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Tfelt-Hansen J, Garcia R, Albert C, Merino J, Krahn A, Marijon E, Basso C, Wilde AAM, Haugaa KH. Risk stratification of sudden cardiac death: a review. Europace 2023; 25:euad203. [PMID: 37622576 PMCID: PMC10450787 DOI: 10.1093/europace/euad203] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/03/2023] [Indexed: 08/26/2023] Open
Abstract
Sudden cardiac death (SCD) is responsible for several millions of deaths every year and remains a major health problem. To reduce this burden, diagnosing and identification of high-risk individuals and disease-specific risk stratification are essential. Treatment strategies include treatment of the underlying disease with lifestyle advice and drugs and decisions to implant a primary prevention implantable cardioverter-defibrillator (ICD) and perform ablation of the ventricles and novel treatment modalities such as left cardiac sympathetic denervation in rare specific primary electric diseases such as long QT syndrome and catecholaminergic polymorphic ventricular tachycardia. This review summarizes the current knowledge on SCD risk according to underlying heart disease and discusses the future of SCD prevention.
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Affiliation(s)
- Jacob Tfelt-Hansen
- Cardiology Department, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark
- Section of Forensic Genetics, Department of Forensic Medicine, Copenhagen University, Frederik V’s Vej 11, Copenhagen 2100, Denmark
| | - Rodrigue Garcia
- Cardiology Department, University Hospital of Poitiers, 2 rue de la Milétrie, Poitiers 86000, France
- Centre d'Investigation Clinique 1402, University Hospital of Poitiers, 2 rue de la Milétrie, Poitiers 86000, France
| | - Christine Albert
- Cardiology Department, Smidt Heart Institute, Cedars-Sinai Hospital, Los Angeles, CA, USA
| | - Jose Merino
- Department of Cardiology, La Paz University Hospital, IdiPaz, P. Castellana, 261, Madrid 28046, Spain
- Department of Cardiology, Viamed Santa Elena University Hospital, C/La Granja, 8, Madrid 28003, Spain
| | - Andrew Krahn
- Centre for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eloi Marijon
- Cardiology Department, European Georges Pompidou Hospital, Paris, France
| | - Cristina Basso
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, Padova 35121, Italy
| | - Arthur A M Wilde
- Department of Cardiology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Department of Cardiology, Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Kristina Hermann Haugaa
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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Sun X, Sun S, Qin H, Mu K. Study on the Effect of Prehospital Emergency Nursing Model Based on Network Information Sharing Platform in Acute Ischemic Stroke. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:3363672. [PMID: 35770127 PMCID: PMC9236781 DOI: 10.1155/2022/3363672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 05/31/2022] [Indexed: 11/28/2022]
Abstract
Background Acute ischemic stroke is one of the most common emergencies in clinical medicine. Prehospital first aid of ischemic stroke has become the focus and focus of the global medical community. The combination of network information technology and prehospital first aid can better serve the treatment of ischemic stroke. Objective To explore the effect of prehospital emergency nursing model based on network information sharing platform in acute ischemic stroke. Methods 78 patients with acute ischemic stroke from February 2020 to October 2021 were studied. Patients were randomly divided into study group (n = 39) and control group (n = 39). The control group was given routine first aid nursing. Prehospital first aid nursing based on network information sharing platform was used in the study group. Alarm response time, on-site first aid response time, hospital handover time, National Institutes of Health Stroke scale (NIHSS) at 12 and 24 hours after admission, Glasgow coma scale (GCS) at 12 and 24 hours after admission, incidence of poor prognosis, and nursing satisfaction score at 24 hours after admission were recorded. Results The emergency response time and hospital handover time in the study group were significantly shorter than those in the control group (P < 0.05). The NIHSS score and the incidence of poor prognosis at 12 and 24 hours after admission in the study group were lower than those in the control group (P < 0.05). The GCS scores at 12 hours and 24 hours after admission in the study group were higher than those in the control group (P < 0.05). The NSNS score of the study group was higher than that of the control group. Conclusion Prehospital first aid nursing based on network information sharing platform has great application value in patients with acute ischemic stroke. It can shorten the time of first aid, improve patients' consciousness, and reduce the incidence of poor prognosis.
