Out-of-hospital cardiac arrest across the World: First report from the International Liaison Committee on Resuscitation (ILCOR)

Association between postresuscitation 12-lead ECG features and long-term neurological outcome after out-of-hospital cardiac arrest: a post-hoc subanalysis of the PEACE study

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) has low survival rates worldwide. For the diagnosis of acute coronary syndrome causing OHCA and the identification of patients eligible for immediate coronary angiography, the post-return of spontaneous circulation electrocardiogram (post-ROSC ECG) is crucial. However, it is still unclear whether post-ROSC ECG features also pose a sensible feature for outcome prediction.

METHODS

This retrospective study analysed adult non-traumatic OHCA cases with post-ROSC ECGs admitted to one of the three participating centers in Vienna (Austria), Pavia (Italy) and Lugano (Switzerland) between 01/2015 and 12/2018, and reports ECG features, survival and neurological outcome (at hospital discharge and after one year). Univariable and multivariable logistic regression assessed associations between ECG features and neurological outcome.

RESULTS

STEMI was diagnosed in 53.5% of post-ROSC ECGs. 68.1% of patients were discharged, with 59.5% having a favorable neurological outcome. One year later, 61.6% of non-STEMI patients had a favorable outcome compared to 54% of STEMI patients. Univariable analysis indicated that ST-elevations in II, III, and aVF, as well as a broader QRS complex significantly influenced neurological outcomes at one year.

CONCLUSIONS

ECG after ROSC can identify patients at high risk of death after OHCA earlier than other prognostic methods, not only in terms of short-term mortality, but also in terms of neurological outcome one year after OHCA. Wider QRS complex and ST-elevations in II, III, or aVF were identified as specific prognosticators.

Use of CPR feedback devices in resuscitation training: A systematic review and meta-analysis of randomized controlled trials

Objectives

The use of cardiopulmonary resuscitation (CPR) feedback devices during training is increasing. This review evaluates whether incorporating CPR feedback devices in training improves patient survival, CPR quality in actual resuscitation, skill acquisition and retention after training.

Methods

This systematic review was part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR). We searched MEDLINE, EMBASE, and SCOPUS databases from inception to September 30, 2024, including randomized controlled trials (RCTs) in all languages (with an English abstract) comparing CPR training with and without feedback devices. Outcome included patient survival, quality of clinical performance in resuscitation, and CPR skill acquisition and retention. Non-RCT studies, unpublished work without peer review or animal studies were excluded. Risk of bias was assessed using Cochrane tools, and certainty of evidence was graded using the Grading of Recommendations Assessment, development and Evaluation (GRADE) approach. Standardized mean difference (SMD) were calculated and pooled effects were analyzed using random-effects models. PROSPERO CRD42023488130.

Results

We identified 20 RCTs with 4579 participants. Risks of bias ranged from low to critical (low: 8, moderate: 9, and critical: 3). No studies evaluated the patient survival, clinical performance in resuscitation or cost-effectiveness. Compared to no feedback, using CPR feedback devices during training significantly improved key quality metrics. Pooled effect sizes were 0.76 (95%CI 0.02 - 1.50) for mean compression depth (15 studies), 0.98 (95%CI: 0.10 - 1.87) for depth compliance (16 studies), 0.29 (95%CI: 0.10 - 0.48) for mean rate (17 studies), 0.44 (95%CI: 0.23 - 0.66) for rate compliance (9 studies), and 0.53 (95%CI: 0.31 - 0.75) for recoil compliance (10 studies) in favour of using feedback devices during training. Heterogeneity was large (I2 > 50%) in all analyses. Planned subgroup analyses revealed no statistically significant interaction between healthcare professionals and laypersons. Using the GRADE approach, the certainty of evidence was downgraded for certain outcomes due to critical risk of bias for 3 studies and inconsistency but upgraded for strong association.

Conclusion

The use of CPR feedback devices during resuscitation training improves key quality metrics of CPR performance, with moderate to high certainty of evidence. However, further studies are needed to evaluate the impact on cost-effectiveness, clinical performance and patient outcomes.

How stepwise interventions in pre-hospital emergency care enhance out-of-hospital cardiac arrest management in a Megacity in China

OBJECTIVE

A series of improvements have been formulated and implemented to prompt the inadequate pre-hospital care capacity for out-of-hospital cardiac arrest (OHCA) management in China. The aim of this study is to investigate the combined association of those stepwise interventions with OHCA management in Shenzhen, as a representative city in China.

METHODS

This registry-based retrospective study included emergency medical services (EMS)-treated adult OHCA patients with presumed cardiac etiology in Shenzhen, China, covering the period from January 1, 2011 to December 31, 2022. During this period, three key interventions were implemented sequentially: a public access defibrillation (PAD) program on October 1, 2017, a civilian cardiopulmonary resuscitation (CPR) training program on July 1, 2020, and telecommunicator cardiopulmonary resuscitation (T-CPR) on November 23, 2021. The outcomes of bystander CPR and return of spontaneous circulation (ROSC) were compared with pre-intervention controls.

RESULTS

A total of 6,571 EMS-treated presumed cardiac etiology adult OHCA patients were included, among which were 623 cases with bystander-witnessed OHCA and a shockable rhythm. Across four periods, the rates of both bystander CPR (8.55 vs. 12.60 vs. 18.31 vs. 23.10%) and ROSC (6.01 vs. 5.29 vs. 9.59 vs. 8.33%) showed an increasing trend. For the rate of bystander CPR, the likelihood was significantly increased after implementation of the PAD program (OR 1.64 [95% CI 1.21-2.23]) and civilian CPR training program (OR 2.12 [95% CI: 1.52-2.95]), and after the addition of the T-CPR application (OR 3.06 [95% CI: 2.14-4.39]), compared with the pre-period. Similarly, cumulative interventions were associated with a higher ROSC (OR 0.84 [95% CI: 0.62-1.14], OR 1.52 [95% CI: 1.07-1.89], OR 1.42 [95% CI: 1.07-1.89]) when compared with the pre-period. In subgroup analysis, cumulative interventions significantly improved the rate of bystander CPR in cases where OHCA occurred in public locations, and ROSC in cases where the time from symptom onset to calling 120 was within 10 min.

CONCLUSION

Stepwise interventions in pre-hospital emergency care increased likelihood of bystander CPR and ROSC following pre-hospital resuscitation significantly. This improvement is attributed to the coordination and cumulative effect of multiple positive interventions for OHCA management.

Epidemiology and outcomes of out-of-hospital cardiac arrest in Zhejiang, China based on Electronic Medical Record Surveillance

Background

Out-of-hospital cardiac arrest (OHCA) is a critical challenge for public health, with wide variation in epidemiology and outcomes in different countries and regions. We aimed to describe the epidemiology and outcomes for OHCA in Zhejiang, China based on Electronic Medical Record Surveillance.

Methods

This retrospective study using the Zhejiang Emergency Command Center Electronic Medical Record System in Zhejiang Province, China. We included OHCA cases with non-traumatic, aged 18 years and above and had resuscitation attempted by emergency medical services (EMS). All data were collected and reported using the Utstein template. The primary outcomes were survival to discharge or 30th day, the secondary outcomes were survival with favorable neurological outcomes.

Results

6923 non-traumatic OHCA patients with aged 18 and above were identified. The OHCA incidence assessed by EMS was 37.6 per 100,000 population. The median age was 68 (54-79) years, with more than half of patients aged 65 or older. 4860 (70.2%) were male, 5033 (72.7%) had cardiac arrest at home. 2889 (41.7%) patients had bystander cardiopulmonary resuscitation (CPR). Among 6923 non-traumatic, 608 (8.8%) patients had shockable rhythm, 497 (7.2%) patients achieved return of spontaneous circulation (ROSC), 82 (1.2%) patients survived to hospital discharge. Under 65 years of age who received bystander CPR, 173 (12.1%) patients achieved ROSC, 43 (3.0%) patients survived to hospital discharge.

Conclusion

The survival after OHCA in Zhejiang Province is unsatisfactory, especially for those above 65 years patients. Electronic Medical Record Surveillance can assist the implementation of the chain of survival to improve outcomes.

Physical, psychological, cognitive, social health outcomes, and health-related quality of life in out-of-hospital cardiac arrest survivors and their caregivers: Protocol of the quality cardiac arrest survivorship cohort study (QualiCAS)

Background

Out-of-hospital cardiac arrest (OHCA) is an emergency with historically low survival rates. Advances in resuscitation and post-resuscitation care have improved survival, precipitating greater scientific interest in OHCA patients' survivorship. However, there is insufficient high-quality population-based long-term survivorship data and limited research on the impact of OHCA sequelae on survivors' caregivers.

Objective

Our primary aim is to determine neurological function, physical, psychological, cognitive, social outcomes, and health-related quality of life (HRQoL) of OHCA survivors in Singapore. Secondary aims are to quantify caregivers' burden and its association with their HRQoL, and psychological well-being.

Methods

The Quality Cardiac Arrest Survivorship Cohort Study (QualiCAS) is a prospective population-based cohort study of OHCA survivors and their caregivers in Singapore. Participants aged ≥18 years and caregivers aged ≥21 years will be recruited from all public hospitals in Singapore. Health outcomes will be evaluated at 3, 6, and 12 months, and 3 and 5 years using the Hospital Anxiety and Depression Scale, PTSD Checklist for DSM-5, Fatigue Severity Scale, Montreal Cognitive Assessment Tool, EQ-5D-5L, Community Integration Questionnaire-Revised, Barthel Index, Lawton's Instrumental Activities of Daily Living, Timed Up and Go Test, Handgrip strength assessment, and Zarit Burden Interview.

Discussion

This study allows us to understand the natural history of OHCA survivorship and quantify the burdens on patients and their caregivers. Findings can guide clinical follow-up, identify high-risk patients, intervention targets, and inform rehabilitation strategies for OHCA sequelae.

Modifiable Risk Factors and Attributable Burden of Cardiac Arrest: An Exposome-wide and Mendelian Randomization Analysis

BACKGROUND

In this study, we aimed to identify nonclinical modifiable risk factors associated with sudden cardiac arrest (SCA) incidence, and to assess attributable burden.

