medicine, Hallym University College of Medicine, Seoul, Korea
| | - Ai-Rhan Ellen Kim
- Department of Pediatrics, Ulsan University College of Medicine, Seoul, Korea
| | - Sung Oh Hwang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | | |
Collapse
|
30
|
Coronary angiography findings in patients with shock-resistant ventricular fibrillation cardiac arrest. Resuscitation 2021; 164:54-61. [PMID: 34023425 DOI: 10.1016/j.resuscitation.2021.05.006] [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: 12/17/2020] [Revised: 04/16/2021] [Accepted: 05/10/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Shock-resistant ventricular fibrillation (VF) poses a therapeutic challenge during out-of-hospital cardiac arrest (OHCA). For these patients, new treatment strategies are under active investigation, yet underlying trigger(s) and substrate(s) have been poorly characterised, and evidence on coronary angiography (CAG) data is often limited to studies without a control group. METHODS In our OHCA-registry, we studied CAG-findings in OHCA-patients with VF who underwent CAG after hospital arrival. We compared baseline demographics, arrest characteristics, CAG-findings and outcomes between patients with VF that was shock-resistant (defined as >3 shocks) or not shock-resistant (≤3 shocks). RESULTS Baseline demographics, arrest location, bystander resuscitation and AED-use did not differ between 105 patients with and 196 patients without shock-resistant VF. Shock-resistant VF-patients required more shocks, with higher proportions endotracheal intubation, mechanical CPR, amiodaron and epinephrine. In both groups, significant coronary artery disease (≥1 stenosis >70%) was highly prevalent (78% vs. 77%, p = 0.76). Acute coronary occlusions (ACOs) were more prevalent in shock-resistant VF-patients (41% vs. 26%, p = 0.006). Chronic total occlusions did not differ between groups (29% vs. 33%, p = 0.47). There was an association between increasing numbers of shocks and a higher likelihood of ACO. Shock-resistant VF-patients had lower proportions 24-h survival (75% vs. 93%, p < 0.001) and survival to discharge (61% vs. 78%, p = 0.002). CONCLUSION In this cohort of OHCA-patients with VF and CAG after transport, acute coronary occlusions were more prevalent in patients with shock-resistant VF compared to VF that was not shock-resistant, and their clinical outcome was worse. Confirmative studies are warranted for this potentially reversible therapeutic target.
Collapse
|
31
|
Soar J, Böttiger BW, Carli P, Couper K, Deakin CD, Djärv T, Lott C, Olasveengen T, Paal P, Pellis T, Perkins GD, Sandroni C, Nolan JP. European Resuscitation Council Guidelines 2021: Adult advanced life support. Resuscitation 2021; 161:115-151. [PMID: 33773825 DOI: 10.1016/j.resuscitation.2021.02.010] [Citation(s) in RCA: 407] [Impact Index Per Article: 135.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
These European Resuscitation Council Advanced Life Support guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.
Collapse
Affiliation(s)
- Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Pierre Carli
- SAMU de Paris, Centre Hospitalier Universitaire Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, and Université Paris Descartes, Paris, France
| | - Keith Couper
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Medical School, University of Warwick, Coventry,UK
| | - Charles D Deakin
- University Hospital Southampton NHS Foundation Trust, Southampton, UK; South Central Ambulance Service NHS Foundation Trust, Otterbourne,UK
| | - Therese Djärv
- Dept of Acute and Reparative Medicine, Karolinska University Hospital, Stockholm, Sweden, Department of Medicine Solna, Karolinska Institutet,Stockholm, Sweden
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-Universitaet Mainz, Germany
| | - Theresa Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Tommaso Pellis
- Department of Anaesthesia and Intensive Care, Azienda Sanitaria Friuli Occidentale, Italy
| | - Gavin D Perkins
- University of Warwick, Warwick Medical School and University Hospitals Birmingham NHS Foundation Trust, Coventry, UK
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry, CV4 7AL; Royal United Hospital, Bath, UK
| |
Collapse
|
32
|
Just the facts: double sequential external defibrillation for refractory ventricular fibrillation. CAN J EMERG MED 2021; 23:156-158. [PMID: 33709364 DOI: 10.1007/s43678-020-00039-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 10/20/2020] [Indexed: 10/22/2022]
|
33
|