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Affiliation(s)
- Xia Sun
- Pre-Hospital Emergency Department, Xingtai People's Hospital, 054000, China
| | - Suwei Sun
- Department of Critical Care Medicine, The First Affiliated Hospital of Xingtai Medical College (Xingtai First Hospital), 054000, China
| | - Hua Qin
- Ophthalmic Plastic and Lacrimal Disease Ward, HeBei Eye Hospital, 054000, China
| | - Kai Mu
- Pre-Hospital Emergency Department, Xingtai People's Hospital, 054000, China
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Comparative Analysis of Emergency Medical Service Provider Workload During Simulated Out-of-Hospital Cardiac Arrest Resuscitation Using Standard Versus Experimental Protocols and Equipment. Simul Healthc 2018; 13:376-386. [PMID: 30407958 DOI: 10.1097/sih.0000000000000339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Protocolized automation of critical, labor-intensive tasks for out-of-hospital cardiac arrest (OHCA) resuscitation may decrease Emergency Medical Services (EMS) provider workload. A simulation-based assessment method incorporating objective and self-reported metrics was developed and used to quantify workloads associated with standard and experimental approaches to OHCA resuscitation. METHODS Emergency Medical Services-Basic (EMT-B) and advanced life support (ALS) providers were randomized into two-provider mixed-level teams and fitted with heart rate (HR) monitors for continuous HR and energy expenditure (EE) monitoring. Subjects' resting salivary α-amylase (sAA) levels were measured along with Borg perceived exertion scores and multidimensional workload assessments (NASA-TLX). Each team engaged in the following three OHCA simulations: (1) baseline simulation in standard BLS/ALS roles; (2) repeat simulation in standard roles; and then (3) repeat simulation in reversed roles, ie, EMT-B provider performing ALS tasks. Control teams operated with standard state protocols and equipment; experimental teams used resuscitation-automating devices and accompanying goal-directed algorithmic protocol for simulations 2 and 3. Investigators video-recorded resuscitations and analyzed subjects' percent attained of maximal age-predicted HR (%mHR), EE, sAA, Borg, and NASA-TLX measurements. RESULTS Ten control and ten experimental teams completed the study (20 EMT-Basic; 1 EMT-Intermediate, 8 EMT-Cardiac, 11 EMT-Paramedic). Median %mHR, EE, sAA, Borg, and NASA-TLX scores did not differ between groups at rest. Overall multivariate analyses of variance did not detect significant differences; univariate analyses of variance for changes in %mHR, Borg, and NASA-TLX from resting state detected significant differences across simulations (workload reductions in experimental groups for simulations 2 and 3). CONCLUSIONS A simulation-based OHCA resuscitation performance and workload assessment method compared protocolized automation-assisted resuscitation with standard response. During exploratory application of the assessment method, subjects using the experimental approach appeared to experience reduced levels of physical exertion and perceived workload than control subjects.
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Kim JY, Hwang SO, Shin SD, Yang HJ, Chung SP, Lee SW, Song KJ, Hwang SS, Cho GC, Moon SW, Kim K, Kim WY, Oh S, Kwak YH. Korean Cardiac Arrest Research Consortium (KoCARC): rationale, development, and implementation. Clin Exp Emerg Med 2018; 5:165-176. [PMID: 30269452 PMCID: PMC6166039 DOI: 10.15441/ceem.17.259] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 09/24/2017] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE This study aimed to describe the conceptualization, development, and implementation processes of the newly established Korean Cardiac Arrest Resuscitation Consortium (KoCARC) to improve out-of-hospital cardiac arrest (OHCA) outcomes. METHODS The KoCARC was established in 2014 by recruiting hospitals willing to participate voluntarily. To enhance professionalism in research, seven research committees, the Epidemiology and Preventive Research Committee, Community Resuscitation Research Committee, Emergency Medical System Resuscitation Research Committee, Hospital Resuscitation Research Committee, Hypothermia and Postresuscitation Care Research Committee, Cardiac Care Resuscitation Committee, and Pediatric Resuscitation Research Committee, were organized under a steering committee. The KoCARC registry was developed with variables incorporated in the currently existing regional OHCA registries and Utstein templates and were collected via a web-based electronic database system. The KoCARC study population comprises patients visiting the participating hospitals who had been treated by the emergency medical system for OHCA presumed to have a cardiac etiology. RESULTS A total of 62 hospitals volunteered to participate in the KoCARC, which captures 33.0% of the study population in Korea. Web-based data collection started in October 2015, and to date (December 2016), there were 3,187 cases compiled in the registry collected from 32 hospitals. CONCLUSION The KoCARC is a self-funded, voluntary, hospital-based collaborative research network providing high level evidence in the field of OHCA and resuscitation. This paper will serve as a reference for subsequent KoCARC manuscripts and for data elements collected in the study.
