Delays in Cardiopulmonary Resuscitation, Defibrillation, and Epinephrine Administration All Decrease Survival in In-hospital Cardiac Arrest

Artificial intelligence for predicting shockable rhythm during cardiopulmonary resuscitation: In-hospital setting

AIM OF THE STUDY

This study aimed to develop an artificial intelligence (AI) model capable of predicting shockable rhythms from electrocardiograms (ECGs) with compression artifacts using real-world data from emergency department (ED) settings. Additionally, we aimed to explore the black box nature of AI models, providing explainability.

METHODS

This study is retrospective, observational study using a prospectively collected database. Adult patients who presented to the ED with cardiac arrest or experienced cardiac arrest in the ED between September 2021 and February 2024 were included. ECGs with a compression artifact of 5 s before every rhythm check were used for analysis. The AI model was designed based on convolutional neural networks. The ECG data were assigned into training, validation, and testing sets on a per-patient basis to ensure that ECGs from the same patient did not appear in multiple sets. Gradient-weighted class activation mapping was employed to demonstrate AI explainability.

RESULTS

A total of 1,889 ECGs with compression artifacts from 172 patients were used. The area under the receiver operating characteristic curve (AUROC) for shockable rhythm prediction was 0.8672 (95% confidence interval [CI]: 0.8161-0.9122). The AUROCs for manual and mechanical compression were 0.8771 (95% CI: 0.8054-0.9408) and 0.8466 (95% CI: 0.7630-0.9138), respectively.

CONCLUSION

This study was the first to accurately predict shockable rhythms during compression using an AI model trained with actual patient ECGs recorded during resuscitation. Furthermore, we demonstrated the explainability of the AI. This model can minimize interruption of cardiopulmonary resuscitation and potentially lead to improved outcomes.

Critical Event Checklists for Simulated In-Hospital Dysrhythmias in Children with Heart Disease

Children with heart disease are at increased risk of unstable dysrhythmias and in-hospital cardiac arrest (IHCA). Clinician adherence to lifesaving processes of care is an important contributor to improving patient outcomes. This study evaluated whether critical event checklists improve adherence to lifesaving processes during simulated acute events secondary to unstable dysrhythmias. A randomized controlled trial was conducted in a cardiac ward in a tertiary care, academic children's hospital. Unannounced simulated emergencies involving dysrhythmias in pediatric patients with underlying cardiac disease were conducted weekly. Responders were pediatric and anesthesiology residents, respiratory therapists, and bedside registered nurses. Six teams were randomized into two groups-three received checklists (intervention) and three did not (control). Each team participated in four simulated scenarios over a 4-week pediatric cardiology rotation. Participants received a brief slideshow presentation, which included a checklist orientation, at the start of their rotation. Simulations were video and audio recorded and those with three or more participants were included for analysis. The primary outcome was team adherence to lifesaving processes, expressed as the percentage of completed critical management steps. Secondary outcomes included participant perceptions of the checklist usefulness in identifying and managing dysrhythmias. We used generalized estimating equations (GEE) models, which accounted for clustering within groups, to evaluate the effects of the intervention. A total of 24 simulations were conducted; one of the 24 simulations was excluded due to an insufficient number of participants. In our GEE analysis, 81.21% (78.96%, 83.47%) of critical steps were completed with checklists available versus 68.06% (59.38%, 76.74%) without checklists (p = 0.004). Ninety-three percent of study participants reported that they would use the checklists during an unstable dysrhythmia of a child with underlying cardiac disease. Checklists were associated with improved adherence to lifesaving processes during simulated resuscitations for unstable pediatric dysrhythmias. These findings support the use of scenario specific checklists for the management of unstable dysrhythmias in simulations involving pediatric patients with underlying cardiac disease. Future studies should investigate whether checklists are as effective in actual pediatric in-hospital emergencies.

Management of Paediatric Cardiac Arrest due to Shockable Rhythm-A Simulation-Based Study at Children's Hospitals in a German Federal State

(1) Background: To improve the quality of emergency care for children, the Hessian Ministry for Social Affairs and Integration offered paediatric simulation-based training (SBT) for all children's hospitals in Hesse. We investigated the quality of paediatric life support (PLS) in simulated paediatric resuscitations before and after SBT. (2) Methods: In 2017, a standardised, high-fidelity, two-day in-house SBT was conducted in 11 children's hospitals. Before and after SBT, interprofessional teams participated in two study scenarios (PRE and POST) that followed the same clinical course of apnoea and cardiac arrest with a shockable rhythm. The quality of PLS was assessed using a performance evaluation checklist. (3) Results: 179 nurses and physicians participated, forming 47 PRE and 46 POST interprofessional teams. Ventilation was always initiated. Before SBT, chest compressions (CC) were initiated by 87%, and defibrillation by 60% of teams. After SBT, all teams initiated CC (p = 0.012), and 80% defibrillated the patient (p = 0.028). The time to initiate CC decreased significantly (PRE 123 ± 11 s, POST 76 ± 85 s, p = 0.030). (4) Conclusions: The quality of PLS in simulated paediatric cardiac arrests with shockable rhythm was poor in Hessian children's hospitals and improved significantly after SBT. To improve children's outcomes, SBT should be mandatory for paediatric staff and concentrate on the management of shockable rhythms.

Emergency critical care: closing the gap between onset of critical illness and intensive care unit admission

Critical illness is an exquisitely time-sensitive condition and follows a disease continuum, which always starts before admission to the intensive care unit (ICU), in the majority of cases even before hospital admission. Reflecting the common practice in many healthcare systems that critical care is mainly provided in the confined areas of an ICU, any delay in ICU admission of critically ill patients is associated with increased morbidity and mortality. However, if appropriate critical care interventions are provided before ICU admission, this association is not observed. Emergency critical care refers to critical care provided outside of the ICU. It encompasses the delivery of critical care interventions to and monitoring of patients at the place and time closest to the onset of critical illness as well as during transfer to the ICU. Thus, emergency critical care covers the most time-sensitive phase of critical illness and constitutes one missing link in the chain of survival of the critically ill patient. Emergency critical care is delivered whenever and wherever critical illness occurs such as in the pre-hospital setting, before and during inter-hospital transfers of critically ill patients, in the emergency department, in the operating theatres, and on hospital wards. By closing the management gap between onset of critical illness and ICU admission, emergency critical care improves patient safety and can avoid early deaths, reverse mild-to-moderate critical illness, avoid ICU admission, attenuate the severity of organ dysfunction, shorten ICU length of stay, and reduce short- and long-term mortality of critically ill patients. Future research is needed to identify effective models to implement emergency critical care systems in different healthcare systems.