Lee SGW, Park JH, Ro YS, Hong KJ, Song KJ, Shin SD. Time to first defibrillation and survival outcomes of out-of-hospital cardiac arrest with refractory ventricular fibrillation. Am J Emerg Med 2021; 40:96-102. [DOI: 10.1016/j.ajem.2020.12.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/15/2020] [Accepted: 12/09/2020] [Indexed: 11/30/2022] Open
|
34
|
Miraglia D, Ramzy M. Double external defibrillation for shock-refractory ventricular fibrillation cardiac arrest: A step towards standardization. Am J Emerg Med 2020; 41:73-79. [PMID: 33387933 DOI: 10.1016/j.ajem.2020.12.031] [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: 09/11/2020] [Revised: 12/07/2020] [Accepted: 12/10/2020] [Indexed: 11/16/2022] Open
Abstract
Double (or dual) external defibrillation (DED) has increasingly been used in the last few years by a number of emergency medical services (EMS) as a last resort to terminate ventricular fibrillation and pulseless ventricular tachycardia in adult patients who remain refractory to standard defibrillation. However, no randomized controlled trials comparing DED with standard defibrillation focusing on patient-oriented outcomes as the primary objective have been published to date. Selection criteria, procedure techniques, and protocol are not clearly defined and vary across observational studies. The terms and/or nomenclature used to describe DED are confusing and vary throughout the literature. Despite increased use of DED, many questions remain as to which patients will derive the most benefit from DED, when to implement DED, and the optimal form of delivering DED. The present paper provides a brief overview of the background, procedure techniques, pad placement, and factors affecting how DED is delivered. A further objective of this paper is to offer a proposal for a uniform nomenclature and a standardized protocol in the form of a flowchart for EMS agencies to guide further clinical trials and best practices. This paper should not only help give background on novel definitions and clarify nomenclature for this practice, but more importantly should help institutions lay the groundwork for performing EMS-based large trials to further investigate the effectiveness of DED.
Collapse
Affiliation(s)
- Dennis Miraglia
- Department of Internal Medicine, Good Samaritan Hospital, Aguadilla, PR, United States.
| | - Mark Ramzy
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| |
Collapse
|
35
|
Roach C, Tainter CR, Sell RE, Wardi G. Resuscitating Resuscitation: Advanced Therapies for Resistant Ventricular Dysrhythmias. J Emerg Med 2020; 60:331-341. [PMID: 33339645 DOI: 10.1016/j.jemermed.2020.10.051] [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: 09/02/2020] [Accepted: 10/22/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND More than 640,000 combined in-hospital and out-of-hospital cardiac arrests occur annually in the United States. However, survival rates and meaningful neurologic recovery remain poor. Although "shockable" rhythms (i.e., ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT)) have the best outcomes, many of these ventricular dysrhythmias fail to return to a perfusing rhythm (resistant VF/VT), or recur shortly after they are resolved (recurrent VF/VT). OBJECTIVE This review discusses 4 emerging therapies in the emergency department for treating these resistant or recurrent ventricular dysrhythmias: beta-blocker therapy, dual simultaneous external defibrillation, stellate ganglion blockade, and extracorporeal cardiopulmonary resuscitation. We discuss the underlying physiology of each therapy, review relevant literature, describe when these approaches should be considered, and provide evidence-based recommendations for these techniques. DISCUSSION Esmolol may mitigate some of epinephrine's negative effects when used during resuscitation, improving both postresuscitation cardiac function and long-term survival. Dual simultaneous external defibrillation targets the region of the heart where ventricular fibrillation typically resumes and may apply a more efficient defibrillation across the heart, leading to higher rates of successful defibrillation. Stellate ganglion blocks, recently described in the emergency medicine literature, have been used to treat patients with recurrent VF/VT, resulting in significant dysrhythmia suppression. Finally, extracorporeal cardiopulmonary resuscitation is used to provide cardiopulmonary support while clinicians correct reversible causes of arrest, potentially resulting in improved survival and good neurologic functional outcomes. CONCLUSION These emerging therapies do not represent standard practice; however, they may be considered in the appropriate clinical scenario when standard therapies are exhausted without success.