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Affiliation(s)
- Joo Yeong Kim
- Department of Emergency Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Sung Oh Hwang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hyuk Jun Yang
- Department of Emergency Medicine, Gachon University College of Medicine, Incheon, Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Woo Lee
- Department of Emergency Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Kyung Jun Song
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seung Sik Hwang
- Department of Preventive Medicine, Seoul National University School of Public Health, Seoul, Korea
| | - Gyu Chong Cho
- Department of Emergency Medicine, Kang Dong Sacred Heart Hospital, Hallym University School of medicine, Seoul, Korea
| | - Sung Woo Moon
- Department of Emergency Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Kyuseok Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Young Ho Kwak
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
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Larribau R, Deham H, Niquille M, Sarasin FP. Improvement of out-of-hospital cardiac arrest survival rate after implementation of the 2010 resuscitation guidelines. PLoS One 2018; 13:e0204169. [PMID: 30248116 PMCID: PMC6152955 DOI: 10.1371/journal.pone.0204169] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 09/03/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The implementation of cardiopulmonary resuscitation guidelines, updated every five years, appears to improve patient survival rates after Out-Of-Hospital Cardiac Arrest (OHCA). The aim of this study is: 1) to measure the level of improvement in the prognosis of OHCA patient survival rates for the years 2009 and 2010 and the following two years 2011 and 2012; and 2) correlate the improvement in prognosis with the updated 2010 Advanced Cardiovascular Life Support (ACLS) Guidelines. METHOD We performed a retrospective observational study based on Geneva's OHCA register that includes data from January 1, 2009 to December 31, 2012. We compared the evolution of prognostic factors that influenced survival at hospital discharge between the periods before and after the implementation of the 2010 guidelines. We then compared the survival rates between each period. Finally, we adjusted the effects on survival in the second period to prognostic factors not linked with the care provided by Emergency Medical Services (EMS) teams, using a multivariable logistic regression model. Changes in advanced resuscitation treatment provided by EMS personnel were also examined. RESULTS 795 OHCA were resuscitated between 1st January, 2009 and 31st December, 2012. The prognosis of patient survival at the time of hospital discharge rose from 10.33% in 2009-2010 to 17.01% in 2011-2012 (p = 0.007). After making adjustments for the effect of improved survival rates on the second period with factors not related to care provided by EMS teams, the odds ratio (OR) remains comparable (OR = 1.87, 95% CI [1.08-3.22]). Measured changes in treatment provided by EMS personnel were minor. CONCLUSIONS Survival rate for OHCA patients improved significantly in 2011-2012. This study suggests that it was probably the improvement in the quality of care provided during CPR and post-cardiac arrest care that have contributed to the increase in survival rates at the time of hospital discharge.
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Affiliation(s)
- Robert Larribau
- Division of Emergency Medicine, Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Hélène Deham
- Division of Emergency Medicine, Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Marc Niquille
- Division of Emergency Medicine, Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - François Pierre Sarasin
- Division of Emergency Medicine, Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
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Nadolny K, Szarpak L, Gotlib J, Panczyk M, Sterlinski M, Ladny JR, Smereka J, Galazkowski R. An analysis of the relationship between the applied medical rescue actions and the return of spontaneous circulation in adults with out-of-hospital sudden cardiac arrest. Medicine (Baltimore) 2018; 97:e11607. [PMID: 30045296 PMCID: PMC6078650 DOI: 10.1097/md.0000000000011607] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 06/28/2018] [Indexed: 12/11/2022] Open
Abstract
Sudden cardiac arrest (SCA) is a significant medical and social issue, the main cause of death in Europe and the United States.The aim of the research was to evaluate the effectiveness of emergency medical procedures applied by emergency medical teams in prehospital care in the context of return of spontaneous circulation (ROSC).The case-control study was based on the medical documentation of the Rescue Service in Katowice (responsible for monitoring 2.7 million inhabitants of the region) referring to 2016. The research involved exclusively adults (ie, individuals older than 18 years) with out-of-hospital cardiac arrest (OHCA). After considering the above inclusion criteria, there were 1603 dispatch order forms (0.64% of all dispatch orders) involved in further research.On the basis of the emergency medical procedure forms, the actions of emergency medical teams were verified as medical procedures (endotracheal intubation, the use of suction pumps, defibrillation, the use of alternatives providing airway patency and ROSC was determined.The analysis covered 1603 cases of OHCA. SCA turned out more frequent in men than in women (P = .000). Most often, SCA occurred in domestic conditions during the day and was witnessed by a third person. In 59.9% of the cases, actions were taken by witnesses, which increased the probability of ROSC. Patients were usually intubated (51.4%). Respirators were used less frequently (20.2%). Ventricular fibrillation (VF) was reported only in 22.0% of the cases. The ROSC rate was higher in the group of patients with diagnosed VF than in those with nonshockable rhythms (VF, 55.43% vs asystole, 24.05%; P = .000).Successful resuscitation depends on the quality of emergency medical procedures performed at the place of incident. The highest probability of ROSC is related with defibrillation (in the cases of VF or ventricular tachycardia with no pulse), intubation, the application of a respirator, and performing mechanical ventilation, as well as with a shorter time from dispatch to arrival.