METHODS

Data on 125 potentially modifiable risk factors were extracted from the UK Biobank cohort. An exposome-wide association study was conducted using a Cox proportional hazard model, followed by validation of significant associations using Mendelian randomization to identify causal relationships. The attributable burden of SCA was evaluated on the basis of improvements in unfavourable profiles. We also evaluated the attributable burden to be eliminated via improvement of unfavourable profiles.

RESULTS

Of 502,094 individuals, 3147 developed SCA during a median follow-up duration of 13.8 years. SCA was associated with 56 risk factors spanning lifestyles, physical measures, psychosocial factors, socioeconomic status, and the local environment. Mendelian randomization analysis confirmed protective effects associated with 2 factors (ie, higher rates of consumption of champagne and/or white wine and fruit intake) and adverse effects associated with 7 factors (ie, time spent using the computer, fed-up feelings, greater arm fat mass and percentage, body mass index, systolic blood pressure, and lower education level). Between 40% (conservative elimination) and 63% (thorough elimination) of SCA cases could be prevented by improving unfavourable profiles, with lifestyle modifications accounting for the largest proportion of preventable cases, followed by improvements in physical measures, psychosocial factors, socioeconomic status, and the local environment.

CONCLUSIONS

This large-scale, prospective cohort study offers compelling evidence on the profile of modifiable risk factors and the attributable burden of SCA.

Association between air pollutants and out-of-hospital cardiac arrest: a 5-year time series analysis

AIMS

We aimed to analyse the yet unclear correlation between air pollutant concentrations and out-of-hospital cardiac arrest (OHCA) in Shenzhen, China.

METHODS AND RESULTS

A 5-year time series analysis of all OHCA events reported to the Shenzhen Emergency Center was conducted. Quasi-Poisson regression, controlling for meteorological variables (daily mean relative temperature and humidity) with multivariable fractional polynomial and using Fourier series to adjust for long-term trends and account for periodic patterns, was used to assess the association among particulate matter of 2.5 μm (PM2.5), ozone (O3), particulate matter of ≥10 μm (PM10), carbon monoxide (CO), nitrogen dioxide (NO2), sulfur dioxide (SO2), and OHCA. Data from 16 769 patients who experienced OHCA were analysed. An increase of 10 μg/m3 in PM2.5 was associated with a higher risk of OHCA (relative risk (RR): 1.026 [95% confidence interval [CI]: 1.001-1.053]) on lag Day 1. A similar increase in PM10 was linked to an immediate risk of OHCA on the onset day (RR: 1.02 [95% CI: 1.005-1.036]) and a cumulative risk on lag Day 1 (RR: 1.021 [95% CI: 1.003-1.039]). An increased risk of OHCA was associated with NO2 and O3 exposure, while a reduced risk of OHCA was associated with SO2 and CO exposure in the subsequent 5 days. The relationship between PM2.5 and OHCA varied by gender and arrest rhythm. A reduction in the average daily PM2.5 concentration by 1 µg/m³ could decrease the incidence of OHCA attributable to PM2.5 exposure by 4.60%, while a reduction by 3 µg/m³ could decrease it by 18.41% on lag Day 1. PM2.5 was significantly associated with the occurrence of OHCA on lag Day 1. This association was modulated by gender and arrest rhythm.

CONCLUSION

Improving the levels of PM2.5, NO2, and O3 could decrease the risk of OHCA and the demand for emergency medical service related to PM2.5 exposure.

Association between arterial carbon dioxide tension and poor outcomes after cardiac arrest: A meta-analysis

BACKGROUND

Abnormal arterial carbon dioxide tension (PaCO2) is a common finding after cardiac arrest (CA). Inconsistent results regarding the association between abnormal PaCO2 and poor outcomes have been reported previously. We performed a meta-analysis to evaluate whether hypocapnia or hypercapnia is associated with an increased risk of hospital mortality and poor neurological outcomes in adult patients with CA.

METHODS

PubMed, Embase, and the Cochrane Library databases were searched through October 2024 to determine studies investigating the association between PaCO2 and the risk of hospital mortality and/or poor neurological outcomes in adult patients with CA. A random-effects model was used to calculate the pooled odds ratio (OR) with 95% confidence intervals (CIs) for cohort studies and relative risks (RRs) with 95% CIs for randomized controlled trials (RCTs).

RESULTS

A total of 14 cohort studies and 3 RCTs comprising 72344 patients were included. Pooled analysis indicated that hypocapnia was associated with an increased risk of hospital mortality (nine cohort studies, OR 1.37; 95% CI, 1.18-1.59; P < 0.0001) and poor neurological outcomes (five cohort studies, OR, 1.75; 95% CI, 1.04-2.96; P = 0.035). Within cohort studies, hypercapnia was associated with increased risk of hospital mortality (10 trials, OR 1.40; 95% CI, 1.13-1.73; P = 0.002), but not associated with poor neurological outcomes (six cohort studies, OR, 1.57; 95% CI, 0.87-2.83; P = 0.130). Within RCTs, mild hypercapnia was not associated with an increased risk of poor neurological outcomes after CA.

CONCLUSIONS

Current evidence indicated that hypocapnia was associated with an increased risk of hospital mortality and poor neurological outcomes after CA; however, hypercapnia was associated with an increased risk of hospital mortality but did not appear to be associated with increased poor neurological outcomes after CA.

SYSTEMATIC REVIEW PROTOCOL

INPLASY 2024100120. Registered 28 October 2024.

Emergency medicine updates: Cardiac arrest airway management

INTRODUCTION

Cardiac arrest is the loss of systemic circulation. The approach to airway management is an important component of the resuscitation of patients in cardiac arrest.

OBJECTIVE

This paper evaluates key evidence-based updates concerning airway management in cardiac arrest.

DISCUSSION

Management of cardiac arrest focuses on cardiopulmonary resuscitation (CPR), including high-quality chest compressions and ventilation. Resuscitation should prioritize circulation with high-quality compressions, but as the resuscitation continues, airway management is necessary to provide ventilation. During initial CPR efforts, a compression to ventilation ratio of 30:2 is recommended. Bag-valve-mask (BVM) ventilation is an effective means of ventilation during CPR efforts, though providers should ensure appropriate mask seal with a two-person BVM strategy (one person holding the mask and one person ventilating) if possible. Breaths should be provided over less than 1 s with enough tidal volume to cause chest rise. Advanced airways include a supraglottic airway (SGA) or endotracheal tube via endotracheal intubation (ETI). If an advanced airway is present, one asynchronous ventilation should be provided every 8-10 s. An advanced airway may be considered with an asphyxial cause of arrest, those with prolonged arrest or transport, and cases managed with limited numbers of experienced personnel, though compressions must not be interrupted for placement of an advanced airway. An SGA is a viable option for an advanced airway. In settings with high ETI success rate, ETI may be performed, but in other settings SGA is recommended. If performing ETI, video laryngoscopy is associated with an improved view of the glottis and higher first pass success compared to direct laryngoscopy. Cricoid pressure is not recommended. Confirmation of ETI is necessary. Following ETI and return of spontaneous circulation, a lung protective strategy of ventilation is recommended while avoiding hypoxia.

CONCLUSIONS

An understanding of literature updates regarding airway management can improve the ED care of patients in cardiac arrest.

Association between nitrogen dioxide exposure and out-of-hospital cardiac arrest onset in China: A multicenter, time-stratified, case-crossover study

Studies on the association between nitrogen dioxide (NO2) exposure and out-of-hospital cardiac arrest (OHCA) are limited and present inconsistent results. In the context of global urbanization, a large population is exposed to high ambient NO2 pollution, highlighting the need for further clarification of NO2-related health hazards. Furthermore, previous studies mostly applied exposure data from monitoring stations, with relatively few investigations examining acute effects using high-resolution modeled data. To explore the association between NO2 and cardiac OHCA onset risk, a time-stratified case-crossover study was conducted using data from emergency medical service (EMS) systems across 23 Chinese provinces throughout 2020. Conditional logistic regression models were used to investigate the potential association between NO2 and OHCA onset. Individual-level NO2 data from both models and monitoring stations were analyzed separately to evaluate their comparability in practice. The analysis incorporated 76,263 EMS-attended cardiac OHCA onsets. The health estimates from NO2 predictions and measurements were comparable without statistically significant differences, with each 10 µg/m3 increase associated with a 1.16% (95% confidence interval [CI]: 0.38-1.94%) and 1.03% (95% CI: 0.37-1.69%) increase in the risk of OHCA onset, respectively. This nationwide multicenter study demonstrated adverse effects of NO2 exposure on OHCA onset in a large population residing in regions with higher and variable NO2 levels. These findings contribute robust epidemiological evidence to this field and offer new evidence to support global policymaking, particularly in developing countries. Additionally, modeled NO2 predictions with high resolution and coverage can serve as effective alternatives to traditional monitoring station data in epidemiological studies.

Comparison between norepinephrine plus epinephrine and norepinephrine plus vasopressin after return of spontaneous circulation in patients with out-of-hospital cardiac arrest

There is insufficient evidence regarding the use of second-line vasopressors following norepinephrine administration in the post-resuscitation management of patients with out-of-hospital cardiac arrest (OHCA). Therefore, this study aimed to investigate the survival outcomes between norepinephrine plus epinephrine and norepinephrine plus vasopressin as vasopressor combinations after return of spontaneous circulation (ROSC) in patients with OHCA. This retrospective observational study included data from a prospective multicenter registry. Adult patients with OHCA who achieved sustained ROSC and received vasopressor combinations of norepinephrine plus epinephrine or norepinephrine plus vasopressin were included in the study. The variable of interest was the vasopressor combination either norepinephrine plus epinephrine or norepinephrine plus vasopressin within 24 h from sustained ROSC. The primary outcome was survival to discharge. Multivariable logistic regression analysis was conducted. Between October 2015 and June 2024, 901 patients were analyzed. Survival to discharge and good neurological outcome were significantly higher in the group with norepinephrine plus epinephrine than in the group with norepinephrine plus vasopressin (17.0% vs. 9.1%, p = 0.001, and 8.1% vs. 3.2%, p = 0.002, respectively). Norepinephrine plus vasopressin was independently associated with worse survival to discharge and neurological outcome compared to norepinephrine plus epinephrine, after adjusting for potential confounders (adjusted odds ratio [aOR] 0.454, 95% confidence interval [CI] 0.277-0.746, p = 0.002 and aOR 0.346, 95% CI 0.150-0.794, p = 0.012, respectively). These findings were maintained in multiple regression models and sensitivity analyses. Norepinephrine plus epinephrine administration within 24 h from sustained ROSC showed better survival to discharge than norepinephrine plus vasopressin in patients with OHCA.