Pro-Con Debate: Universal Versus Selective Continuous Monitoring of Postoperative Patients

In this Pro-Con commentary article, we discuss use of continuous physiologic monitoring for clinical deterioration, specifically respiratory depression in the postoperative population. The Pro position advocates for 24/7 continuous surveillance monitoring of all patients starting in the postanesthesia care unit until discharge from the hospital. The strongest arguments for universal monitoring relate to inadequate assessment and algorithms for patient risk. We argue that the need for hospitalization in and of itself is a sufficient predictor of an individual's risk for unexpected respiratory deterioration. In addition, general care units carry the added risk that even the most severe respiratory events will not be recognized in a timely fashion, largely due to higher patient to nurse staffing ratios and limited intermittent vital signs assessments (e.g., every 4 hours). Continuous monitoring configured properly using a "surveillance model" can adequately detect patients' respiratory deterioration while minimizing alarm fatigue and the costs of the surveillance systems. The Con position advocates for a mixed approach of time-limited continuous pulse oximetry monitoring for all patients receiving opioids, with additional remote pulse oximetry monitoring for patients identified as having a high risk of respiratory depression. Alarm fatigue, clinical resource limitations, and cost are the strongest arguments for selective monitoring, which is a more targeted approach. The proponents of the con position acknowledge that postoperative respiratory monitoring is certainly indicated for all patients, but not all patients need the same level of monitoring. The analysis and discussion of each point of view describes who, when, where, and how continuous monitoring should be implemented. Consideration of various system-level factors are addressed, including clinical resource availability, alarm design, system costs, patient and staff acceptance, risk-assessment algorithms, and respiratory event detection. Literature is reviewed, findings are described, and recommendations for design of monitoring systems and implementation of monitoring are described for the pro and con positions.

Frequency, Prognosis, and Clinical Features of Unexpected versus Expected Cardiac Arrest in the Emergency Department: A Retrospective Analysis

Background: Though out-of-hospital CA (OHCA) is widely reported, data on in-hospital CA (IHCA) and especially cardiac arrest (CA) in the emergency department (CAED) are scarce. This study aimed to determine the frequency, prevalence, and clinical features of unexpected CAED and compare the data with those of expected CAED. Methods: We defined unexpected CAED as CA occurring in patients in non-critical ED-care areas; classified as not requiring strict monitoring. This classification was the modified Japanese Triage and Acuity Scale and physician assessment. A retrospective analysis of cases from 2016 to 2018 was performed, in comparison to other patients experiencing CAED. Results: The 38 cases of unexpected CA in this study constituted 34.5% of CA diagnosed in the ED and 8.4% of all CA treated in the ED. This population did not differ significantly from other CAED regarding demographics, comorbidities, and survival rates. The commonest symptoms were dyspnoea, disorders of consciousness, generalised weakness, and chest pain. The commonest causes of death were acute myocardial infarction, malignant neoplasms with metastases, septic shock, pulmonary embolism, and heart failure. Conclusions: Unexpected CAED represents a group of potentially avoidable CA and deaths. These patients should be analysed, and ED management should include measures aimed at reducing their incidence.

Predictors of 30-day survival after emergent percutaneous coronary intervention following ventricular tachyarrhythmias complicating acute myocardial infarction

BACKGROUND

Little has been reported on the predictors of 30-day survival after emergent percutaneous coronary intervention (PCI) following life-threatening ventricular tachyarrhythmias associated with acute myocardial infarction (AMI).

METHODS

We analyzed 55 consecutive patients who underwent an emergent PCI after ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) complicating AMI between September 2014 and March 2023 in our hospital. These patients were categorized into two groups: survival group (S group) who survived >30 days after the emergent PCI and death group (D group) who died by 30 days after the emergent PCI. We compared the patient characteristics, coronary angiographic findings, and PCI procedures between the two groups.

RESULTS

S group consisted of 40 patients. In the univariate analysis, absence of diabetes mellitus, presence of immediate cardiopulmonary resuscitation (CPR), low arterial lactate, and single-vessel coronary artery disease (CAD) were associated with 30-day survival after the emergent PCI (P = 0.048, P < 0.001, P = 0.009, and P = 0.003, respectively). In the multivariate analysis, presence of immediate CPR and single-vessel CAD were independently associated with 30-day survival after the emergent PCI (P = 0.023 and P = 0.032, respectively).

CONCLUSIONS

Immediate CPR and single-vessel CAD were significant predictors of 30-day survival after the emergent PCI following VF or pulseless VT complicating AMI. Absence of diabetes mellitus and low arterial lactate were associated with 30-day survival in the univariate analysis.

Improving response time and survival in ward based in-hospital cardiac arrest: A quality improvement initiative

BACKGROUND

Survival in cardiac arrest is associated with rapid initiation of high-quality cardiopulmonary resuscitation (CPR) and advanced life support. To improve ROSC rates and survival, we identified the need to reduce response times and implement coordinated resuscitation by dedicated cardiac arrest teams (CATs). We aimed to improve ROSC rates by 10% within 6 months, and subsequent survival to hospital discharge.

METHODS

We used the Model for Improvement to implement a ward-based cardiac arrest quality improvement (QI) initiative across 3 Plan-Do-Study-Act (PDSA) cycles. QI interventions focused on instituting dedicated CATs and resuscitation equipment, staff training, communications, audit framework, performance feedback, as well as a cardiac arrest documentation form. The primary outcome was the rate of ROSC, and the secondary outcome was survival to hospital discharge. Process measures were call center processing times, CAT response times and CAT nurses' knowledge and confidence regarding CPR. Balancing measures were the number of non-cardiac arrest activations and the number of cardiac arrest activations in patients with existing do-not-resuscitate orders.

RESULTS

After adjustments for possible confounders in the multivariate analysis, there was a significant improvement in ROSC rate post-intervention as compared to the pre-intervention period (OR 2.05 [1.04-4.05], p = 0.04). Median (IQR) call center processing times decreased from 1.8 (1.6-2.0) pre-intervention to 1.4 (1.4-1.6) minutes post-intervention (p = 0.03). Median (IQR) CAT response times decreased from 5.1 (4.5-7.0) pre-intervention to 3.6 (3.4-4.3) minutes post-intervention (p < 0.001). After adjustments for possible confounders in the multivariate analysis, there was no significant improvement in survival to hospital discharge post-intervention as compared to the pre-intervention period (OR 0.71 [0.25-2.06], p = 0.53).