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Affiliation(s)
- Klaudiusz Nadolny
- Department of Emergency Medicine and Disasters, Medical University of Bialystok, Bialystok
| | - Lukasz Szarpak
- Department of Emergency Medicine, Lazarski University, Warsaw
| | - Joanna Gotlib
- Division of Teaching and Outcomes of Education, Faculty of Health Sciences, Medical University of Warsaw
| | - Mariusz Panczyk
- Division of Teaching and Outcomes of Education, Faculty of Health Sciences, Medical University of Warsaw
| | - Maciej Sterlinski
- Department of Arrhythmia, The Cardinal Stefan Wyszynski Institute of Cardiology
| | - Jerzy Robert Ladny
- Department of Emergency Medicine and Disasters, Medical University of Bialystok, Bialystok
| | - Jacek Smereka
- Department of Emergency Medical Service, Wroclaw Medical University
| | - Robert Galazkowski
- Department of Emergency Medical Service, Medical University of Warsaw, Warsaw, Poland
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Smith CM, Lim Choi Keung SN, Khan MO, Arvanitis TN, Fothergill R, Hartley-Sharpe C, Wilson MH, Perkins GD. Barriers and facilitators to public access defibrillation in out-of-hospital cardiac arrest: a systematic review. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2017; 3:264-273. [PMID: 29044399 DOI: 10.1093/ehjqcco/qcx023] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 07/12/2017] [Indexed: 11/14/2022]
Abstract
Public access defibrillation initiatives make automated external defibrillators available to the public. This facilitates earlier defibrillation of out-of-hospital cardiac arrest victims and could save many lives. It is currently only used for a minority of cases. The aim of this systematic review was to identify barriers and facilitators to public access defibrillation. A comprehensive literature review was undertaken defining formal search terms for a systematic review of the literature in March 2017. Studies were included if they considered reasons affecting the likelihood of public access defibrillation and presented original data. An electronic search strategy was devised searching MEDLINE and EMBASE, supplemented by bibliography and related-article searches. Given the low-quality and observational nature of the majority of articles, a narrative review was performed. Sixty-four articles were identified in the initial literature search. An additional four unique articles were identified from the electronic search strategies. The following themes were identified related to public access defibrillation: knowledge and awareness; willingness to use; acquisition and maintenance; availability and accessibility; training issues; registration and regulation; medicolegal issues; emergency medical services dispatch-assisted use of automated external defibrillators; automated external defibrillator-locator systems; demographic factors; other behavioural factors. In conclusion, several barriers and facilitators to public access defibrillation deployment were identified. However, the evidence is of very low quality and there is not enough information to inform changes in practice. This is an area in urgent need of further high-quality research if public access defibrillation is to be increased and more lives saved. PROSPERO registration number CRD42016035543.
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Affiliation(s)
- Christopher M Smith
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
- Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS, UK
| | | | - Mohammed O Khan
- Institute of Digital Healthcare, WMG, University of Warwick, Coventry CV4 7AL, UK
| | | | - Rachael Fothergill
- London Ambulance Service NHS Trust, 18-20 Pocock Street, London SE1 0BW, UK
| | | | - Mark H Wilson
- Imperial College, Neurotrauma Centre, St Mary's Hospital, Praed Street, London W2 1NY, UK
| | - Gavin D Perkins
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
- Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS, UK
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Nord A, Svensson L, Karlsson T, Claesson A, Herlitz J, Nilsson L. Increased survival from out-of-hospital cardiac arrest when off duty medically educated personnel perform CPR compared with laymen. Resuscitation 2017; 120:88-94. [PMID: 28870719 DOI: 10.1016/j.resuscitation.2017.08.234] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 08/16/2017] [Accepted: 08/23/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Bystander cardiopulmonary resuscitation (CPR) has been proved to save lives; however, whether survival is affected by the training level of the bystander is not fully described. AIM To describe if the training level of laymen and medically educated bystanders affect 30-day survival in out-of-hospital cardiac arrests (OHCA). METHODS This observational study included all witnessed and treated cases of bystander CPR reported to the Swedish Registry of Cardiopulmonary Resuscitation between 2010 and 2014. Bystander CPR was divided into two categories: (a) lay-byCPR (non-medically educated) and (b) med-byCPR (off duty medically educated personnel). RESULTS During 2010-2014, 24,643 patients were reported to the OHCA registry, of which 6850 received lay-byCPR and 1444 med-byCPR; 16,349 crew-witnessed and non-witnessed cases and those with missing information were excluded from the analysis. The median interval from collapse to call for emergency medical services was 2min in both groups (p=0.97) and 2min from collapse to start of CPR for lay-byCPR versus 1min for med-byCPR (p<0.0001). There were no significant differences in CPR methods used; 64.3% (lay-byCPR) and 65.7% (med-byCPR) applied compressions and ventilation, respectively (p=0.33). The 30-day survival was 14.7% for lay-byCPR and 17.2% for the med-byCPR group (p=0.02). The odds ratio adjusted for potential confounders regarding survival (med-byCPR versus lay-byCPR) was 1.34 (95% confidence interval, 1.11-1.62; p=0.002). CONCLUSIONS In cases of OHCA, medically educated bystanders initiated CPR earlier and an increased 30-day survival was found compared with laymen bystanders. These results support the need to improve the education programme for laypeople.