Collapse
Affiliation(s)
- Colin Roach
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Christopher R Tainter
- Department of Anesthesiology, Division of Critical Care, University of California, San Diego, San Diego, California
| | - Rebecca E Sell
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, San Diego, California
| | - Gabriel Wardi
- Department of Emergency Medicine, University of California, San Diego, San Diego, California; Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, San Diego, California
| |
Collapse
|
36
|
DOuble SEquential External Defibrillation for Refractory Ventricular Fibrillation (DOSE VF): study protocol for a randomized controlled trial. Trials 2020; 21:977. [PMID: 33243277 PMCID: PMC7689391 DOI: 10.1186/s13063-020-04904-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 11/15/2020] [Indexed: 11/11/2022] Open
Abstract
Background Despite high-quality cardiopulmonary resuscitation (CPR), early defibrillation, and antiarrhythmic medications, some patients remain in refractory ventricular fibrillation (VF) during out-of-hospital cardiac arrest. These patients have worse outcomes compared to patients who respond to initial treatment. Double sequential external defibrillation (DSED) and vector change (VC) defibrillation have been proposed as viable options for patients in refractory VF. However, the evidence supporting the use of novel defibrillation strategies is inconclusive. The objective of this study is to compare two novel therapeutic defibrillation strategies (DSED and VC) against standard defibrillation for patients with treatment refractory VF or pulseless ventricular tachycardia (pVT) during out-of-hospital cardiac arrest. Research question Among adult (≥ 18 years) patients presenting in refractory VF or pulseless ventricular tachycardia (pVT) during out-of-hospital cardiac arrest, does DSED or VC defibrillation result in greater rates of survival to hospital discharge compared to standard defibrillation? Methods This will be a three-arm, cluster randomized trial with repeated crossover conducted in six regions of Ontario, Canada (Peel, Halton, Toronto, Simcoe, London, and Ottawa), over 3 years. All adult (≥ 18 years) patients presenting in refractory VF (defined as patients presenting in VF/pVT and remaining in VF/pVT after three consecutive standard defibrillation attempts during out-of-hospital cardiac arrest of presumed cardiac etiology will be treated by one of three strategies: (1) continued resuscitation using standard defibrillation, (2) resuscitation involving DSED, or (3) resuscitation involving VC (change of defibrillation pads from anterior-lateral to anterior-posterior pad position) defibrillation. The primary outcome will be survival to hospital discharge. Secondary outcomes will include return of spontaneous circulation (ROSC), VF termination after the first interventional shock, VF termination inclusive of all interventional shocks, and number of defibrillation attempts to obtain ROSC. We will also perform an a priori subgroup analysis comparing rates of survival for those who receive “early DSED,” or first DSED shock is shock 4–6, to those who receive “late DSED,” or first DSED shock is shock 7 or later. Discussion A well-designed randomized controlled trial employing a standardized approach to alternative defibrillation strategies early in the treatment of refractory VF is urgently required to determine if the treatments of DSED or VC defibrillation impact clinical outcomes. Trial registration ClinicalTrials.gov NCT04080986. Registered on 6 September 2019. Supplementary information The online version contains supplementary material available at 10.1186/s13063-020-04904-z.
Collapse
|
37
|
Soar J, Berg KM, Andersen LW, Böttiger BW, Cacciola S, Callaway CW, Couper K, Cronberg T, D'Arrigo S, Deakin CD, Donnino MW, Drennan IR, Granfeldt A, Hoedemaekers CWE, Holmberg MJ, Hsu CH, Kamps M, Musiol S, Nation KJ, Neumar RW, Nicholson T, O'Neil BJ, Otto Q, de Paiva EF, Parr MJA, Reynolds JC, Sandroni C, Scholefield BR, Skrifvars MB, Wang TL, Wetsch WA, Yeung J, Morley PT, Morrison LJ, Welsford M, Hazinski MF, Nolan JP. Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2020; 156:A80-A119. [PMID: 33099419 PMCID: PMC7576326 DOI: 10.1016/j.resuscitation.2020.09.012] [Citation(s) in RCA: 129] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.