CONCLUSION

Implementation of a ward-based cardiac arrest QI initiative resulted in an improvement in ROSC rates, median call center and CAT response times.

Prognostic effects of cardiopulmonary resuscitation (CPR) start time and the interval between CPR to extracorporeal cardiopulmonary resuscitation (ECPR) on patient outcomes under extracorporeal membrane oxygenation (ECMO): a single-center, retrospective observational study

BACKGROUND

The impact of the chronological sequence of events, including cardiac arrest (CA), initial cardiopulmonary resuscitation (CPR), return of spontaneous circulation (ROSC), and extracorporeal cardiopulmonary resuscitation (ECPR) implementation, on clinical outcomes in patients with both out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA), is still not clear. The aim of this study was to investigate the prognostic effects of the time interval from collapse to start of CPR (no-flow time, NFT) and the time interval from start of CPR to implementation of ECPR (low-flow time, LFT) on patient outcomes under Extracorporeal Membrane Oxygenation (ECMO).

METHODS

This single-center, retrospective observational study was conducted on 48 patients with OHCA or IHCA who underwent ECMO at Hamad General Hospital (HGH), the tertiary governmental hospital of Qatar, between February 2016 and March 2020. We investigated the impact of prognostic factors such as NFT and LFT on various clinical outcomes following cardiac arrest, including 24-hour survival, 28-day survival, CPR duration, ECMO length of stay (LOS), ICU LOS, hospital LOS, disability (assessed using the modified Rankin Scale, mRS), and neurological status (evaluated based on the Cerebral Performance Category, CPC) at 28 days after the CA.

RESULTS

The results of the adjusted logistic regression analysis showed that a longer NFT was associated with unfavorable clinical outcomes. These outcomes included longer CPR duration (OR: 1.779, 95%CI: 1.218-2.605, P = 0.034) and decreased survival rates for ECMO at 24 h (OR: 0.561, 95%CI: 0.183-0.903, P = 0.009) and 28 days (OR: 0.498, 95%CI: 0.106-0.802, P = 0.011). Additionally, a longer LFT was found to be associated only with a higher probability of prolonged CPR (OR: 1.818, 95%CI: 1.332-3.312, P = 0.006). However, there was no statistically significant connection between either the NFT or the LFT and the improvement of disability or neurologically favorable survival after 28 days of cardiac arrest.

CONCLUSIONS

Based on our findings, it has been determined that the NFT is a more effective predictor than the LFT in assessing clinical outcomes for patients with OHCA or IHCA who underwent ECMO. This understanding of their distinct predictive abilities enables medical professionals to identify high-risk patients more accurately and customize their interventions accordingly.

Compliance with cardiopulmonary resuscitation guidelines in witnessed in-hospital cardiac arrest events and patient outcome on monitored versus non-monitored wards

BACKGROUND

Adherence to cardiopulmonary resuscitation (CPR) guidelines in treatment of in-hospital cardiac arrest (IHCA) have been associated with favourable patient outcome. The aim of this study was to evaluate if compliance with initial CPR guidelines and patient outcome of witnessed IHCA events were associated with the place of arrest defined as monitored versus non-monitored ward.

METHODS

A total of 956 witnessed IHCA events in adult patients at six hospitals during 2018 to 2019, were extracted from the Swedish Registry of Cardiopulmonary Resuscitation. Initial CPR guidelines were: ≤1 min from collapse to alert of the rapid response team, ≤1 min from collapse to start of CPR, ≤3 min from collapse to defibrillation of shockable rhythm.

RESULTS

The odds of compliance with guidelines was higher on monitored wards vs non-monitored wards, even after adjustment for factors that could affect staffing and resources. The place of arrest was not a significant factor for sustained return of spontaneous circulation, survival at 30 days, or neurological status at discharge, when adjusting for clinically relevant confounders. Compliance with initial CPR guidelines remained a significant factor for survival to 30 days and favourable neurological outcome at discharge regardless of other confounders.

CONCLUSION

Compliance with initial CPR guidelines was higher in witnessed IHCA events on monitored wards than on non-monitored wards, which indicates that healthcare professionals in monitored wards are quicker to recognize a cardiac arrest and initiate treatment. When initial CPR guidelines are followed, the place of arrest does not influence patient outcome.

Outcomes of in-hospital cardiac arrests during and after office hours in a single tertiary centre in Singapore

INTRODUCTION

In-hospital cardiac arrest (IHCA) is a significant healthcare burden with a paucity of data in Singapore. Various factors, including time of cardiac arrest, affect survival from acute resuscitation.

METHODS

This was a retrospective cohort study that evaluated the characteristics of patients who sustained an IHCA, including the Cardiac Arrest Survival Post Resuscitation In-hospital (CASPRI) scores, and the impact of arrest time in 220 consecutive cardiac arrests occurring in a tertiary hospital. The primary outcome was rate of return of spontaneous circulation (ROSC) post-IHCA, and the secondary outcome was 90-day survival.

RESULTS

The ROSC rate among patients with IHCA out of and during office hours was 69.5% and 75.4%, respectively (odds ratio [OR] 0.74, 95% confidence interval [CI] 0.39-1.42). There were no statistically significant differences between the CASPRI scores of both groups. After adjusted analysis, the OR of ROSC post-IHCA out of office hours as compared to that during office hours was 0.78 (95% CI 0.39-1.53). The 90-day survival rate of patients who had an IHCA out of and during office hours was 25.7% and 34.6%, respectively (OR 0.65, 95% CI 0.32-1.34). The adjusted OR of 90-day survival was 0.66 (0.28-1.59).

CONCLUSION

The results of this observational study did not show an association between the timing of cardiac arrest and the rate of ROSC or 90-day survival.