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Affiliation(s)
- Anette Nord
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Leif Svensson
- Department of Medicine, Center for Resuscitation Science, Karolinska Institute, Solna, Sweden
| | - Thomas Karlsson
- Health Metrics Unit, Institution of Medicine, Sahlgrenska Academy, University of Gothenburg University, Gothenburg, Sweden
| | - Andreas Claesson
- Department of Medicine, Center for Resuscitation Science, Karolinska Institute, Solna, Sweden
| | - Johan Herlitz
- Prehospen-Center for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
| | - Lennart Nilsson
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
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Timely bystander CPR improves outcomes despite longer EMS times. Am J Emerg Med 2017; 35:1049-1055. [PMID: 28237384 DOI: 10.1016/j.ajem.2017.02.033] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 02/14/2017] [Accepted: 02/15/2017] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES This study aimed to determine the impact of bystander CPR on clinical outcomes in patients with increasing response time from collapse to EMS response. METHODS A population-based observational study was conducted in patients with witnessed out-of-hospital cardiac arrest (OHCA) of presumed cardiac etiology from 2012 to 2014. The time interval from collapse to CPR by EMS providers was categorized into quartile groups: fastest group (<4min), fast group (4 to <8min), late group (8 to <15min), and latest group (15 to <30min). The primary outcome was hospital discharge and the secondary outcome was survival with good neurological outcome. Multivariable logistic regression analysis was performed to evaluate the interaction between bystander CPR and the time interval from collapse to CPR by EMS providers. RESULTS A total of 15,354 OHCAs were analyzed. Bystander CPR was performed in 8591 (56.0%). Survival to hospital discharge occurred in 1632 (10.6%) and favorable neurological outcome in 996 (6.5%). In an interaction model of bystander CPR, compared to the fastest group, adjusted odds ratios (AORs) (95% CIs) for survival to discharge were 0.89 (0.66-1.20) in the fast group, 0.76 (0.57-1.02) in the late group, and 0.52 (0.37-0.73) in the latest group. For favorable neurological outcome, AORs were 1.12 (0.77-1.62) in the fast group, 0.90 (0.62-1.30) in the late group, 0.59 (0.38-0.91) in the latest group. CONCLUSION The survival from OHCA decreases as the ambulance response time increases. The increase in mortality and worsening neurologic outcomes appear to be mitigated in those patients who receive bystander CPR.
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Forslund AS, Jansson JH, Lundblad D, Söderberg S. A second chance at life: people's lived experiences of surviving out-of-hospital cardiac arrest. Scand J Caring Sci 2017; 31:878-886. [DOI: 10.1111/scs.12409] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 10/26/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Ann-Sofie Forslund
- The Northern Sweden MONICA Myocardial Registry; Department of Research; Norrbotten County Council; Luleå Sweden
| | - Jan-Håkan Jansson
- Skellefteå Research Unit; Department of Public Health and Clinical Medicine; Umeå University; Umeå Sweden
| | - Dan Lundblad
- Sunderby Research Unit; Department of Public Health and Clinical Medicine; Umeå University; Umeå Sweden
| | - Siv Söderberg
- Department of Nursing Sciences; Mid Sweden University; Östersund Sweden
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Mulder M, Geocadin RG. Neurology of cardiopulmonary resuscitation. HANDBOOK OF CLINICAL NEUROLOGY 2017; 141:593-617. [PMID: 28190437 DOI: 10.1016/b978-0-444-63599-0.00032-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
This chapter aims to provide an up-to-date review of the science and clinical practice pertaining to neurologic injury after successful cardiopulmonary resuscitation. The past two decades have seen a major shift in the science and practice of cardiopulmonary resuscitation, with a major emphasis on postresuscitation neurologic care. This chapter provides a nuanced and thoughtful historic and bench-to-bedside overview of the neurologic aspects of cardiopulmonary resuscitation. A particular emphasis is made on the anatomy and pathophysiology of hypoxic-ischemic encephalopathy, up-to-date management of survivors of cardiopulmonary resuscitation, and a careful discussion on neurologic outcome prediction. Guidance to practice evidence-based clinical care when able and thoughtful, pragmatic suggestions for care where evidence is lacking are also provided. This chapter serves as both a useful clinical guide and an updated, thorough, and state-of-the-art reference on the topic for advanced students and experienced practitioners in the field.
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Affiliation(s)
- M Mulder
- Department of Critical Care and the John Nasseff Neuroscience Institute, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN, USA
| | - R G Geocadin
- Neurosciences Critical Care Division, Department of Anesthesiology and Critical Care Medicine and Departments of Neurology and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Sudden death and cardiac arrest without phenotype: the utility of genetic testing. Trends Cardiovasc Med 2016; 27:207-213. [PMID: 27692676 DOI: 10.1016/j.tcm.2016.08.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 08/15/2016] [Accepted: 08/24/2016] [Indexed: 12/19/2022]
Abstract
Approximately 4% of sudden cardiac deaths are unexplained [the sudden arrhythmic death syndrome (SADS)], and up to 6-10% of survivors of cardiac arrest do not have an identifiable cardiac abnormality after comprehensive clinical evaluation [idiopathic ventricular fibrillation (IVF)]. Genetic testing may be able to play a role in diagnostics and can be targeted to an underlying phenotype present in family members following clinical evaluation. Alternatively, post-mortem genetic testing (the "molecular autopsy") may diagnose the underlying cause if a clearly pathogenic rare variant is found. Limitations include a modest yield, and the high probability of finding a variant of unknown significance (VUS) leading to a low signal-to-noise ratio. Next generation sequencing enables cost-efficient high throughput screening of a larger number of genes but at the expense of increased genetic noise. The yield from genetic testing is even lower in IVF in the absence of any suggestion of another phenotype in the index case or his/her family, and should be actively discouraged at this time. Future improvements in diagnostic utility include optimization of the use of variant-calling pipelines and shared databases as well as patient-specific models of disease to more accurately assign pathogenicity of variants. Studying "trios" of parents and the index case may better assess the yield of sporadic and recessive disease.