Out-of-hospital cardiac arrest: A 10-year analysis of survival and neurological outcomes

Background Out-of-hospital cardiac arrest (OHCA) is a major public health issue with low survival rates. Objective Identification of predictors for survival and good neurological outcomes following OHCA. Methods This retrospective study included all OHCA patients between January 2014 and December 2023. Data was collected from the local resuscitation registry and hospital electronic medical records. Neurological outcomes were measured using the Cerebral Performance Category (CPC) scale. Results At hospital admission return of spontaneous circulation (ROSC) was achieved in 36 % of cases (411/1128), with overall survival rates of 29 % (328/1128) at 24 h and 16 % (178/1128) at 30 days, respectively. Good neurological outcomes (CPC 1 and 2) were observed in 13 % (144/1128) of patients. The main suspected cause of cardiac arrest was cardiac origin (54 %, 608/1128), followed by hypoxia (11 %, 127/1128). Survivors were significantly younger (60 vs 71 years, p < 0.001), were less disabled (p < 0.001), had a higher incidence of witnessed cardiac arrest (80 % vs 69 %, p = 0.018), received more often bystander cardiopulmonary resuscitation (CPR, 62 % vs 47 %, p = 0.003) or Dispatcher Assisted-CPR (44 % vs 32 %, p = 0.004). Moreover, patients who survived at least 30 days had a higher incidence of shockable initial rhythm (57 % vs 24 %, p < 0.001). Conclusions Patients who survived at least 30 days were younger and male, had less disability, a shockable initial rhythm, and a cardiac arrest in public.

Real-time hemodynamic responses to epinephrine and their association with ROSC in out-of-hospital cardiac arrest

AIM

This study investigated the association between changes in diastolic blood pressure (DBP), mean arterial pressure (MAP), systolic blood pressure (SBP) following epinephrine administration and return of spontaneous circulation (ROSC) in patients with Out-of-hospital cardiac arrest (OHCA).

METHODS

This retrospective observational study included patients with OHCA treated at a tertiary hospital. Invasive arterial blood pressure monitoring data were recorded during resuscitation in the emergency department. The primary outcome was sustained ROSC, defined as ROSC maintained for at least 20 min. Blood pressure changes were analysed at 15 s intervals. Delta blood pressure was defined as the difference between each blood pressure at 15-0 s before and 165-180 s after epinephrine administration. The association between delta DBP, delta MAP, delta SBP, and sustained ROSC was analysed.

RESULTS

Among 160 patients included in the analysis, patients who achieved sustained ROSC exhibited significantly greater changes in DBP and MAP than those who did not. Median differences in delta DBP and delta MAP between ROSC and no-ROSC groups were 13.7 mmHg (95% confidence interval (CI): 11.3-13.8, p = 0.001) and 14.9 mmHg (95% CI: 12.6-15.7, p = 0.001), respectively. A restricted cubic spline curve showed positive associations of delta DBP and delta MAP with sustained ROSC probability. Multivariable analysis showed adjusted odds ratios of 1.02 (95% CI: 1.00-1.04, p = 0.040) for delta DBP and 1.01 (95% CI: 1.00-1.03, p = 0.010) for delta MAP.

CONCLUSION

Greater delta DBP and delta MAP following epinephrine administration during cardiopulmonary resuscitation were associated with higher likelihood of achieving sustained ROSC in patients with OHCA.

Escalating vs Fixed Energy Defibrillation in Out-of-Hospital Cardiac Arrest Ventricular Fibrillation

Importance

There is limited evidence on whether higher-energy defibrillation is preferred in patients experiencing out-of-hospital cardiac arrest (OHCA) with shockable rhythms.

Objective

To investigate the optimal energy regimen for initial and subsequent defibrillation delivered by biphasic waveform automated external defibrillators (AEDs) in OHCA ventricular fibrillation (VF).

Design, Setting, and Participants

This cohort study was conducted in 48 cities across China, from 2017 to 2023, among 342 patients with OHCA who experienced at least 1 shock.

Exposures

Escalating higher-energy (200-300-360 J) defibrillation or fixed low-energy (200-200-200 J) defibrillation according to the AED program available for use.

Main Outcome and Measures

Sustained and transient termination of VF and establishment of an organized rhythm after defibrillations were the main clinical outcomes.

Results

A total of 342 patients with OHCA were included (mean [SD] age, 57.2 [20.6] years; 273 male [79.8%]) with 782 VF defibrillations; 218 patients (63.8%) with a total of 480 instances (61.4%) of VF rhythm received AED with escalating higher-energy regimens. Most VF episodes were effectively terminated transiently at the first shock (200 J in both groups) (94% in the escalating higher-energy group vs 93% in the fixed lower-energy group; P = .64), but only half remained terminated until the next rhythm analysis (49% vs 47%; P = .68). Comparatively, VF that received escalating higher-energy regimens were more likely to establish sustained organized rhythm (34% vs 25%; P = .008; absolute difference, 9% [95% CI, 2% to 16%]). In refractory VF rhythms, the percentage of cases where sustained organized rhythms were established was significantly greater in escalating higher-energy regimens after second shocks and above (24% vs 13%; P = .008; absolute difference, 11% [95% CI, 3% to 19%]) and third shocks and above (35% vs 18%; P = .003; absolute difference 17% [95% CI, 5% to 27%]).

Conclusions and Relevance

In this retrospective cohort study of patients experiencing OHCA-VF, both the escalating higher-energy (200-300-360 J) regimen and the fixed low-energy (200-200-200 J) regimen were effective for transient VF termination at first shock, whereas the escalating higher-energy regimens were more likely to maintain termination and restore an organized rhythm. Higher-energy regimens were associated with better outcomes after all shocks, especially in patients with refractory VF.

Differences in Care and Outcomes in Cardiogenic Shock in Cardiac Intensive Care Units in the United States and Canada: CCCTN Registry Insights

BACKGROUND

Mortality in cardiogenic shock (CS) remains high. Significant interhospital heterogeneity in critical care therapies has been described, which reflects the lack of high-quality evidence to guide optimal treatment. We aimed to describe differences in practices and clinical outcomes among patients with CS in the United States and Canada.

METHODS

The Critical Care Cardiology Trials Network (CCCTN) is a research network of tertiary cardiac intensive care units (CICUs). Data collection spanned from 2017 to 2022. The analysis included 34 American and 8 Canadian sites. The outcomes of interest included baseline clinical differences, use of critical care monitoring and therapies, and all-cause in-hospital mortality between patients with CS in the United States and Canada admitted to CICUs.

RESULTS

Among 23,299 admissions, 19% had CS (n = 4336, 88% United States vs 12% Canada). The proportion of patient who received invasive hemodynamics (United States: 80.8% vs Canada: 74.8%, P = 0.0015), vasoactive medications (United States: 88.9% vs Canada: 82.1%, P < 0.0001), temporary mechanical circulatory support (tMCS) (United States: 39.4% vs Canada: 23.1%, P < 0.0001) were more frequent in US centres. Intra-aortic balloon pump was the most common tMCS device in both countries. After multivariable adjustment, in-hospital mortality was higher in Canada vs United States (37.1% vs 29.4%, odds ratio [OR]: 1.47; 95% confidence interval [CI], 1.18-1.83).

CONCLUSIONS

In a contemporary registry, management of CS was heterogenous between the United States and Canada, with higher use of invasive monitoring and MCS in the US. Although adjusted mortality was lower in the United States, the effects of these treatments cannot be reliably determined without randomized trial data.

Survival rates with favorable neurological outcomes after in-hospital and out-of-hospital cardiac arrest: A prospective cohort study

OBJECTIVES

To evaluate the survival rates with favorable neurological outcomes among patients who experienced in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA).

DESIGN

This prospective cohort study assessed 554 adult patients with IHCA or OHCA referred to Hamad General Hospital, Qatar, between February 2015 and November 2021. Neurologic outcomes were measured using the Cerebral Performance Category (CPC) score. Survival rate and neurologic status were re-evaluated at 28 days, hospital discharge, and one year after cardiac arrest (CA).

FINDINGS

For all participants, the hospital discharge and one-year survival rates with a favorable neurological outcome (CPC ≤ 2) were 18.5 % and 19.5 %, respectively. Specifically, among patients with IHCA, the rates were 20.5 % and 19 %, while in patients with OHCA, the rates were 16.4 % and 19.9 %, respectively. Multivariate regression analysis indicated that factors male sex (OR: 2.129, 95 % CI: 1.168-3.881, P = 0.014), initial shockable rhythm (OR: 1.691, 95 % CI: 1.024-2.788, P = 0.041), and the use of ECPR (OR: 1.944, 95 % CI: 1.178-3.209, P = 0.009) were associated with increased likelihood of survival with favorable neurological outcomes at 28 days. Conversely, older age, presence of comorbidities, infection, higher APACHE II score, longer hospital stays, and undergoing tracheostomy were linked to decreased chances of survival with favorable neurological outcomes at different time points.

CONCLUSION

Survival with good neurological outcomes after OHCA was 20.3 %, 16.4 %, and 19.9 % at 28 days, hospital discharge, and one year, respectively. Among patients with IHCA, survival with good neurological outcomes was 20.5 %, 20.5 %, and 19 % at 28 days, hospital discharge, and one year, respectively.

IMPLICATIONS FOR CLINICAL PRACTICE

Care of CA patients in a cardiac arrest center is associated with improved long-term survival with favorable neurological outcomes. Prioritizing early intervention for shockable rhythms and utilizing ECPR where appropriate could enhance patient prognosis.

Efficacy of intraosseous access for non-traumatic out-of-hospital cardiac arrest: A meta-analysis of randomised controlled trials and propensity-score matched studies

Introduction

Intravenous (IV) and intraosseous (IO) routes are the primary options for vascular access for out-of-hospital cardiac arrest (OHCA). However, the optimal route for improving clinical outcomes remains uncertain.

Materials and methods

We searched the Web of Science, PubMed, EMBASE and Cochrane Library databases until December 1, 2024. We expressed outcome data as relative risk (RR) with 95% CIs. Subgroup analysis and meta-regression analysis were conducted to explore the sources of heterogeneity.