Inhibition of γδ T Cells Alleviates Blood-Brain Barrier in Cardiac Arrest and Cardiopulmonary Resuscitation in Mice

Ischemia/reperfusion (I/R) injury is the leading cause of death following cardiac arrest (CA) and cardiopulmonary resuscitation (CPR). γδT cells are suggested to aggravate blood-brain barrier (BBB) injury in various pathological processes. We herein investigate the effects of γδT cells inhibitor (UC7-13D5) against I/R injury post-CA/CPR. C57BL/6 mice were subjected to CA through injection of KCL (70 μL of 0.5 mol/L) and cessation of mechanical ventilation followed by CPR. Flow cytometry was performed to measure the proportion of CD3-positive cells after intraperitoneal injection of 200 μg UC7-13D5 at 6 h, 24 h, and 48 h post-resuscitation into mice. Neurological scores and modified neurological severity scores were assessed to examine neurological functions. Brain edema was estimated via brain water content measurements. Immunohistochemistry of caspase-3 and immunofluorescence staining of claudin-1, ZO-1 and CD31 were performed to detect neuronal apoptosis, BBB integrity and angiogenesis. Microvascular morphology in the cortical area was assessed via H&E staining. Oxidative stress was determined by measuring malondialdehyde, myeloperoxidase, xanthine oxidase, superoxide dismutase, and glutathione peroxidase activities. Western blotting was performed to measure the protein levels of Nuclear factor-E2-related factor 2 (Nrf2) and Heme oxygenase-1 (HO-1). UC7-13D5 effectively depleted γδT cells. Inhibition of γδT cells improved neurological deficits and reduced brain edema post-CA/CPR. γδT cells depletion attenuated neuronal apoptosis, BBB disruption and oxidative stress and promoted angiogenesis following CA/CPR. Inhibition of γδT cells facilitated the activation of the Nrf2/HO-1 pathway in CA/CPR-induced mice. Inhibition of γδT cells alleviates neurological deficits and cerebral edema in mice with CA/CPR by inhibiting neuronal apoptosis, BBB disruption and oxidative stress, and promoting angiogenesis via activation of the Nrf2/HO-1 pathway.

Nurses' Perceptions Towards Resuscitated Patients: A Qualitative Study

Nurses' perceptions of resuscitated patients may affect their care, and this has not been investigated in previous literature. The aim of this study was to explore nurses' perceptions towards resuscitated patients. In this descriptive-qualitative study seventeen clinical nurses participated using purposive sampling. In-depth, semi-structured interviews were conducted and data were analyzed by conventional content analysis. Four main categories emerged: Injured, undervalued, problematic, and destroyer of resources. Participants considered resuscitated patients to have multiple physical injuries, which are an important source of legal problems and workplace violence, and they believed that these patients will eventually die. Resuscitated patients are considered forgotten and educational cases. Iranian nurses have a strong negative perception towards resuscitated patients. Improving the quality of cardiopulmonary resuscitation, improving the knowledge and skills of personnel in performing resuscitation, and supporting managers and doctors to nurses in the post-resuscitation period can change the attitude of nurses and improve post-resuscitation care.

Resuscitation team training in Rwanda: A mixed method study exploring the combination of the VAST course with Advanced Cardiac Life Support training

Introduction

The influence of non-technical skills training on resuscitation performance in low-resource settings is unknown. This study investigates combining the Vital Anaesthesia Simulation Training Course with Advanced Cardiac Life Support training on resuscitation performance in Rwanda.

Methods

Participants in this mixed method study are members of resuscitation teams in three district hospitals in Rwanda. The intervention was participation in a 2-day Advanced Cardiac Life Support course followed by the 3-day Vital Anaesthesia Simulation Training Course. Quantitative primary endpoints were time to initiation of cardiopulmonary resuscitation, time to epinephrine administration, and time to defibrillation. Qualitative data on workplace implementation were gathered during focus groups held 3-months post-intervention.

Results

Forty-seven participants were recruited. Quantitative data showed a statistically significant decrease in time to cardiopulmonary resuscitation, epinephrine administration, and defibrillation from pre- to post-Advanced Cardiac Life Support, with times of [43.3 (49.7) seconds] versus [16.5 (20) sec], p = <0.001; [137.3 (108.9) sec] versus [51.3 (37.9)], p = <0.001; and [218.5 (105.8) sec] versus [110.8 (87.1) sec], p = <0.001; respectively. These improvements were maintained following the Vital Anaesthesia Simulation Training Course, and at 3-month retention testing. Qualitative analysis highlighted five key themes: ability to initiate cardiopulmonary resuscitation; team coordination for task allocation; empowerment; desire for training and mentorship; and advocacy for system improvement.

Conclusion

A modified 2-day Advanced Cardiac Life Support course improved resuscitation time indicators with retention 3-months later. Combining the Vital Anaesthesia Simulation Training Course and Advanced Cardiac Life Support led to better team coordination, empowerment to act, and advocacy for system improvement. This pairing of courses has promise for improving Advanced Cardiac Life Support skills amongst healthcare workers in low-resource settings.ClinicalTrials.gov Identifier: NCT05278884.

Empowering telemetry technicians and enhancing communication to improve in-hospital cardiac arrest survival

Delays in treatment of in-hospital cardiac arrests (IHCAs) are associated with worsened survival. We sought to assess the impact of a bundled intervention on IHCA survival in patients on centralised telemetry. A retrospective quality improvement study was performed of a bundled intervention which incorporated (1) a telemetry hotline for telemetry technicians to reach nursing staff; (2) empowerment of telemetry technicians to directly activate the IHCA response team and (3) a standardised escalation system for automated critical alerts within the nursing mobile phone system. In the 4-year study period, there were 75 IHCAs, including 20 preintervention and 55 postintervention. Cox proportional hazard regression predicts postintervention individuals have a 74% reduced the risk of death (HR 0.26, 95% CI 0.08 to 0.84) during a code and a 55% reduced risk of death (HR 0.45, 95% CI 0.23 to 0.89) prior to hospital discharge. Overall code survival improved from 60.0% to 83.6% (p=0.031) with an improvement in ventricular tachycardia/ventricular fibrillation (VT/VF) code survival from 50.0% to 100.0% (p=0.035). There was no difference in non-telemetry code survival preintervention and postintervention (71.4% vs 71.3%, p=0.999). The bundled intervention, including improved communication between telemetry technicians and nurses as well as empowerment of telemetry technicians to directly activate the IHCA response team, may improve IHCA survival, specifically for VT/VF arrests.

Defibrillation in the Cardiac Arrest Patient

Defibrillation is one of the few interventions known to favorably impact survival in cardiac arrest. In witnessed arrest, survival improves with defibrillation as early as possible, whereas it may improve outcomes to administer high-quality chest compressions for 90 seconds before defibrillation in unwitnessed arrest. Minimizing pre-, peri-, and post-shock pauses has been shown to have mortality benefits. Refractory ventricular fibrillation has high mortality rates, and there is ongoing research into promising adjunctive treatment modalities. There remains no consensus on optimal pad positioning and defibrillation energy level, however, recent data suggest anteroposterior pad placement may be superior to anterolateral placement.