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Lundin A, Djärv T, Engdahl J, Hollenberg J, Nordberg P, Ravn-Fischer A, Ringh M, Rysz S, Svensson L, Herlitz J, Lundgren P. Drug therapy in cardiac arrest: a review of the literature. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2015; 2:54-75. [DOI: 10.1093/ehjcvp/pvv047] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 10/28/2015] [Indexed: 01/01/2023]
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Mauri R, Burkart R, Benvenuti C, Caputo ML, Moccetti T, Del Bufalo A, Gallino A, Casso C, Anselmi L, Cassina T, Klersy C, Auricchio A. Better management of out-of-hospital cardiac arrest increases survival rate and improves neurological outcome in the Swiss Canton Ticino. Europace 2015; 18:398-404. [PMID: 26346920 PMCID: PMC4801166 DOI: 10.1093/europace/euv218] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 05/26/2015] [Indexed: 01/28/2023] Open
Abstract
Aim To determine the incidence of out-of-hospital cardiac arrest (OHCA) fulfilling Utstein criteria in the Canton Ticino, Switzerland, the survival rate of OHCA patients and their neurological outcome. Methods and results All OHCAs treated in Canton Ticino between 1 January 2005 and 31 December 2014 were followed until either death or hospital discharge. The survival and neurological outcome of those OHCA fulfilling Utstein criteria are reported. A total of 3367 OHCAs occurred in the Canton Ticino over a 10-year period. Resuscitation was attempted in 2298 patients; of those 1492 (65%) were of presumed cardiac origin, 454 fulfilling the Utstein comparator criteria. About 69% [95% confidence interval (CI), 66.6–71.4%] of the patients had a bystander-witnessed arrest; a dispatched cardiopulmonary resuscitation (CPR) steadily and significantly increased from 2005 to 2014. Out-of-hospital cardiac arrest occurred prevalently home (67%), in men (71%) of a mean age of 71 ± 13 years. There were no statistically significant differences either in demographic characteristics of OHCA victims over these years or in presenting rhythm. There was a progressive increase in the survival at discharge from 15% in 2005 to 55% in 2014; overall 96% (95% CI, 93.3–99.9%) of the survivors had a good neurological outcome. Conclusion The significant increase in Utstein comparator survival rates and improved neurological outcome in OHCA victims in Canton Ticino are the result of an effective OHCA management programme which includes large-scale public education, a coordinated fast EMS response, high density of external defibrillators, and advances in clinical interventions for OHCAs.
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Affiliation(s)
- Romano Mauri
- Fondazione Ticino Cuore, Breganzona, Switzerland Anesthesiology and Intensive Care, Clinica Luganese, Lugano, Switzerland
| | | | | | - Maria Luce Caputo
- Fondazione Ticino Cuore, Breganzona, Switzerland Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Tiziano Moccetti
- Fondazione Ticino Cuore, Breganzona, Switzerland Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Alessandro Del Bufalo
- Fondazione Ticino Cuore, Breganzona, Switzerland Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Augusto Gallino
- Fondazione Ticino Cuore, Breganzona, Switzerland Division of Cardiology, Ospedale Regionale di Bellinzona, Bellinzona, Switzerland
| | - Carlo Casso
- Fondazione Ticino Cuore, Breganzona, Switzerland Federazione Cantonale Ticinese Servizi Autoambulanze, Lugano, Switzerland
| | - Luciano Anselmi
- Fondazione Ticino Cuore, Breganzona, Switzerland Federazione Cantonale Ticinese Servizi Autoambulanze, Lugano, Switzerland
| | - Tiziano Cassina
- Division of Anesthesiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Catherine Klersy
- Service of Biometry and Clinical Epidemiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Angelo Auricchio
- Fondazione Ticino Cuore, Breganzona, Switzerland Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
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Mentzelopoulos SD, Mantzanas M, van Belle G, Nichol G. Evolution of European Union legislation on emergency research. Resuscitation 2015; 91:84-91. [PMID: 25796997 DOI: 10.1016/j.resuscitation.2015.03.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 02/24/2015] [Accepted: 03/11/2015] [Indexed: 11/17/2022]
Abstract
AIM Emergency research is necessary to prevent exposure of patients to unvalidated clinical practice (nonmaleficence), and to improve the dismal prognosis of disorders requiring emergent treatment such as cardiac arrest (beneficence). Regulations that govern clinical research should conform to bioethical principles of respect for nonmaleficence, beneficence, autonomy, and justice. Our objectives are to review the evolution of European Union (EU) legislation on emergency research, and to identify potentially remaining problems. DATA SOURCES EU legislative sources on clinical research and medical literature describing the impact of EU Regulations on emergency research. RESULTS Article 5 of EU Directive 2001/20/EC required consent before enrolment in a research study to ensure the autonomy of potentially incapacitated research subjects. However, obtaining such consent is often impossible in emergency situations. Directive 2001/20/EC was criticized for potentially preventing emergency research. Several EU Member States addressed this problem by permitting deferred consent. International ethical guidelines supporting deferred consent were also cited by Good Clinical Practice Directive 2005/28/EC. However, Directive 2001/20/EC was not revised to achieve harmonization of EU emergency research, thus resulting in ongoing "ambiguity" as regards to emergency research legitimacy. This will be definitively addressed by applying EU Regulation No. 536/2014 and repealing Directive 2001/20/EC. The new EU Regulation permits using deferred consent under clearly specified conditions, and may foster emergency research that evaluates interventions posing minimal risk relative to standard practice. CONCLUSIONS Legislation related to emergency research in Europe has evolved to increase concordance with bioethical principles so as to increase evidence-based improvements in emergency care.