Results

10 studies involving 39,951 patients were included. In RCTs, no significant differences were observed between IO and IV access in patients with OHCA regarding survival (RR 1.03; 95% CI, 0.88–1.21; P = 0.70; I 2  = 0%), favorable neurological outcomes, or return of spontaneous circulation (ROSC). In PSM studies, IO access was inversely associated with these outcomes. In the meta-regression analysis, adjustment for time interval from call to drug administration, male ratio, and shockable rhythm ratio could explain the heterogeneity.

Conclusions

The analysis of RCTs showed no significant association between types of vascular access and efficiency outcomes. However, IO access was inversely associated with the outcomes in PSM studies. Time interval to drug administration, sex ratio, and initial rhythm could be identified as potential sources of heterogeneity.

Trial registration

Our review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42023466889)

Comparison of ante- and postmortem ventricular wall thickness using echocardiography and autopsy findings

In autopsy practice, the thickness of ventricular walls is one of the parameters used to identify cardiac hypertrophy. The presented study aimed to compare ante- and postmortem measurements of ventricular wall thickness, (i) to determine a postmortem standardized localization and dissection method for ventricular wall measurements, and (ii) to determine the ability of postmortem measurements in recognition of antemortem hypertrophy. A single-center prospective study was conducted at the Institute of Legal Medicine in Hamburg, Germany. Sixty hearts were dissected alternating by the inflow-outflow or short-axis method, and the ventricular walls were measured at different locations and compared with the echocardiographic values of the end-diastolic phase during life of these individuals. The results showed measurement differences between the autoptic and echocardiographic values-for the left ventricle between 3.3 and 5.2 mm, for the right ventricle between 0.2 and 1.1 mm, and for the septum between 1.3 and 1.4 mm. Diagnostic performance of recognizing antemortem hypertrophy with postmortem measurement was poor, except for measuring the right ventricle and septum with the short-axis method (area under the ROC curve of 0.72 and 0.82, respectively). According to the results, cardiac changes may occur postmortem and need to be considered when used for diagnosing cardiac pathology. The postmortem diagnosis of left or right ventricular hypertrophy should always be made in conjunction with other, particularly cardiac, autopsy findings. An autoptic diagnosis of hypertrophy solely by a ventricular wall thickness > 15 mm or > 5 mm alone is not sufficient.

Emergency medicine updates: Managing the patient with return of spontaneous circulation

INTRODUCTION

Patients with return of spontaneous circulation (ROSC) following cardiac arrest are a critically important population requiring close monitoring and targeted interventions in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the management of this condition.

OBJECTIVE

This paper provides evidence-based updates concerning the management of the post-ROSC patient.

DISCUSSION

The patient with ROSC following cardiac arrest is critically ill, including a post-cardiac arrest syndrome which may include hypoxic brain injury, myocardial dysfunction, systemic ischemia and reperfusion injury, and persistent precipitating pathophysiology. Initial priorities in the ED setting in the post-ROSC patient include supporting cardiopulmonary function, addressing and managing the underlying cause of arrest, minimizing secondary cerebral injury, and correcting physiologic derangements. Testing including laboratory assessment, electrocardiogram (ECG), and imaging are necessary, aiming to evaluate for the precipitating cause and assess end-organ injury. Computed tomography head-to-pelvis may be helpful in the post-ROSC patient, particularly when the etiology of arrest is unclear. There are several important components of management, including targeting a mean arterial pressure of at least 65 mmHg, preferably >80 mmHg, to improve end-organ and cerebral perfusion pressure. An oxygenation target of 92-98 % is recommended using ARDSnet protocol, along with carbon dioxide partial pressure values of 35-55 mmHg. Antibiotics should be reserved for those with evidence of infection but may be considered if the patient is comatose, intubated, and undergoing hypothermic targeted temperature management (TTM). Corticosteroids should not be routinely administered. While the majority of cardiac arrests in adults are associated with cardiovascular disease, not all post-ROSC patients require emergent coronary angiography. However, if the patient has ST-segment elevation on ECG following ROSC, emergent angiography and catheterization is recommended. This should also be considered if the patient had an initial history concerning for acute coronary syndrome or a presenting arrhythmia of ventricular fibrillation or pulseless ventricular tachycardia. TTM at 32-34° C does not appear to demonstrate improved outcomes compared with targeted normothermia, but fever should be avoided.

CONCLUSIONS

An understanding of literature updates can improve the ED care of patients post-ROSC.

Mechanistic insights into the neuroprotective effects of low-intensity transcranial ultrasound stimulation in post-cardiac arrest brain injury: Modulation of the Piezo1-Dkk3/PI3K-Akt pathway

Post-cardiac arrest brain injury (PCABI) remains a significant challenge, marked by high mortality and disability rates due to persistent neuroinflammation. This study explored the neuroprotective potential of low-intensity transcranial ultrasound stimulation (LITUS) in mitigating brain damage after cardiopulmonary resuscitation (CPR) using a murine model and in vitro assays. LITUS treatment improved 24-h survival rates and neurological recovery in cardiac arrest (CA) mice, as evidenced by behavioral assessments and reduced neurological deficit scores. Proteomic analyses revealed modulation of Piezo1-Dkk3/PI3K-Akt signaling pathway, characterized by decreased pro-inflammatory cytokines (IL-1β, IL-6, TNF-α). Mechanistic studies demonstrated that LITUS enhanced Piezo1 and Dkk3 activation, promoting calcium influx and anti-inflammatory responses. The Piezo1 antagonist GsMTx4 abrogated these effects, underscoring Piezo1's specific role. Additionally, in vitro experiments using oxygen/glucose deprivation and reoxygenation (OGD/R)-treated BV2 microglial cells confirmed that LITUS reduced inflammatory responses and enhanced cellular recovery via the Piezo1-Dkk3 axis. These findings highlight LITUS as a promising non-invasive therapeutic strategy to ameliorate PCABI by modulating neuroinflammation through the Piezo1-Dkk3/PI3K-Akt pathway. This work provides a basis for translational research and potential clinical applications in improving outcomes for CPR survivors.

P-ROSC, UB-ROSC, and RACA Scores in Predicting the Return of Spontaneous Circulation in Out-of-hospital Cardiac Arrest: A Retrospective Cohort

Introduction

Prehospital Return of Spontaneous Circulation (P-ROSC), Utstein-Based Return of Spontaneous Circulation (UB-ROSC), and Return of Spontaneous Circulation After Cardiac Arrest (RACA) scores have been developed to estimate the likelihood of Return of Spontaneous Circulation (ROSC) in Out-of-hospital cardiac arrest (OHCA). This study aimed to validate and compare these three scoring systems.

Methods

A retrospective cohort study was conducted using electronic medical records of OHCA patients transported by Ramathibodi Emergency Medical Service (EMS) from January 2021 to October 2024. We included all OHCA patients aged >18 years who transported by Ramathibodi EMS. RACA, UB-ROSC, and P-ROSC scores were calculated, and ROSC was recorded. The area under the ROC curve (AUC) of each score were calculated to assess predictive accuracy.

Results

Among 336 OHCA cases, 94 (27.97%) patients achieved ROSC. The RACA score demonstrated the highest predictive accuracy, with an AUC of 0.77 (95% CI: 0.71-0.82). The UB-ROSC score followed with an AUC of 0.72 (95% CI: 0.66-0.78), while the P-ROSC score had the lowest predictive value with an AUC of 0.64 (95% CI: 0.58-0.70). Calibration analysis indicated that the RACA score aligned most closely with observed outcomes compared to the UB-ROSC and P-ROSC scores. The RACA score exhibited the best overall performance in terms of both discrimination and calibration.

Conclusions

Among the three predictive models assessed, the RACA and UB-ROSC scores demonstrated fair predictive accuracy for ROSC in OHCA patients, while the P-ROSC score had poor predictive value.

Incidence and temporal trends of out-of-hospital cardiac arrest in Shenzhen, China (2011-2018)

Background

Out-of-hospital cardiac arrest (OHCA) is a significant global public health issue, few studies describe characteristics and trends in China. This study examines OHCA features and trends in Shenzhen, one of the fastest-growing cities.

Methods

This retrospective study analysed data from the Shenzhen Emergency Center database (2011-2018), including ambulance dispatch and pre-hospital medical records. Descriptive statistics and temporal trends were used to examine the incidence, patients characteristics, pre-hospital treatment, and outcome.

Results

Among 18,772 medical cause OHCA cases, the crude incidence rate was 17.4 per 100,000 population, with an age-standardised rate of 38.4. Incidence increased over time. Resuscitation was attempted in 43.8% of cases, with a median patient age of 56 years and 73.5% being male. Most arrest (69.0%) occurred at home, and 82% were presumed to be cardiac cause.The median response time was 11.2 min. Bystander cardiopulmonary resuscitation (CPR) rates increased from 4.6% in 2011 to 14.5% in 2018, while bystander automated external defibrillator (AED) use remained low (0.2%). Pre-hospital electrocardiogram (ECG) recording improved from 40.6% to 91.9%, with shockable rhythms 2.2%. Intravenous access was established in 69.7% of patients, 51.9% received epinephrine, 19.29% received pre-hospital defibrillation, and 16.4% underwent advanced airway management. The pre-hospital Return of Spontaneous Circulation (ROSC) rate increased from 2.7% to 5.8%, with a total ROSC rate of 3.11%.

Conclusions

OHCA incidence in Shenzhen is lower than both domestic and international levels but increasing. Low bystander intervention rated and prolonged response times contribute to poor outcome, underscoring the need for system improvements.

Exploratory study of serum protein biomarkers for sudden cardiac arrest using protein extension assay: A case-control study

BACKGROUND

Biomarkers associated with the occurrence of sudden cardiac arrest (SCA) are not currently utilized in clinical practice. We aimed to identify novel protein biomarkers associated with sudden cardiac arrest (SCA) using proteomic profiling and evaluate their predictive power alongside traditional cardiovascular risk factors.

METHODS

A total of 42 SCA patients with medical causes, aged ≤ 65 years and whose initial rhythm was shockable, and 42 age- and sex-matched controls were analyzed. The initial serum samples obtained after emergency department visits were used for SCA cases. Using a protein extension assay, we identified significant biomarkers through correlation analysis with SCA and extracted proteins with no or weak correlation with the initial lactate level and arrest-to-sampling time to account for post-cardiac arrest changes. The area under the receiver operating characteristic curve (AUROC) was calculated to assess the predictive performance of the extracted proteins.