Characteristics and neurological survival following intraoperative cardiac arrest in a Swiss University Hospital: a 7-year retrospective observational cohort study

Introduction

Little is known about intraoperative cardiac arrest during anesthesia care. In particular, data on characteristics of cardiac arrest and neurological survival are scarce.

Methods

We conducted a single-center retrospective observational study evaluating anesthetic procedures from January 2015 until December 2021. We included patients with an intraoperative cardiac arrest and excluded cardiac arrest outside of the operating room. The primary outcome was the return of spontaneous circulation (ROSC). Secondary outcomes were sustained ROSC over 20 min, 30-day survival, and favorable neurological outcome according to Clinical Performance Category (CPC) 1 and 2.

Results

We screened 228,712 anesthetic procedures, 195 of which met inclusion criteria and were analyzed. The incidence of intraoperative cardiac arrest was 90 (CI 95% 78-103) in 100,000 procedures. The median age was 70.5 [60.0; 79.4] years, and two-thirds of patients (n = 135; 69.2%) were male. Most of these patients with cardiac arrest had ASA physical status IV (n = 83; 42.6%) or V (n = 47; 24.1%). Cardiac arrest occurred more frequently (n = 104; 53.1%) during emergency procedures than elective ones (n = 92; 46.9%). Initial rhythm was pre-dominantly non-shockable with pulseless electrical activity mostly. Most patients (n = 163/195, 83.6%; CI 95 77.6-88.5%) had at least one instance of ROSC. Sustained ROSC over 20 min was achieved in most patients with ROSC (n = 147/163; 90.2%). Of the 163 patients with ROSC, 111 (68.1%, CI 95 60.4-75.2%) remained alive after 30 days, and most (n = 90/111; 84.9%) had favorable neurological survival (CPC 1 and 2).

Conclusion

Intraoperative cardiac arrest is rare but is more likely in older patients, patients with ASA physical status ≥IV, cardiac and vascular surgery, and emergency procedures. Patients often present with pulseless electrical activity as the initial rhythm. ROSC can be achieved in most patients. Over half of the patients are alive after 30 days, most with favorable neurological outcomes, if treated immediately.

Data-informed debriefing for cardiopulmonary arrest: A randomized controlled trial

Aim

To determine if data-informed debriefing, compared to a traditional debriefing, improves the process of care provided by healthcare teams during a simulated pediatric cardiac arrest.

Methods

We conducted a prospective, randomized trial. Participants were randomized to a traditional debriefing or a data-informed debriefing supported by a debriefing tool. Participant teams managed a 10-minute cardiac arrest simulation case, followed by a debriefing (i.e. traditional or data-informed), and then a second cardiac arrest case. The primary outcome was the percentage of overall excellent CPR. The secondary outcomes were compliance with AHA guidelines for depth and rate, chest compression (CC) fraction, peri-shock pause duration, and time to critical interventions.

Results

A total of 21 teams (84 participants) were enrolled, with data from 20 teams (80 participants) analyzed. The data-informed debriefing group was significantly better in percentage of overall excellent CPR (control vs intervention: 53.8% vs 78.7%; MD 24.9%, 95%CI: 5.4 to 44.4%, p = 0.02), guideline-compliant depth (control vs. intervention: 60.4% vs 85.8%, MD 25.4%, 95%CI: 5.5 to 45.3%, p = 0.02), CC fraction (control vs intervention: 88.6% vs 92.6, MD 4.0%, 95%CI: 0.5 to 7.4%, p = 0.03), and peri-shock pause duration (control vs intervention: 5.8 s vs 3.7 s, MD -2.1 s, 95%CI: -3.5 to -0.8 s, p = 0.004) compared to the control group. There was no significant difference in time to critical interventions between groups.

Conclusion

When compared with traditional debriefing, data-informed debriefing improves CPR quality and reduces pauses in CPR during simulated cardiac arrest, with no improvement in time to critical interventions.

Management of Intraoperative Cardiac Arrest

Perioperative arrests are both uncommon and heterogeneous and have not been described or studied to the same extent as cardiac arrest in the community. These crises are usually witnessed, frequently anticipated, and involve a rescuer physician with knowledge of the patient's comorbidities and coexisting anesthetic or surgically related pathophysiology ultimately leading to better outcomes. This article reviews the most probable causes of intraoperative arrest and their management.

Improving Time to Defibrillation Following Ventricular Tachycardia (VTach) and Ventricular Fibrillation (VFib) Cardiac Arrest: A Multicenter Retrospective and Prospective Quality Improvement Study

The goal of this study was to identify how often 2 independent centers defibrillated patients within the American Heart Association recommended 2-minute time interval following ventricular fibrillation/ventricular tachycardia arrest. A retrospective chart review revealed significant delays in defibrillation. Simulation sessions and modules were implemented to train nursing staff in a single nursing unit at a Philadelphia teaching hospital. Recruited nurses completed a code blue simulation session to establish a baseline time to defibrillation. They were then given 2 weeks to complete an online educational module. Upon completion, they participated in a second set of simulation sessions to assess improvement. First round simulations resulted in 33% with delayed defibrillation and 27% no defibrillation. Following the module, 77% of the second round of simulations ended in timely defibrillation, a statistically significant improvement ( P < 0.00001). Next steps involve prospective collection of the code blue data to analyze improvement in real code blue events.

Feasibility of accelerated code team activation with code button triggered smartphone notification

INTRODUCTION

Studies support rapid interventions to improve outcomes in patients with in-hospital cardiac arrest. We sought to decrease the time to code team activation and improve dissemination of patient-specific data to facilitate targeted treatments.

METHODS

We mapped code blue buttons behind each bed to patients through the electronic medical record. Pushing the button sent patient-specific data (admitting diagnosis, presence of difficult airway, and recent laboratory values) through a secure messaging system to the responding teams' smartphones. The code button also activated a hospital-wide alert through the operator. We piloted the system on seven medicine inpatient units from November 2019 through May 2022. We compared the time from code blue button press to smartphone message receipt vs traditional operator-sent overhead page.

RESULTS

The code button was the primary mode of code team activation for 12/35 (34.3%) cardiac arrest events. The code team received smartphone notifications a median of 78 s (IQR = 47-127 s) before overhead page. The median time to adrenaline administration for codes activated with the code button was not significantly different (240 s (IQR 142-300 s for code button) vs 148 s (IQR = 34-367 s) for overhead page, p = 0.89). Survival to discharge was 3/12 (25.0%) for codes activated with the code button vs 4/23 (17.4%) when activated by calling the operator (p = 0.67).