Collapse
|
38
|
Nolan JP, Maconochie I, Soar J, Olasveengen TM, Greif R, Wyckoff MH, Singletary EM, Aickin R, Berg KM, Mancini ME, Bhanji F, Wyllie J, Zideman D, Neumar RW, Perkins GD, Castrén M, Morley PT, Montgomery WH, Nadkarni VM, Billi JE, Merchant RM, de Caen A, Escalante-Kanashiro R, Kloeck D, Wang TL, Hazinski MF. Executive Summary: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2020; 142:S2-S27. [PMID: 33084397 DOI: 10.1161/cir.0000000000000890] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
|
39
|
Nolan JP, Maconochie I, Soar J, Olasveengen TM, Greif R, Wyckoff MH, Singletary EM, Aickin R, Berg KM, Mancini ME, Bhanji F, Wyllie J, Zideman D, Neumar RW, Perkins GD, Castrén M, Morley PT, Montgomery WH, Nadkarni VM, Billi JE, Merchant RM, de Caen A, Escalante-Kanashiro R, Kloeck D, Wang TL, Hazinski MF. Executive Summary 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2020; 156:A1-A22. [PMID: 33098915 PMCID: PMC7576314 DOI: 10.1016/j.resuscitation.2020.09.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
40
|
Cheskes S, Drennan IR. Refibrillation after defibrillation: The shocking truth. Resuscitation 2020; 157:269-271. [PMID: 33080367 DOI: 10.1016/j.resuscitation.2020.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Sheldon Cheskes
- Sunnybrook Centre for Prehospital Medicine, Toronto, ON, Canada; University of Toronto, Department of Family and Community Medicine, Division of Emergency Medicine, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michaels Hospital, Toronto, ON, Canada.
| | - Ian R Drennan
- Sunnybrook Centre for Prehospital Medicine, Toronto, ON, Canada; Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| |
Collapse
|
41
|
Merchant RM, Topjian AA, Panchal AR, Cheng A, Aziz K, Berg KM, Lavonas EJ, Magid DJ. Part 1: Executive Summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S337-S357. [DOI: 10.1161/cir.0000000000000918] [Citation(s) in RCA: 190] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
|
42
|
Berg KM, Soar J, Andersen LW, Böttiger BW, Cacciola S, Callaway CW, Couper K, Cronberg T, D’Arrigo S, Deakin CD, Donnino MW, Drennan IR, Granfeldt A, Hoedemaekers CW, Holmberg MJ, Hsu CH, Kamps M, Musiol S, Nation KJ, Neumar RW, Nicholson T, O’Neil BJ, Otto Q, de Paiva EF, Parr MJ, Reynolds JC, Sandroni C, Scholefield BR, Skrifvars MB, Wang TL, Wetsch WA, Yeung J, Morley PT, Morrison LJ, Welsford M, Hazinski MF, Nolan JP, Issa M, Kleinman ME, Ristagno G, Arafeh J, Benoit JL, Chase M, Fischberg BL, Flores GE, Link MS, Ornato JP, Perman SM, Sasson C, Zelop CM. Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2020; 142:S92-S139. [DOI: 10.1161/cir.0000000000000893] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
This
2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.
Collapse
|
43
|
Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, O’Neil BJ, Peberdy MA, Rittenberger JC, Rodriguez AJ, Sawyer KN, Berg KM, Arafeh J, Benoit JL, Chase M, Fernandez A, de Paiva EF, Fischberg BL, Flores GE, Fromm P, Gazmuri R, Gibson BC, Hoadley T, Hsu CH, Issa M, Kessler A, Link MS, Magid DJ, Marrill K, Nicholson T, Ornato JP, Pacheco G, Parr M, Pawar R, Jaxton J, Perman SM, Pribble J, Robinett D, Rolston D, Sasson C, Satyapriya SV, Sharkey T, Soar J, Torman D, Von Schweinitz B, Uzendu A, Zelop CM, Magid DJ. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S366-S468. [DOI: 10.1161/cir.0000000000000916] [Citation(s) in RCA: 371] [Impact Index Per Article: 92.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
44
|
Miraglia D, Alonso W. A review of pre-hospital case series among those with time to double external defibrillation and neurologic outcomes. Am J Emerg Med 2020; 38:2703-2712. [PMID: 33046315 DOI: 10.1016/j.ajem.2020.08.031] [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: 05/19/2020] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Double external defibrillation (DED) has been used as a final effort to terminate refractory ventricular fibrillation/pulseless ventricular tachycardiac (rVF/pVT). Data surrounding time to DED and patient-centered outcomes remains limited. OBJECTIVES This study summarizes patient-level data from case-series of observed survival and neurologic outcomes following the use of DED for rVF/pVT among those with data regarding time to DED. METHODS We conducted a literature search of PubMed, MEDLINE (OVID interface), and Scopus from January 1, 2000, through January 5, 2020. The literature was screened according to inclusion and exclusion criteria. Two investigators independently conducted the literature search, study selection, and data extraction. RESULTS Our database search identified 3139 records. Of these, 1660 studies were eliminated following inspection of the titles and 22 studies underwent full-text screening, three included in the final analysis, describing a total of 29 cases. All studies were considered to have critical risk of bias. For the critical outcomes of survival to discharge and neurologically intact survival we identified that patients who received DED before 30 min from collapse compared to those who received DED after 30 min had better survival to discharge (33.3% [5/15] vs. 7.1% [1/14]) and neurologically intact survival (20.0% [3/15] vs. 7.1% [1/14]). Overall, 20.6% of patients survived to discharge, 13.8% with neurologically intact survival. It is noteworthy that the patients who were discharged with a CPC of 1 received two, four, five, and three standard shocks before receiving DED, and the time between their onset of cardiac arrest to their first DED attempt was recorded to be 15, 26, 26, and 32 min, respectively. CONCLUSION We would like to indicate that there is not enough evidence to suggest that early use of pre-hospital DED is associated with improved outcomes. Further research should strive to address these issues before conclusions can be drawn.