RESULTS

Among the 246 distinct proteins that met quality criteria, 97 showed a strong correlation with SCA. Among these 97 proteins, 44 showed weak or no correlation with lactate levels, and 12 showed weak or no correlation with onset-to-sampling time. Two proteins (AXL receptor tyrosine kinase [AXL] and TIMP Metallopeptidase inhibitor 4 [TIMP-4]) met all the criteria for biomarker extraction. Both showed significant associations with SCA and enhanced predictive power when combined with traditional risk factors in multivariable analysis. The AUROC for the baseline model using traditional risk factors was 0.692 (95% confidence interval [CI] 0.578-0.806), which improved significantly with the addition of AXL and TIMP-4 (AUROC [95% CI] 0.891 [0.817-0.964] and 0.910 [0.910-0.997], respectively).

CONCLUSION

AXL and TIMP-4 may be crucial role in the early detection and risk assessment of SCA. Future research to verify the utility of AXL and TIMP-4 in large cohorts is warranted.

Sex Disparity in Extracorporeal Membrane Oxygenation Clinical Trial Enrollment

OBJECTIVES

Multiple studies have shown that extracorporeal membrane oxygenation (ECMO) is used clinically more often in men than women. Because clinical trials provide the basis for identifying patients who are likely to benefit from medical therapies, we hypothesized that sex-based imbalances in ECMO trial enrollment may both reflect and perpetuate these observed disparities. Our objective was to determine whether sex-based enrollment imbalances exist within the published ECMO clinical trial literature.

DESIGN

Cross-sectional analysis.

SETTING

Randomized controlled trials published between 2003 and 2023 that either tested ECMO as a treatment modality or tested another intervention among patients receiving ECMO.

PATIENTS

Not applicable.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We used the Cochrane Highly Sensitive Search Strategy to search PubMed for eligible trials. Data on participant demographics, trial characteristics, and journal information were abstracted for each publication. The primary outcome of interest was the proportion of male and female participants in each published trial. The initial literature search identified 774 articles. Of these, 31 were eligible for inclusion, and 28 provided data on the sex of study participants. Twenty-six of these 28 trials (93%) enrolled more men than women, and in aggregate women comprised 28% (95% CI, 26-30%) of all trial participants (551/1956 subjects). Trials involving extracorporeal cardiopulmonary resuscitation (ECPR) exhibited the largest sex-based enrollment differences (83% men) followed by venoarterial ECMO for cardiogenic shock (73% men). Among trials published in journals with impact factors of ten or higher 74% (95% CI, 72-76%) of participants were men. Only two trials (7%) provided data on the race or ethnicity of study participants.

CONCLUSIONS

Substantial sex-based disparity exists in published ECMO clinical trials. Underrepresentation of women relative to disease prevalence is most significant among trials utilizing venoarterial ECMO for cardiogenic shock and ECPR for cardiac arrest, limiting the applicability of findings from these trials for women.

Development and Evaluation of a Novel Resuscitation Teamwork Model for Out-of-Hospital Cardiac Arrest in the Emergency Department

STUDY OBJECTIVE

Cardiopulmonary resuscitation (CPR) is critical for out-of-hospital cardiac arrest patients but is prone to rapid changes and errors. Effective teamwork and leadership are essential for high-quality CPR. We aimed to introduce the Airway-Circulation-Leadership-Support (A-C-L-S) teamwork model in the emergency department (ED) to address these challenges.

METHODS

The study comprised 2 phases. The development phase involved reviewing CPR videos, categorizing problems, and formulating strategies using the Systems Engineering Initiative for Patient Safety model. Resuscitation tasks were organized into A-C-L-S domains using hierarchical task analysis. Equipment and environmental deficits were optimized ergonomically with a pit-crew style arrangement. Mnemonics enhanced teamwork and leadership. The evaluation phase assessed postimplementation ED resuscitation team performance, focusing on adherence, timeliness, and quality of A-C-L-S tasks.

RESULTS

The development phase produced a structured teamwork model, assigning tasks, tools, mnemonics, and positions based on A-C-L-S domains. The A-team manages the airway and optimizes end-tidal CO2 levels; the C-team focuses on high-quality chest compressions and defibrillation. Leadership coordinates resuscitation efforts using goal-directed mnemonics (DABCD2E3), whereas the S-team handles medications, timekeeping, and recording. The evaluation phase showed improvements in adherence and timeliness of A-C-L-S tasks, with sustained increases in chest compression fraction before mechanical CPR, from 67.2% preimplementation to 83.0% postimplementation, 89.1% after 1 year, and 86.1% after 2 years. Overall, chest compression fraction also improved from 81.7% to 88.6%, peaking at 92.2% after 1 year and maintaining 90.8% after 2 years.

CONCLUSION

The A-C-L-S teamwork model is feasible, applicable, and effective. Further research is needed to assess its influence on patient outcomes.

Neuroprotective Effects of Inhaled Xenon Gas on Brain Structural Gray Matter Changes After Out-of-Hospital Cardiac Arrest Evaluated by Morphometric Analysis: A Substudy of the Randomized Xe-Hypotheca Trial

BACKGROUND

We have earlier reported that inhaled xenon combined with hypothermia attenuates brain white matter injury in comatose survivors of out-of-hospital cardiac arrest (OHCA). A predefined secondary objective was to assess the effect of inhaled xenon on the structural changes in gray matter in comatose survivors after OHCA.

METHODS

Patients were randomly assigned to receive either inhaled xenon combined with target temperature management (33 °C) for 24 h (n = 55, xenon group) or target temperature management alone (n = 55, control group). A change of brain gray matter volume was assessed with a voxel-based morphometry evaluation of high-resolution structural brain magnetic resonance imaging (MRI) data with Statistical Parametric Mapping. Patients were scheduled to undergo the first MRI between 36 and 52 h and a second MRI 10 days after OHCA.

RESULTS

Of the 110 randomly assigned patients in the Xe-Hypotheca trial, 66 patients completed both MRI scans. After all imaging-based exclusions, 21 patients in the control group and 24 patients in the xenon group had both scan 1 and scan 2 available for analyses with scans that fulfilled the quality criteria. Compared with the xenon group, the control group had a significant decrease in brain gray matter volume in several clusters in the second scan compared with the first. In a between-group analysis, significant reductions were found in the right amygdala/entorhinal cortex (p = 0.025), left amygdala (p = 0.043), left middle temporal gyrus (p = 0.042), left inferior temporal gyrus (p = 0.008), left parahippocampal gyrus (p = 0.042), left temporal pole (p = 0.042), and left cerebellar cortex (p = 0.005). In the remaining gray matter areas, there were no significant changes between the groups.

CONCLUSIONS

In comatose survivors of OHCA, inhaled xenon combined with targeted temperature management preserved gray matter better than hypothermia alone.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT00879892.

Maternal and neonatal outcomes following resuscitative hysterotomy for out of hospital cardiac arrest: A systematic review

OBJECTIVE

To examine maternal and neonatal outcomes following Resuscitative Hysterotomy for out of hospital cardiac arrest (OHCA) and to compare with timing from cardiac arrest to delivery.

METHODS

The review was registered with PROSPERO (CRD42023445064). Studies included pregnant women with out of hospital cardiac arrest and resuscitative hysterotomy performed (in any setting) during cardiac arrest. We searched MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL), from inception to 25th May 2024, restricted to humans. We included randomised controlled trials, observational studies, cases series or case reports. Two reviewers independently assessed study eligibility, extracted study data, and assessed risk of bias using validated tools. Data are summarised in a narrative synthesis.

RESULTS

We included 42 publications (one cohort study, three case series and 38 case reports) including a total of 66 women and 68 neonates. Maternal and newborn survival to hospital discharge was 4.5% and 45.0% respectively. The longest duration from collapse to resuscitative hysterotomy for maternal survival with normal neurological function was 29 min and for neonates was 47 min. There were reported neonatal survivors born at 26 weeks gestation with good outcomes. The certainty of evidence was very low due to risk of bias.

CONCLUSION

There are low rates of maternal survival following resuscitative hysterotomy for OHCA. There are documented neonatal survivors after extended periods of maternal resuscitation, and at extremely preterm gestations (<28 weeks). Further prospective research should assess both maternal and neonatal outcomes to better inform future clinical practice.

Cardiac arrest: Pre-hospital strategies to facilitate successful resuscitation and improve recovery rates

The estimated annual incidence of out-of-hospital cardiac arrest (OHCA) is approximately 120 cases per 100000 inhabitants in western countries. Although the rates of bystander cardiopulmonary resuscitation (CPR) and use of automated external defibrillator are increasing, the likelihood of survival to hospital discharge is no more than 8%. To date, various devices and methods have been utilized in the initial CPR approach targeting to improve survival and neurological outcomes in OHCA patients. The aim of this review is to discuss strategies that facilitate resuscitation, increase the chance to achieve return to spontaneous circulation and improve survival to hospital discharge and neurological outcomes in the pre-hospital setting.

Preexisting hemodialysis and survival outcome in out-of-hospital cardiac arrest patients: Ulsan, South Korea

Background

Although the incidence of sudden cardiac death is higher in hemodialysis (HD) patients, whether out-of-hospital cardiac arrest (OHCA) survival outcomes are poorer in this group remains unclear. This study aimed to assess the impact of HD on survival outcomes among adult nontraumatic OHCA patients and to compare these outcomes between HD and non-HD groups.

Methods

This observational cohort study retrospectively analyzed data from adult nontraumatic OHCA patients in Ulsan, South Korea, from January 2017 through December 2022. Multivariable logistic regression analysis was applied to evaluate whether HD was a risk factor for survival in OHCA patients. Survival was compared between the two groups in unadjusted, balanced groups by propensity score matching (PSM) and inverse probability of the treatment weighting (IPWT).