CONCLUSION

Implementation of a smartphone-based code button notification system reduced time to code team activation by 78 s. Larger cohorts are necessary to assess effects on patient outcomes.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Time-to-Task in Interval Simulated Cardiopulmonary Resuscitation Training: A Method for Maintaining Resuscitation Skills

PURPOSE

The literature supports interval simulation training as a means of improving nurses' cardiopulmonary resuscitation (CPR) skills. The aim of this project was to improve the time-to-task skills in single-rescuer basic life support (BLS) in an outpatient surgery center through interval simulation training.

DESIGN

Quality Improvement project.

METHODS

Twenty-nine nursing staff were included in this pretest/post-test within subjects interventional design quality improvement project. A 2-minute pretest cardiac arrest simulation was performed in the outpatient surgery center where time-to-task and quality of CPR data were collected. The pretest was followed by a lecture and CPR training. Three months later, the simulation was post-tested in an identical scenario with measures of time-to-task and quality of CPR.

FINDINGS

T4he mean times for code bell activation and initiation of CPR decreased significantly following the interval simulation training (P < .05). A clinically significant decrease was seen in the mean time-to-task placement of a backboard on code team arrival.

CONCLUSION

Interval simulation training is an effective means of maintaining CPR skills in the outpatient surgery center setting.

Assessing team behaviours and time to defibrillation during simulated cardiac arrest: a pilot study of internal medicine trainees

Understanding team behaviours leading to successful outcomes in resuscitation could help guide future training. Guidelines recommend defibrillation for shockable rhythm cardiac arrests within 2 minutes. This observational pilot study aimed to determine whether teamwork behaviours among medical trainees differed when time to defibrillation (TTD) was less than 2 minutes, versus 2 minutes or more.

Following ethical approval, groups of six internal medicine trainee (IMT) doctors in Scotland formed an

Twenty-three videos involving 138 trainees were scored using the TEAM tool. Scores ranged from 19–39.5/44 (mean 28.2). Mean TTD was 86.2 seconds (range 24–224), with 17/23 teams achieving defibrillation in under 2 minutes. Those achieving fast TTD achieved higher TEAM scores, and the result was statistically significant (30.1 ± 5.0 vs 22.9 ± 3.3,

This observational pilot study found that improved team performance, as measured by the TEAM tool, was associated with faster defibrillation by IMT doctors in simulated cardiac arrest. It highlighted the importance of adaptability as a team behaviour associated with successful performance, which is of interest to those involved in training high stakes emergency teams.

Critical illness-related cardiac arrest: Protocol for an investigation of the incidence and outcome of cardiac arrest within intensive care units in the United Kingdom

Critical illness-related cardiac arrest (CIRCA) as a distinct entity is not well described epidemiologically. There is currently a knowledge gap regarding how many occur in the UK or the impact on patient outcome. The CIRCA study is a prospective multi-centre observational cohort study of patients in the United Kingdom experiencing a cardiac arrest while in a Critical Care Unit embedded in the Case Mix Programme and National Cardiac Arrest Audit. The duration of data collection is 12 months, with surviving patients and family members receiving questionnaire follow-up at 90 days, 180 days and 12 months. This paper describes the protocol for the CIRCA study which received favourable ethical opinion from South Central - Berkshire Research Ethics Committee and approval from the Health Research Authority. Study registration is on clinicaltrials.gov (NCT04219384).

Targeted Temperature Management in Postresuscitation Care After Incorporating Results of the TTM2 Trial

Cardiac arrest still accounts for a substantial proportion of cardiovascular related deaths and is associated with a tremendous risk of neurological injury and, among the few survivors, poor quality of life. Critical determinants of survival and long‐term functional status after cardiac arrest are timely initiation of cardiopulmonary resuscitation and use of an external defibrillator for patients with a shockable rhythm. Outcomes are still far from satisfactory, despite ongoing efforts to improve cardiac arrest response systems, as well as elaborate postresuscitation algorithms. Targeted temperature management at the wide range between 32 °C and 36 °C has been one of the main therapeutic strategies to improve neurological outcome in postresuscitation care. This recommendation has been mainly based on 2 small randomized trials that were published 20 years ago. Most recent data derived from the TTM2 (Targeted Hypothermia Versus Targeted Normothermia After Out‐of‐Hospital Cardiac Arrest) trial, which included 1861 patients, challenge this strategy. It showed no benefit of targeted hypothermia at 33 °C over normothermia at 36 °C to 37.5 °C with fever prevention. Because temperature management at lower temperatures also correlated with an increased risk of side effects without any benefit in the TTM2 trial, a modification of the guidelines with harmonizing temperature management to normothermia might be necessary.

The impact of cognitive aids on resuscitation performance in in-hospital cardiac arrest scenarios: a systematic review and meta-analysis

Different cognitive aids have been recently developed to support the management of cardiac arrest, however, their effectiveness remains barely investigated. We aimed to assess whether clinicians using any cognitive aids compared to no or alternative cognitive aids for in-hospital cardiac arrest (IHCA) scenarios achieve improved resuscitation performance. PubMed, EMBASE, the Cochrane Library, CINAHL and ClinicalTrials.gov were systematically searched to identify studies comparing the management of adult/paediatric IHCA simulated scenarios by health professionals using different or no cognitive aids. Our primary outcomes were adherence to guideline recommendations (overall team performance) and time to critical resuscitation actions. Random-effects model meta-analyses were performed. Of the 4.830 screened studies, 16 (14 adult, 2 paediatric) met inclusion criteria. Meta-analyses of eight eligible adult studies indicated that the use of electronic/paper-based cognitive aids, in comparison with no aid, was significantly associated with better overall resuscitation performance [standard mean difference (SMD) 1.16; 95% confidence interval (CI) 0.64; 1.69; I² = 79%]. Meta-analyses of the two paediatric studies, showed non-significant improvement of critical actions for resuscitation (adherence to guideline recommended sequence of actions, time to defibrillation, rate of errors in defibrillation, time to start chest compressions), except for significant shorter time to amiodarone administration (SMD - 0.78; 95% CI - 1.39; - 0.18; I² = 0). To conclude, the use of cognitive aids appears to have benefits in improving the management of simulated adult IHCA scenarios, with potential positive impact on clinical practice. Further paediatric studies are necessary to better assess the impact of cognitive aids on the management of IHCA scenarios.