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Affiliation(s)
| | | | - Gerald van Belle
- Clinical Trial Center, Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Graham Nichol
- Clinical Trial Center, Department of Biostatistics, University of Washington, Seattle, WA, USA; University of Washington-Harborview Center for Prehospital Emergency Care, Department of Medicine, University of Washington, Seattle, WA, USA.
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Manolis AS. The clinical challenge of preventing sudden cardiac death immediately after acute ST-elevation myocardial infarction. Expert Rev Cardiovasc Ther 2014; 12:1427-37. [PMID: 25382137 DOI: 10.1586/14779072.2014.981159] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Unfortunately, of all patients experiencing acute myocardial infarction (MI), usually in the form of ST-elevation MI, 25-35% will die of sudden cardiac death (SCD) before receiving medical attention, most often from ventricular fibrillation. For patients who reach the hospital, prognosis is considerably better and has improved over the years. Reperfusion therapy, best attained with primary percutaneous coronary intervention compared to thrombolysis, has made a big difference in reducing the risk of SCD early and late after ST-elevation MI. In-hospital SCD due to ventricular tachyarrhythmias is manageable, with either preventive measures or drugs or electrical cardioversion. There is general agreement for secondary prevention of SCD post-MI with implantation of a cardioverter defibrillator (ICD) when malignant ventricular arrhythmias occur late (>48 h) after an MI, and are not due to reversible or correctable causes. The major challenge remains that of primary prevention, that is, how to prevent SCD during the first 1-3 months after ST-elevation MI for patients who have low left ventricular ejection fraction and are not candidates for an ICD according to current guidelines, due to the results of two studies, which did not show any benefits of early (<40 days after an MI) ICD implantation. Two recent documents may provide direction as to how to bridge the gap for this early post-MI period. Both recommend an electrophysiology study to guide implantation of an ICD, at least for those developing syncope or non-sustained ventricular tachycardia, who have an inducible sustained ventricular tachycardia at the electrophysiology study. An ICD is also recommended for patients with indication for a permanent pacemaker due to bradyarrhythmias, who also meet primary prevention criteria for SCD.
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De Wolf D, Matthys D. Sports preparticipation cardiac screening: what about children? Eur J Pediatr 2014; 173:711-9. [PMID: 23775539 DOI: 10.1007/s00431-013-2064-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Accepted: 06/05/2013] [Indexed: 10/26/2022]
Abstract
UNLABELLED Sudden cardiac death in young athletes is a devastating event. Screening programs have been proposed to prevent sudden cardiac death in young athletes. Mortality rates and causes of death differ among young adults and children. Children have a considerably lower incidence of sudden cardiac death. Data lack to compare athletes and non-athletes in childhood, but 40-50 % of sudden cardiac death in this age group seems to be related to exercise. Screening programs including history and physical exam are not very sensitive or specific and will result in important numbers of false-positives and false-negatives. Especially, interpretation of ECG in children is different from ECG in adults, with less accurate diagnoses as a consequence. Secondary prevention by widespread education of simple resuscitation techniques and use of automatic external defibrillators if available will probably save as many lives as any screening program. CONCLUSION Sufficient data are lacking to support general preparticipation screening with history, physical exam, and ECG in competitive children. Nevertheless, the impact of such a program, together with secondary preventive measures, should be evaluated in large prospective studies.