Results

The study included 2,489 patients (64 HD group and 2,425 non-HD group). Undergoing HD was not significantly associated with any return of spontaneous circulation (ROSC) (adjusted odds ratio [95% confidence interval], p-value, 1.648 [0.934-2.907], 0.085), survival to discharge (1.544 [0.734-3.250], 0.252), or neurological outcomes (0.394 [0.017-9.346], 0.564). There were also no significant differences observed in any ROSC (1.648 [0.934-2.907], 0.085), survival to discharge (1.544 [0.734-3.250], 0.252), or favorable neurological outcome (0.394 [0.017-9.346], 0.564) between the two unadjusted groups. The insignificant survival differences were persistently observed in the PSM group and IPWT group.

Conclusion

Although HD may pose a risk factor for cardiac arrest, our study did not find a significant association with survival outcomes in OHCA patients. Additionally, no notable survival difference was observed between HD and non-HD groups. Therefore, resuscitation efforts in HD patients should not be underestimated.

Impact of epinephrine on neurological outcomes in out-of-hospital cardiac arrest after automated external defibrillator use in Japan

OHCA (out-of-hospital cardiac arrest) patients have improved neurological outcomes with public-access automated external defibrillator (PAD) use. However, the benefit of epinephrine administration after PAD use remains controversial. The purpose of the study was to investigate the impact of epinephrine administration on neurological outcomes in OHCA patients after PAD use. This study assessed 2,059,417 patients from the All-Japan Utstein Registry between 2005 and 2021. Patients were categorized into two groups: shockable and non-shockable rhythms on emergency medical service (EMS) arrival. Propensity score matching was used to adjust for various confounders and to analyze the impact of epinephrine administration on one-month favorable neurological outcomes. Criteria for bystander PAD was met by 11,629 (0.56%) of the enrolled patients. The mean age was 70 years with 71.9% male. Among them, 38.6% had shockable rhythms and 61.4% had non-shockable rhythms. After the matching, epinephrine administration negatively affected one-month favorable neurological outcome in patients with both shockable (14.7% vs. 41.1%, OR = 0.24, 95% CI = 0.19-0.31) and non-shockable rhythms (3.6% vs. 10.8%, OR = 0.31, 95% CI = 0.23-0.42). These findings suggest that epinephrine administration did not improve neurological outcomes in patients with OHCA after PAD use, providing insights to optimize EMS protocols for OHCA.

Breaking down barriers: Call-taker strategies to address caller perception of inappropriateness of cardiopulmonary resuscitation during the emergency ambulance call

BACKGROUND

Ambulance call-takers perform the critical role of prompting callers to initiate and continue cardiopulmonary resuscitation (CPR) for patients with suspected out-of-hospital cardiac arrest (OHCA). This study aimed to identify call-taker strategies to address callers' perceptions of CPR 'inappropriateness' (perceiving the patient as dead and beyond help, or as showing signs of life).

METHODS

Using a linguistic approach, we analysed 31 calls previously identified as having an inappropriateness barrier to CPR initiation or continuation. In Phase 1, we listened to call recordings and studied call transcripts to identify the strategies and linguistic features used by call-takers. Phase 2 was a discourse analysis of transcript extracts to describe how certain strategies, identified in Phase 1, were used in the caller-call-taker interactions.

RESULTS

Call-takers used various strategies when responding to callers who considered CPR inappropriate. Call-takers rarely used a single strategy or linguistic feature in isolation, tending to use combinations of minimal tokens of alignment (e.g. caller name or encouragements statements), with deontics (including directives/commands and statements of obligation e.g. "do this for me") and provision of either context (e.g. "the ambulance is on its way") or a rationale ("he's not breathing effectively so we need to perform CPR to help him"). Most call-taker attempts were successful, with callers overcoming 71% of initiation barriers and 88% of continuation barriers.

CONCLUSIONS

Call-takers used a combination of linguistic features (minimal/symbolic tokens, deontics) and strategies (providing unscripted statements about the context or a rationale for CPR) to overcome barriers of perceived inappropriateness to CPR.

Incidence and risk stratification of caller noncompliance with dispatcher instructions for cardiopulmonary resuscitation

Aim

This study aimed to describe the incidence of, identify risk factors for, and develop a simple risk-scoring model for cases where callers fail to follow dispatcher instructions regarding cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest.

Methods

Using the Tokyo Fire Department's database, cases of out-of-hospital cardiac arrest in adults where callers received dispatcher instructions regarding CPR between 1 January 2018 and 31 December 2022 were identified. Factors associated with noncompliance with CPR instructions were determined using multivariable logistic regression analysis. A simple scoring model was developed to stratify the caller noncompliance probability.

Results

Overall, 19,525 cases were included. Bystander CPR was not provided in 11,443 (58.6%) of these cases; the 1-month favorable neurological outcome rate was significantly lower in this group (1.1% vs. 2.2%, p < 0.001). Regression analysis revealed that patient age, male patient sex, emergency call at night, cardiac arrest in the bathroom, and a familial relationship between the caller and the patient were significantly associated with noncompliance. The scoring model assigned 1 point for each of the following criteria: patient aged ≥65 years, familial relationship between the caller and the patient, and cardiac arrest in the bathroom. It also stratified caller noncompliance probability, with scores of 0, 1, 2, and 3 corresponding to probabilities of 48.0%, 50.8%, 61.3%, and 70.5%, respectively.

Conclusion

We found that callers frequently did not follow dispatcher CPR instructions and identified risk factors for caller noncompliance. Furthermore, the simple scoring model developed effectively stratified the probability of caller noncompliance associated with dispatcher instructions.

"Shrink back is not my intention": a qualitative exploration of Chinese security guards' experiences with bystander CPR

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a major public health burden worldwide. Promoting bystander cardiopulmonary resuscitation (B-CPR) is a key element in improving the survival rate of OHCA. The security guard is a specific population in China that plays a significant role as bystanders in public settings. However, less is known about their experiences regarding B-CPR intention and performance. This study aimed to explore the experiences and perspectives of Chinese security guards regarding B-CPR and identify barriers to its performance.

METHODS

Fifteen in-depth interviews were conducted with security guards in various public settings, including hospitals, residential living areas, office buildings, and public transportation stations. All interviews were audio recorded. Two researchers independently analyzed the transcripts through deductive and inductive content analysis. Informed by the "Intention-focused" model of B-CPR performance, deductive content analysis was initially performed to identify categories that align with the theoretical framework and thereby validate the theory. Subsequently, inductive content analysis was applied to code newly discovered content, therefore enriching the theory.

RESULTS

An "intention & performance-focused" model of B-CPR was developed. It was revealed that security personnel were more inclined to perform CPR without hesitation when the victim was a trusted individual. However, when faced with unfamiliar individuals, they tended to shrink back due to various barriers. Specifically, four layers of barriers to CPR performance were identified, encompassing security personnel factors, victim-related factors, organizational factors, and societal factors. Participants also shared their perspectives on the desired CPR training, including trainers, training contents, training formats, and training incentives.

CONCLUSION

Security guards should receive comprehensive CPR training to maximize their occupational value. In addition to strengthening CPR-related training, which includes theoretical knowledge and hands-on practice, psychological coping skills for managing overwhelming emotions and understanding relevant laws are also essential training elements that cannot be overlooked. When developing relevant intervention strategies, policies, and regulations, it's critical to consider the country's context and the cooperation of the organization where the security guard is employed. The model developed in this study can provide a reference for designing interventions and policy to improve the B-CPR intention and performance for other specific groups.

Optimizing brain protection after cardiac arrest: advanced strategies and best practices

Cardiac arrest (CA) is associated with high incidence and mortality rates. Among patients who survive the acute phase, brain injury stands out as a primary cause of death or disability. Effective intensive care management, including targeted temperature management, seizure treatment and maintenance of normal physiological parameters, plays a crucial role in improving survival and neurological outcomes. Current guidelines advocate for neuroprotective strategies to mitigate secondary brain injury following CA, although certain treatments remain subjects of debate. Clinical examination and neuroimaging studies, both invasive and non-invasive neuromonitoring methods and serum biomarkers are valuable tools for predicting outcomes in comatose resuscitated patients. Neuromonitoring, in particular, provides vital insights for identifying complications, personalizing treatment approaches and forecasting prognosis in patients with brain injury post-CA. In this review, we offer an overview of advanced strategies and best practices aimed at optimizing brain protection after CA.

Monocyte programmed death-ligand 1 upregulation in early post-out-of-hospital cardiac arrest is associated with increased risk of acute respiratory distress syndrome

Background

Out-of-hospital cardiac arrest (OHCA) is a major public health problem. Acute respiratory distress syndrome (ARDS) is a common condition in OHCA patients. We investigated the relationship between the expression of programmed death-1 (PD-1) related molecules and the development and prognosis of ARDS.

Methods

Between January 2021 and December 2023, post-resuscitated patients were screened for eligibility in the study. PD-1 related molecules expression was measured by flow cytometry at 48 h of admission in patients with OHCA. The prognostic variables were the development of ARDS during hospitalization and the 28-day patient mortality rate. We analyzed the relationship between the expression of PD-1-related molecules and the development of secondary ARDS in OHCA patients, and assessed the correlation of this expression with the prognosis of ARDS patients.

Results

In total, 107 consecutive OHCA patients were enrolled in this study. The median age of the enrolled patients was 60 years, with an age range of 53 to 67 years, and 71 % were male. Among the cardiac arrest patients, 44.8 % had a cardiac etiology, 30.8 % were witnessed, 17.8 % received bystander CPR, and 66.4 % had an initial rhythm of asystole. Our results showed that only monocyte ligand programmed death ligand-1 (PD-L1) expression was significantly elevated in the ARDS group of OHCA patients (P < 0.001). Among patients with ARDS, the expression of PD-L1 on monocytes in non-survivors was significantly higher than in survivors (P < 0.05). The Receiver operating characteristic curves analysis demonstrates that monocyte PD-L1 expression has predictive potential for the development and prognosis of ARDS. Multivariate logistic regression analysis showed that monocyte PD-L1 expression was an independent predictor of mortality in OHCA patients with ARDS.

Conclusions

This study indicates that patients with increased PD-L1 on monocytes after OHCA may be more likely to develop ARDS. The expression of PD-L1 on monocytes was an independent predictive factor for the incidence of ARDS and mortality rate in OHCA patients.

Outcome, compliance with inclusion criteria and cost of extracorporeal cardiopulmonary resuscitation (ECPR) in out-of-hospital cardiac arrest: A retrospective cohort study

Introduction

The primary aim was to describe the outcome, the compliance with inclusion criteria and the characteristics of patients who underwent extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA). The secondary aim was to calculate the cost of ECPR for the patients and the public Belgian healthcare system.