Septic Shock and Cardiac Arrest in Obstetrics: A Practical Simplified Clinical View

Septic shock and cardiac arrest during pregnancy, despite being uncommon, carry a high mortality rate among pregnant individuals. Basic initial management strategies are fundamental to improve clinical outcomes; obstetricians and maternal-fetal medicine specialists need to be familiar with such interventions.

Correlation between the warning symptoms and prognosis of cardiac arrest

BACKGROUND

A low survival rate in patients with cardiac arrest is associated with failure to recognize the condition in its initial stage. Therefore, recognizing the warning symptoms of cardiac arrest in the early stage may play an important role in survival.

AIM

To investigate the warning symptoms of cardiac arrest and to determine the correlation between the symptoms and outcomes.

METHODS

We included all adult patients with all-cause cardiac arrest who visited Peking University Third Hospital or Beijing Friendship Hospital between January 2012 and December 2014. Data on population, symptoms, resuscitation parameters, and outcomes were analysed.

RESULTS

Of the 1021 patients in the study, 65.9% had symptoms that presented before cardiac arrest, 25.2% achieved restoration of spontaneous circulation (ROSC), and 7.2% survived to discharge. The patients with symptoms had higher rates of an initial shockable rhythm (12.2% vs 7.5%, P = 0.020), ROSC (29.1% vs 17.5%, P = 0.001) and survival (9.2% vs 2.6%, P = 0.001) than patients without symptoms. Compared with the out-of-hospital cardiac arrest (OHCA) without symptoms subgroup, the OHCA with symptoms subgroup had a higher rate of calls before arrest (81.6% vs 0.0%, P < 0.001), health care provider-witnessed arrest (13.0% vs 1.4%, P = 0.001) and bystander cardiopulmonary resuscitation (15.5% vs 4.9%, P = 0.002); a shorter no flow time (11.7% vs 2.8%, P = 0.002); and a higher ROSC rate (23.8% vs 13.2%, P = 0.011). Compared to the in-hospital cardiac arrest (IHCA) without symptoms subgroup, the IHCA with symptoms subgroup had a higher mean age (66.2 ± 15.2 vs 62.5 ± 16.3 years, P = 0.005), ROSC (32.0% vs 20.6%, P = 0.003), and survival rates (10.6% vs 2.5%, P < 0.001). The top five warning symptoms were dyspnea (48.7%), chest pain (18.3%), unconsciousness (15.2%), paralysis (4.3%), and vomiting (4.0%). Chest pain (20.9% vs 12.7%, P = 0.011), cardiac etiology (44.3% vs 1.5%, P < 0.001) and survival (33.9% vs 16.7%, P = 0.001) were more common in males, whereas dyspnea (54.9% vs 45.9%, P = 0.029) and a non-cardiac etiology (53.3% vs 41.7%, P = 0.003) were more common in females.

CONCLUSION

Most patients had warning symptoms before cardiac arrest. Dyspnea, chest pain, and unconsciousness were the most common symptoms. Immediately recognizing these symptoms and activating the emergency medical system prevents resuscitation delay and improves the survival rate of OHCA patients in China.

The impact of clinical result acquisition and interpretation on task performance during a simulated pediatric cardiac arrest: a multicentre observational study

PURPOSE

The acquisition and interpretation of clinical results during resuscitations is common; however, this can delay critical clinical tasks, resulting in increased morbidity and mortality. This study aims to determine the impact of clinical result acquisition and interpretation by the team leader on critical task completion during simulated pediatric cardiac arrest before and after team training.

METHODS

This is a secondary data analysis of video-recorded simulated resuscitation scenarios conducted during Teams4Kids (T4K) study (June 2011-January 2015); scenarios included cardiac arrest before and after team training. The scenario included either a scripted paper or a phone call delivery of results concurrently with a clinical transition to pulseless ventricular tachycardia. Descriptive statistics and non-parametric tests were used to compare team performance before and after training.

RESULTS

Performance from 40 teams was analyzed. Although the time taken to initiate CPR and defibrillation varied depending on the type of interruption and whether the scenario was before or after team training, these findings were not significantly associated with the leader's behaviour [Kruskal-Wallis test (p > 0.05)]. An exact McNemar's test determined no statistically significant difference in the proportion of leaders involved or not in interpreting results between and after the training (exact p value = 0.096).

CONCLUSIONS

Team training was successful in reducing time to perform key clinical tasks. Although team training modified the way leaders behaved toward the results, this behaviour change did not impact the time taken to start CPR or defibrillate. Further understanding the elements that influence time to critical clinical tasks provides guidance in designing future simulated educational activities, subsequently improving clinical team performance and patient outcomes.

An In Situ Mock Code Program in the Pediatric Intensive Care Unit: A Multimodal Nurse-Led Quality Improvement Initiative

BACKGROUND

Lifesaving resuscitation is required for approximately 1 in 100 patients in the pediatric intensive care unit. Certification renewal alone is insufficient to guarantee adequate knowledge, skills, and confidence among staff members involved in infrequent resuscitation events.

LOCAL PROBLEM

Knowledge and skill gaps were identified in pediatric intensive care unit staff members involved in patient resuscitation events. The primary aim of this quality improvement project was to optimize patient resuscitations through improved staff performance and coordination between interdisciplinary roles.

METHODS

A multidisciplinary committee was created to develop, implement, and evaluate a mock code program. Surveys were administered before and after the intervention to assess self-perceived resuscitation performance and program effectiveness. Code sheets were analyzed for documentation quality and adherence to pediatric advanced life support guidelines. The committee used a multimodal approach to education, including high-and low-fidelity in situ mock code simulations and supplemental educational events.

RESULTS

From September 2018 through January 2020, the committee conducted 65 events for almost 500 participants. Nurses' levels of self-reported confidence in initiating pediatric advanced life support interventions and identifying cardiac rhythms increased, as did perceived level of competence and knowledge. Most unit staff members considered the mock code program to be "very to extremely effective" in increasing resuscitation competence, confidence, communication, teamwork, and role clarity. Adherence to recommended resuscitation behaviors improved, as did code sheet documentation quality.

CONCLUSION

An in situ mock code program using a multimodal approach to education can be a successful educational adjunct to biennial pediatric advanced life support certification.

Development and application of "Special defibrillator for teaching and training"

Background

To provide an economical and practical defibrillator for first aid teaching and training, to reduce the cost of teaching and training, increase teaching and training equipment, provide trainees with more hands-on training sessions, and improve first aid capabilities.