Collapse
Affiliation(s)
- Dennis Miraglia
- Department of Internal Medicine, Good Samaritan Hospital, Aguadilla, PR, United States.
| | - Wilfredo Alonso
- Department of Internal Medicine, Good Samaritan Hospital, Aguadilla, PR, United States
| |
Collapse
|
45
|
Miraglia D, Miguel LA, Alonso W. Double Defibrillation for Refractory In- and Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. J Emerg Med 2020; 59:521-541. [DOI: 10.1016/j.jemermed.2020.06.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/12/2020] [Accepted: 06/01/2020] [Indexed: 02/07/2023]
|
46
|
Deakin CD, Morley P, Soar J, Drennan IR. Double (dual) sequential defibrillation for refractory ventricular fibrillation cardiac arrest: A systematic review. Resuscitation 2020; 155:24-31. [PMID: 32561473 DOI: 10.1016/j.resuscitation.2020.06.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/05/2020] [Accepted: 06/09/2020] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Cardiac arrests associated with shockable rhythms such as ventricular fibrillation or pulseless VT (VF/pVT) are associated with improved outcomes from cardiac arrest. The more defibrillation attempts required to terminate VF/pVT, the lower the survival. Double sequential defibrillation (DSD) has been used for refractory VF/pVT cardiac arrest despite limited evidence examining this practice. We performed a systematic review to summarize the evidence related to the use of DSD during cardiac arrest. METHODS This review was performed according to PRISMA and registered on PROSPERO (ID: CRD42020152575). We searched Embase, Pubmed, and the Cochrane library from inception to 28 February 2020. We included adult patients with VF/pVT in any setting. We excluded case studies, case series with less than five patients, conference abstracts, simulation studies, and protocols for clinical trials. We predefined our outcomes of interest as neurological outcome, survival to hospital discharge, survival to hospital admission, return of spontaneous circulation (ROSC), and termination of VF/pVT. Risk of bias was examined using ROBINS-I or ROB-2 and certainty of studies were reported according to GRADE methodology. RESULTS Overall, 314 studies were identified during the initial search. One hundred and thirty studies were screened during title and abstract stage and 10 studies underwent full manuscript screening, nine included in the final analysis. Included studies were cohort studies (n = 4), case series (n = 3), case-control study (n = 1) and a prospective pilot clinical trial (n-1). All studies were considered to have serious or critical risk of bias and no meta-analysis was performed. Overall, we did not find any differences in terms of neurological outcome, survival to hospital discharge, survival to hospital admission, ROSC, or termination of VF/pVT between DSD and a standard defibrillation strategy. CONCLUSION The use of double sequential defibrillation was not associated with improved outcomes from out-of-hospital cardiac arrest, however the current literature has a number of limitations to interpretation. Further high-quality evidence is needed to answer this important question.
Collapse
Affiliation(s)
- Charles D Deakin
- University Hospital Southampton NHS Foundation Trust, Southampton, UK; South Central Ambulance Service NHS Foundation Trust, Otterbourne, UK.
| | - Peter Morley
- Royal Melbourne Hospital, Melbourne, Australia; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Ian R Drennan
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
47
|
Drennan IR, Cheskes S. Dual sequential defibrillation: Moving from a trot to a gallop! Resuscitation 2020; 152:91-92. [PMID: 32389598 DOI: 10.1016/j.resuscitation.2020.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/04/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Ian R Drennan
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sheldon Cheskes
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Sunnybrook Centre for Prehospital Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Family and Community Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| |
Collapse
|
48
|
Dual sequential defibrillation: Hold your horses! Resuscitation 2020; 150:189-190. [PMID: 32194161 DOI: 10.1016/j.resuscitation.2020.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/09/2020] [Indexed: 11/23/2022]
|