Methods

Single-centre retrospective cohort study in Antwerp University Hospital. We included all patients who underwent ECPR for OHCA from 2018 to 2020. Medical records were assessed to determine the clinical outcome and invoices were assessed to calculate the charged fees. We collected all relevant cost components at the most detailed level (micro costing technique).

Results

Sixty-five patients who received ECPR for OHCA were included. Thirty-eight patients (58%) died within one week after ECPR initiation. After one year, twelve patients (18.5%) were still alive of which ten (15.4%) had a good neurological outcome (Cerebral Performance Category (CPC) 1 or 2). Forty-nine patients (75.4%) met the ECPR inclusion criteria. A total of 2,552,498.34 euro was charged. The patients and the public Belgian healthcare system contributed to a 255,250 euro cost for each survivor after one year with good neurological outcome.

Conclusion

Our analysis highlights the complex interplay between clinical efficacy and financial implications in the utilization of ECPR. While ECPR demonstrates potential in improving survival rates and neurological outcomes among cardiac arrest patients, its adoption presents substantial economic challenges. Inappropriate patient selection may lead to significant increases in resource utilisation without improved outcome.

Characteristics, outcomes, and prognostic factors in patients with hanging-induced out-of-hospital cardiac arrest: An analysis of a nationwide registry in Japan

AIM

To investigate the characteristics, outcomes, and prognostic factors of patients with hanging-induced out-of-hospital cardiac arrest (OHCA).

METHODS

We analysed data from a population-based Japanese nationwide OHCA registry (2021-2022), comparing patients aged ≥18 years with hanging-induced OHCA to those with other OHCA causes. The primary outcome was 1-month favourable neurological outcomes. Prognostic factors for hanging-induced OHCA were identified using multivariable logistic regression analysis.

RESULTS

Of 263,426 OHCAs, 7,878 (3.0 %) were hanging-induced, with an incidence of 3.1 per 100,000 person-years. Patients with hanging-induced OHCA were younger (median age; 58 vs. 81 years), more frequently males (60.2 % vs. 57.5 %), and less likely to have a witness (1.7 % vs. 42.1 %) and initial shockable rhythm (0.4 % vs. 5.9 %). The chance of 1-month favourable neurological outcomes was significantly lower in patients with hanging-induced OHCA than those with other OHCA causes (0.4 % vs. 2.5 %). Factors associated with favourable neurological outcomes included younger age, witnessed arrest, initial non-asystole cardiac rhythm, and prehospital return of spontaneous circulation (ROSC). Patients with initial non-asystole rhythm and prehospital ROSC had an 11.1 % probability of favourable neurological outcomes, whereas 97.1 % of patients lacking these characteristics had only a 0.1 % probability.

CONCLUSIONS

Prognosis following hanging-induced OHCAs was significantly worse compared to OHCAs of other causes. While some patients with initial non-asystole rhythm and prehospital ROSC may benefit from cardiopulmonary resuscitation, most lack these favourable features and have an exceedingly low chance of achieving favourable neurological outcomes at 1-month post-arrest.

The reality of rurality: Understanding the impact of remoteness on out-of-hospital cardiac arrest in Western Australia - A retrospective cohort study

INTRODUCTION

Western Australia (WA) spans a large, sparsely-populated area of Australia, presenting a challenge for the provision of Emergency Medical Service (EMS), particularly for time-critical emergencies such as out-of-hospital cardiac arrest (OHCA).

OBJECTIVE

To assess the impact of rurality on the epidemiology, incidence and survival of OHCA in WA.

METHODS

We conducted a retrospective cohort study of EMS-attended OHCA in WA from 2015 to 2022. Incidence was calculated on all OHCAs, but the study cohort for the multivariable regression analysis of rurality on survival outcomes consisted of OHCAs of medical aetiology with EMS resuscitation attempted. Rurality was categorised into four categories, derived from the Australian Standard Geographic Classification - Remoteness Areas.

RESULTS

The age-standardised incidence of EMS-attended OHCA per 100 000 population increased with increasing remoteness: Major Cities = 104.9, Inner Regional = 123.3, Outer Regional = 138.0 and Remote = 103.9. Compared to Major Cities, the adjusted odds for return of spontaneous circulation (ROSC) at hospital were lower in Inner Regional (aOR = 0.71, 95%CI 0.53-0.95), Outer Regional (aOR = 0.62, 95%CI 0.45-0.86) and Remote areas (aOR = 0.52, 95%CI 0.35-0.77) but there was no statistically significant difference for 30-day survival. Relative to Major Cities, Regional and Remote areas had longer response times, shorter transport-to-hospital times, and higher rates of bystander CPR and automated external defibrillator use.

CONCLUSIONS

Out-of-hospital cardiac arrest in rural areas had lower odds of ROSC at hospital compared to metropolitan areas, despite adjustment for known prognostic covariates. Despite WA's highly sparse regional population, these differences in ROSC are consistent with those reported in other international studies.

Air temperature and humidity impact out-of-hospital-cardiac-arrests in Germany: A 10-year cohort study from the German Resuscitation Registry

Objectives

This study examines the impact of temperature variations on out-of-hospital-cardiac-arrests in Germany over a decade (2010-2019). Out-of-hospital-cardiac-arrests affects 164 per 100,000 inhabitants annually in Germany, 11% survive to hospital discharge. The following study investigates days with the following characteristics: summer days, frost days, and high humidity days. Furthermore, the study explores incidence, causes, demographics, and outcomes of out-of-hospital-cardiac-arrests.

Methods

Data from the German Resuscitation Registry and Meteorological Service were combined for analysis. The theory posits that temperature and humidity play a significant role in the occurrence and outcomes of out-of-hospital-cardiac-arrests, potentially triggering pre-existing health issues.

Results

Findings reveal increased out-of-hospital-cardiac-arrests during frost days (6.39 up to 7.00, p < 0.001) monthly per 100,000 inhabitants), notably due to cardiac-related causes. Conversely, out-of-hospital-cardiac-arrests incidence decreases on summer days (6.61-5.79, p < 0.001 monthly per 100,000 inhabitants). High-humidity days exhibit a statistically significant increase in out-of-hospital-cardiac-arrests incidence (6.43-6.89, p < 0.001 monthly per 100,000 inhabitants).

Conclusion

In conclusion, there's a notable rise in out-of-hospital-cardiac-arrests incidence and worse outcomes during cold days, and a significant increase in out-of-hospital-cardiac-arrests during high-humidity days. Moreover, extreme temperature events in unaccustomed regions also elevate out-of-hospital-cardiac-arrests rates. However, the dataset lacks sufficient hot days for conclusive findings, hinting that very hot days might also affect out-of-hospital-cardiac-arrests incidence. Further research, particularly on hotter days, is essential.No third-party funding was received for this study.

Out-of-hospital cardiac arrest in Bahrain: National retrospective cohort study

Aim

There is limited research on Out-of-hospital cardiac arrest (OHCA) in the Gulf Cooperation Council (GCC) and especially in Bahrain. This is the first study to describe the incidence, characteristics, and outcomes of OHCA in Bahrain.

Methods

This was a retrospective national observational study on OHCA patients in Bahrain using the Utstein framework for resuscitation. Data was collected between 1st July 2022 to 30th June 2023 from the electronic medical records of the only three governmental hospitals emergency departments (EDs) and National Ambulance (NA).

Results

The annual incidence of OHCA attended by (Emergency Medical Services) EMS was nearly 21 per 100,000 population. The majority were males (n = 228, 68.8 %) with median age of 65 years (IQR=49-78). Most OHCA cases were witnessed (n = 265, 81 %), with (n = 247, 76 %) happened at home/residence. Rates for bystander CPR was low (n = 122, 36.8 %) and bystander automated external defibrillator (AED) was not performed in any of the cases. The OHCA cases transported by the NA was (n = 314, 94.8 %), with median response time of 9 min (IQR=7-12). However, only (n = 20, 6.0 %) were witnessed by EMS, and (n = 7, 2.1 %) received EMS defibrillation for shockable rhythms. First monitored rhythms included shockable rhythm in (n = 28, 8.5 %) versus non-shockable rhythm in (n = 303, 91.5 %). In the EDs, return of spontaneous circulation was achieved in (n = 60, 18.1 %) cases. But survival rate to hospital discharge at 30-day was (n = 4, 1.2 %) and survival rate to hospital discharge with good neurological outcomes was (n = 0, 0 %). Conclusion: In Bahrain the estimated annual incidence of OHCA is 21 individuals per 100,000 population, with a very low survival rate. Solutions should focus on community-level CPR and AED training, evaluating OHCA care provided by EMS, and establishing OHCA registry.

Perspectives on cardiopulmonary resuscitation in the frail population: a scoping review

Frail and elderly persons approaching end of life who suffer cardiac arrest are often subject to rigorous, undignified, and inappropriate resuscitation attempts despite poor outcomes. This scoping review aims to investigate how people feel about the appropriateness of CPR in this population. This review was guided by the PRISMA-ScR methodological framework. A search strategy was developed for four online databases (MEDLINE, EMCARE, PSYCHINFO, CINAHL). Two reviewers were utilised for title/abstract screening, full text review and data extraction. Full text, peer reviewed studies were eligible for inclusion which discussed perspectives in the frail and/or elderly population with a focus on cardiopulmonary resuscitation (CPR). The database search yielded 3693 references (MEDLINE n = 1417, EMCARE n = 1505, PSYCHINFO n = 13, CINAHL n = 758). Following removal of duplicates (n = 953), title and abstract screening was performed on 2740 papers. A total of 2634 articles did not meet the inclusion criteria. Twenty-five studies were included in the scoping review and analysed for data extraction. Five themes emerged: (i) Preferences towards CPR, (ii) Preferences against CPR, (iii) Poor knowledge of CPR/Estimated survival rates, (iv) Do Not Resuscitate Orders, and (v) Decisional authority. This scoping review maps and describes the common perspectives shared by CPR stakeholders in the frail/elderly population. Findings revealed CPR decisions are often made based on incorrect knowledge, DNAR orders are frequently underused, CPR decisional authority remains vague and healthcare professionals have mixed views on the appropriateness of CPR in this population.