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Affiliation(s)
- Daniel De Wolf
- Department of Pediatric Cardiology, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium,
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Characteristics and prognosis of sudden cardiac death in Greater Paris. Intensive Care Med 2014; 40:846-54. [DOI: 10.1007/s00134-014-3252-5] [Citation(s) in RCA: 124] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 02/18/2014] [Indexed: 11/28/2022]
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Hahn DK, Geocadin RG, Greer DM. Quality of evidence in studies evaluating neuroimaging for neurologic prognostication in adult patients resuscitated from cardiac arrest. Resuscitation 2014; 85:165-72. [DOI: 10.1016/j.resuscitation.2013.10.031] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2013] [Revised: 10/17/2013] [Accepted: 10/29/2013] [Indexed: 11/25/2022]
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Marijon E, Bougouin W, Celermajer DS, Perier MC, Benameur N, Lamhaut L, Karam N, Dumas F, Tafflet M, Prugger C, Mustafic H, Rifler JP, Desnos M, Le Heuzey JY, Spaulding CM, Avillach P, Cariou A, Empana JP, Jouven X. Major regional disparities in outcomes after sudden cardiac arrest during sports. Eur Heart J 2013; 34:3632-40. [DOI: 10.1093/eurheartj/eht282] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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Validity of reported data in the Swedish Cardiac Arrest Register in selected parts in Sweden. Resuscitation 2013; 84:952-6. [DOI: 10.1016/j.resuscitation.2012.12.026] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Revised: 12/07/2012] [Accepted: 12/27/2012] [Indexed: 11/17/2022]
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Kitamura T, Iwami T, Kawamura T, Nitta M, Nagao K, Nonogi H, Yonemoto N, Kimura T. Nationwide Improvements in Survival From Out-of-Hospital Cardiac Arrest in Japan. Circulation 2012; 126:2834-43. [DOI: 10.1161/circulationaha.112.109496] [Citation(s) in RCA: 257] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Tetsuhisa Kitamura
- From the Kyoto University Health Service, Kyoto (T. Kitamura, T.I., T. Kawamura); Department of Emergency Medicine, Osaka Medical College, Takatsuki (M.N.); Department of Cardiology, Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Nihon University Surugadai Hospital, Tokyo (K.N.); Division of Cardiovascular Care Unit, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka (H.N.); Department of Epidemiology and Biostatistics, National Center of
| | - Taku Iwami
- From the Kyoto University Health Service, Kyoto (T. Kitamura, T.I., T. Kawamura); Department of Emergency Medicine, Osaka Medical College, Takatsuki (M.N.); Department of Cardiology, Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Nihon University Surugadai Hospital, Tokyo (K.N.); Division of Cardiovascular Care Unit, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka (H.N.); Department of Epidemiology and Biostatistics, National Center of
| | - Takashi Kawamura
- From the Kyoto University Health Service, Kyoto (T. Kitamura, T.I., T. Kawamura); Department of Emergency Medicine, Osaka Medical College, Takatsuki (M.N.); Department of Cardiology, Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Nihon University Surugadai Hospital, Tokyo (K.N.); Division of Cardiovascular Care Unit, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka (H.N.); Department of Epidemiology and Biostatistics, National Center of
| | - Masahiko Nitta
- From the Kyoto University Health Service, Kyoto (T. Kitamura, T.I., T. Kawamura); Department of Emergency Medicine, Osaka Medical College, Takatsuki (M.N.); Department of Cardiology, Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Nihon University Surugadai Hospital, Tokyo (K.N.); Division of Cardiovascular Care Unit, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka (H.N.); Department of Epidemiology and Biostatistics, National Center of
| | - Ken Nagao
- From the Kyoto University Health Service, Kyoto (T. Kitamura, T.I., T. Kawamura); Department of Emergency Medicine, Osaka Medical College, Takatsuki (M.N.); Department of Cardiology, Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Nihon University Surugadai Hospital, Tokyo (K.N.); Division of Cardiovascular Care Unit, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka (H.N.); Department of Epidemiology and Biostatistics, National Center of
| | - Hiroshi Nonogi
- From the Kyoto University Health Service, Kyoto (T. Kitamura, T.I., T. Kawamura); Department of Emergency Medicine, Osaka Medical College, Takatsuki (M.N.); Department of Cardiology, Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Nihon University Surugadai Hospital, Tokyo (K.N.); Division of Cardiovascular Care Unit, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka (H.N.); Department of Epidemiology and Biostatistics, National Center of
| | - Naohiro Yonemoto
- From the Kyoto University Health Service, Kyoto (T. Kitamura, T.I., T. Kawamura); Department of Emergency Medicine, Osaka Medical College, Takatsuki (M.N.); Department of Cardiology, Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Nihon University Surugadai Hospital, Tokyo (K.N.); Division of Cardiovascular Care Unit, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka (H.N.); Department of Epidemiology and Biostatistics, National Center of
| | - Takeshi Kimura
- From the Kyoto University Health Service, Kyoto (T. Kitamura, T.I., T. Kawamura); Department of Emergency Medicine, Osaka Medical College, Takatsuki (M.N.); Department of Cardiology, Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Nihon University Surugadai Hospital, Tokyo (K.N.); Division of Cardiovascular Care Unit, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka (H.N.); Department of Epidemiology and Biostatistics, National Center of
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Scholefield BR, Bingham RM. Cardiac arrest in infancy; is it always depressing? Resuscitation 2012; 83:541-2. [DOI: 10.1016/j.resuscitation.2012.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 03/03/2012] [Indexed: 10/28/2022]
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