Retrospective Review of the Image Quality of Monoplane Transesophageal Echocardiography in Prehospital Out-of-Hospital Cardiac Arrest: A Single Center Pilot Study

OBJECTIVES

Out of Hospital Cardiac Arrest (OHCA) is a frequently encountered pathology with resultant poor outcomes in the majority of patients. Echocardiography has been utilized to help guide clinical decision making and monitor effectiveness of resuscitative efforts. Transthoracic echocardiography (TTE) the mainstay of point-of-care ultrasound (POCUS) real time resuscitative imaging has limitations, most notably is the disruption of closed chest compressions. Trans-esophageal echocardiography (TEE) is an emerging technology in emergency care and can potentially overcome these limitations but image quality and accuracy of use in the prehospital environment remains unknown. Our primary objective is to identify the accuracy of Emergency Medical Services (EMS) fellow physicians in performing TEE via the identification of key cardiac structures. Secondarily we assess image quality as well as accuracy on cardiac activity interpretation as compared to TEE-experienced cardiologists.

METHODS

A pilot study using descriptive analysis of a retrospective case-series with specific focus on inter-rater reliability as well as pragmatic management alterations based on real-time image interpretation by EMS physicians. After focused education, 13 patients were eligible for prehospital TEE who suffering OHCA from July 2022 to June 2023. Ultrasound (US) images were interpreted by EMS fellow physicians and over-read by cardiologists with specific focus on inter-rater reliability. After collection of patients presenting data and US images, analysis was performed.

RESULTS

Of 13 patients initially screened, 10 patients were included in a study with a median age of 50 years old (41-70). Three patients were excluded due to equipment malfunction or insufficient image capture. An interrater reliability identified a kappa of 0.96 with respect to identification of cardiac structures and a kappa of 0.65 for identification of cardiac activity.

CONCLUSIONS

In this small study of prehospital TEE, EMS fellow physicians had high inter-rater reliability in image interpretation pertaining to anatomy and cardiac activity when compared with cardiologists. Further research is needed to determine its efficacy, safety, and widespread application in the prehospital setting.

Impact of an emergency department closure on out-of-hospital cardiac arrest survival and emergency medical service system in Ulsan, South Korea

Introduction

This study evaluated the impact of an emergency department (ED) closure on out-of-hospital cardiac arrest survival outcomes and the emergency medical service system in Ulsan, South Korea.

Methods

We conducted a retrospective observational cohort study from March 2017 to February 2021 and compared survival to hospital discharge and favorable neurological outcomes. We investigated transport time intervals (TTIs) in the total study population and subgroup covered by the closed ED. The analysis methods included propensity score matching (PSM), inverse propensity weighting (IPW), and logistic regression analysis.

Results

The study included 692 and 920 patients before and after ED closure groups, respectively. After adjusting for covariates, the adjusted odds ratios and 95 % confidence interval for survival discharge and favorable neurological outcomes were 1.040 (0.749-1.444, p = 0.814) and 2.845 (1.563-5.177, p = 0.001), respectively. PSM showed values of 1.015 (0.727-1.416, p = 0.932) for discharge survival and 1.777 (1.074-2.941, p = 0.025) for neurological outcomes. IPW showed values of 0.980 (0.762-1.261, p = 0.875) for discharge survival and 1.782 (1.196-2.656, p = 0.005) for neurological outcomes. The TTI increased from 5.8 ± 5.0 to 6.7 ± 5.5 min (p < 0.001) in the total population and from 9.2 ± 7.9 to 16.2 ± 6.5 min (p < 0.001) in the subgroup.

Conclusions

The findings suggest that while the overall system may remain stable, subgroups could be disproportionately affected by an ED closure, underscoring the importance of the ongoing monitoring of survival outcomes and transport times.

Early prehospital mechanical cardiopulmonary resuscitation use for out-of-hospital cardiac arrest: an observational study

BACKGROUND

The use of mechanical cardiopulmonary resuscitation device has been very prevalent in out-of-hospital cardiac arrest rescue. This study aimed to investigate whether the timing of mechanical cardiopulmonary resuscitation device set-up correlated with the the outcome of cardiac arrest patients.

METHODS

We retrospectively reviewed adult nontrauma cardiac arrest cases in New Taipei City, Taiwan, from January to December 2022. Demographic data, intervention-related factors, and the time variables of mechanical cardiopulmonary resuscitation were collected. The outcomes included the return of spontaneous circulation and 24-hour survival. We compared patients who achieved spontaneous circulation and those who did not with univariate and multivariable regression analyses.

RESULTS

In total, 1680 patients who received mechanical cardiopulmonary resuscitation were included in the analysis. Reducing the time interval from manual chest compression initiation to device setup was independently associated with the return of spontaneous circulation and 24-hour survival, especially in the subgroup of patients of initial shockable rhythm. Receiver operating characteristic analysis revealed that the outcome of patients with an initial shockable rhythm could be predicted by the mechanical cardiopulmonary resuscitation setup time, with areas under the curve of 60.8% and 63.9% for ROSC and 24-hour survival, respectively. The cutoff point was 395.5 s for patients with an initial shockable rhythm.

CONCLUSION

A positive correlation was found between early mechanical cardiopulmonary resuscitation intervention and the outcomes of out-of-hospital cardiac arrest patients. The time between manual chest compression and device setup could predict the return of spontaneous circulation and 24-hour survival in the subgroup of patients with initially shockable rhythm with the optimal cutoff point at 395.5 s.

Resuscitation on the field of play: a best-practice guideline from Resuscitation Council UK

Sudden cardiac arrest (SCA) is the leading cause of sudden death in athletes during high-level, organised sport. Patient-related and event-related factors provide an opportunity for rapid intervention and the potential for high survival rates. The aim of this consensus was to develop a best-practice guideline for dedicated field-of-play medical teams responding to SCA during an organised sporting event. A task-and-finish group from Resuscitation Council UK identified a stakeholder group of relevant experts and cardiac arrest survivors in March and April 2022. Together, they developed a best-practice guideline using the best available evidence. A public consultation period further refined the guideline before it was finalised in December 2023. Any sudden collapse, without rapid recovery during sporting activity, should be considered an SCA until proven otherwise. Field-of-play medical teams should be empowered to access the collapsed athlete as soon as possible and perform initial essential interventions in situ. This includes a suggested minimum of three cycles of cardiopulmonary resuscitation and defibrillation in persistent shockable rhythms while other aspects of advanced life support are initiated. There should be careful organisation and practice of the medical response, including plans to transport athletes to dedicated facilities for definitive medical care. This best-practice guideline complements, rather than supersedes, existing resuscitation guidelines. It provides a clear approach to how to best treat an athlete with SCA and how to organise the medical response so treatments are delivered effectively and optimise outcomes.

Serum lactate/creatinine ratio and acute kidney injury in cardiac arrest patients

OBJECTIVES

Serum lactate and creatinine levels upon admission in cardiac arrest (CA) patients significantly correlate with acute kidney injury (AKI) post-restoration of autonomic circulation. However, the association between serum lactate/creatinine ratio (LCR) and AKI in this population remains unclear. This study aimed to explore the relationship between LCR at admission and cardiac arrest-associated acute kidney injury (CA-AKI).

DESIGN AND METHODS

We conducted a secondary analysis of previously published data on CA patient resuscitation, categorizing them into tertiles based on LCR levels. Univariate and multivariate logistic regression models and subgroup analyses were employed to investigate the association between LCR and CA-AKI. Non-linear correlations were explored using restricted cubic splines, and a two-piece wise logistic proportional hazards model for both sides of the inflection point was constructed.

RESULTS

A total of 374 patients (72.19 % male) were included, with intensive care unit mortality, in-hospital mortality, and neurologic dysfunction rates of 51.87 %, 56.95 %, and 39.57 %, respectively. The overall CA-AKI incidence was 59.09 %. Multivariate logistic proportional hazards analysis revealed a negative association between LCR and CA-AKI incidence (adjusted odds ratio [OR] 0.85, 95 % confidence intervals [CI] = 0.78-0.93, P=0.001). Triple spline restriction analysis depicted an L-shaped correlation between baseline LCR and CA-AKI incidence. Particularly, a baseline LCR<0.051 was negatively associated with CA-AKI incidence (OR 0.494, 95 % CI=0.319-0.764, P=0.002). Beyond the LCR turning point, estimated dose-response curves remained consistent with a horizontal line.

CONCLUSIONS

Baseline LCR in CA patients exhibits an L-shaped correlation with AKI incidence following restoration of autonomic circulation. The threshold for CA-AKI is 0.051. This finding suggests that LCR may aid in identifying CA patients at high risk of AKI.

Mild therapeutic hypothermia after cardiac arrest - effect on survival with good neurological outcome outside of randomised controlled trials: A registry-based analysis

BACKGROUND

For nearly 20 years, in international guidelines, mild therapeutic hypothermia (MTH) was an important component of postresuscitation care. However, recent randomised controlled trials have questioned its benefits. At present, international guidelines only recommend actively preventing fever, but there are ongoing discussions about whether the majority of cardiac arrest patients could benefit from MTH treatment.

OBJECTIVE

The aim of this study was to compare the outcome of adult patients treated with and without MTH after cardiac arrest.

DESIGN

Observational cohort study.

SETTING

German Resuscitation Registry covering more than 31 million inhabitants of Germany and Austria.

PATIENTS

All adult patients between 2006 and 2022 with out-of-hospital or in-hospital cardiac arrest and comatose on admission.

MAIN OUTCOME MEASURES

Primary endpoint: hospital discharge with good neurological outcome [cerebral performance categories (CPC) 1 or 2]. Secondary endpoint: hospital discharge. We used a multivariate binary logistic regression analysis to identify the effects on outcome of all known influencing variables.

RESULTS

We analysed 33 933 patients (10 034 treated with MTH, 23 899 without MTH). The multivariate regression model revealed that MTH was an independent predictor of CPC 1/2 survival and of hospital discharge with odds ratio (95% confidence intervals) of 1.60 (1.49 to 1.72), P < 0.001 and 1.89 (1.76 to 2.02), P < 0.001, respectively.

CONCLUSION

Our data indicate the existence of a positive association between MTH and a favourable neurological outcome after cardiac arrest. It therefore seems premature to refrain from giving MTH treatment for the entire spectrum of patients after cardiac arrest. Further prospective studies are needed.