Methods

Developing a special teaching defibrillator with the same structure and operation configuration as the clinical medical emergency defibrillator. The appearance, structure and operating accessories of the two defibrillators are the same. The difference between the defibrillator and the clinical medical emergency defibrillator are as follows: the clinical medical emergency defibrillator can be energized, and there are expensive electronic accessories and defibrillation accessories for charging and discharging in the machine. When discharging, the electrode plate has current discharged into the human body; the power plug of the “special defibrillator for teaching and training” is a fake plug. When the power is plugged in, no current enters the body and the machine. There are no expensive electronic accessories and defibrillation accessories for charging and discharging, and no current is discharged during discharge. Then compare the teaching effect of the special defibrillator for teaching and training and the clinical medical emergency defibrillator (including operation score and attitude after training).

Results

The scores of defibrillator operation in the experimental group of junior college students (87.77 ± 4.11 vs. 83.30 ± 4.56, P < 0.001) and the experimental group of undergraduate students (90.40 ± 3.67 vs. 89.12 ± 3.68, P = 0.011) were higher than those in the corresponding control group; The attitude of junior college students in the experimental group and undergraduate students in the experimental group after training was more positive than that of the corresponding control group (P < 0.05).

Conclusions

The special defibrillator for teaching and training can save the purchase cost of teaching equipment, increase teaching and training resources, and improve the trainee’s defibrillation ability, defibrillation confidence and defibrillation security.

Survival outcomes and resuscitation process measures in maternal in-hospital cardiac arrest

BACKGROUND

Maternal in-hospital cardiac arrest is a rare event with the potential for resuscitation treatment delays because of the difficulty accessing hospital obstetrical units and limited simulation training or resuscitation experience of obstetrical staff. However, it is unclear whether survival rates and processes of care differ between women with a maternal in-hospital cardiac arrest and those with a nonmaternal in-hospital cardiac arrest.

OBJECTIVE

We aimed determine whether to there are delays in process measures and differences in survival outcomes between pregnant and nonpregnant women who have in-hospital cardiac arrest.

STUDY DESIGN

Using data from 2000 to 2019 in the Get With The Guidelines-Resuscitation registry, we compared resuscitation outcomes between women aged 18 to 50 years with a maternal or nonmaternal in-hospital cardiac arrest. Using a nonparsimonious propensity score, we matched patients with a maternal in-hospital cardiac arrest to as many as 10 women with a nonmaternal in-hospital cardiac arrest. We constructed conditional logistic regression models to compare survival outcomes (survival to discharge, favorable neurologic survival [discharge cerebral performance score of 1], and return of spontaneous circulation) and processes of care (delayed defibrillation [>2 minutes] and administration of epinephrine [>5 minutes]) between women with a maternal in-hospital cardiac arrest vs those with a nonmaternal in-hospital cardiac arrest.

RESULTS

Overall, 421 women with a maternal in-hospital cardiac arrest were matched by propensity score to 2316 women with a nonmaternal in-hospital cardiac arrest. The mean age among propensity score-matched women with a maternal in-hospital cardiac arrest was 31.4 (standard deviation, 6.5) years, where 33.7% were of Black race and 86.9% had an initial nonshockable cardiac arrest rhythm. Unadjusted survival rates were higher in women with a maternal in-hospital cardiac arrest than in women with a nonmaternal in-hospital cardiac arrest: survival to discharge of 45.1% vs 26.5%, survival with cerebral performance category 1 status of 36.1% vs 17.7%, and return of spontaneous circulation of 75.8% vs 70.6%. After adjustment, there was no difference in the likelihood of survival to discharge (odds ratio, 1.19; 95% confidence interval, 0.82-1.73) or return of spontaneous circulation (odds ratio, 0.94; 95% confidence interval, 0.65-1.35) between women with a maternal in-hospital cardiac arrest and those with a nonmaternal in-hospital cardiac arrest. However, women with a maternal in-hospital cardiac arrest were more likely to have favorable neurologic survival (odds ratio, 1.57; 95% confidence interval, 1.06-2.33). Compared with women with a nonmaternal in-hospital cardiac arrest, women with a maternal in-hospital cardiac arrest had similar rates of delayed defibrillation (42.5% vs 34.4%; odds ratio, 1.14 [95% confidence interval, 0.41-3.18]; P=.31) and delayed administration of epinephrine (13.8% vs 10.6%; odds ratio, 0.96 [95% confidence interval, 0.50-1.86]; P=.09).

CONCLUSION

Although concerns have been raised about resuscitation outcomes in women with a maternal in-hospital cardiac arrest, the rates of survival and resuscitation processes of care were not worse in women with a maternal in-hospital cardiac arrest.

Full recovery after prolonged resuscitation in a pediatric patient due to fulminant myocarditis: a case report with three-year follow-up

Background

Fulminant myocarditis (FM) is a common life-threatening disease in pediatric patients, which can result in sudden cardiac arrest (CA). Whether prolonged cardiopulmonary resuscitation (CPR) is beneficial to FM induced CA is unknown.

Case presentation

We reported the case of an 8-year-old child with FM. At 14:49 of the day after admission, the ECG monitoring indicated ventricular flutter. The patient was immediately given continuous external cardiac compression. Electric cardioversion (energy 30J) and electric defibrillation (energy 50 J, 100 J, 100 J) were given. Continuous chest compression was conducted until extracorporeal membrane oxygenation (ECMO) successfully placed at 19:30 P.M. The total duration of CPR was 291 min. Nine days later, the ECMO was removed; and 29 days later, the patient was discharged from hospital. In the three years of follow-up, the boy showed a full recovery without neurological sequela. At present, his daily activities have returned to normal and his academic performance at school is excellent.

Conclusions

Prolonged CPR can be used in FM induced in-hospital CA in pediatric patients, especially during preparation for ECMO after the failure of standard resuscitation measures.

Shifting the Paradigm: A Quality Improvement Approach to Proactive Cardiac Arrest Reduction in the Pediatric Cardiac Intensive Care Unit

Supplemental Digital Content is available in the text.

Introduction:

Children with cardiac conditions are at higher risk of in-hospital pediatric cardiopulmonary arrest (CA), resulting in significant morbidity and mortality. Despite the elevated risk, proactive cardiac arrest prevention programs in the cardiac intensive care unit (CICU) remain underdeveloped. Our team developed a multidisciplinary program centered on developing a quality improvement (QI) bundle for patients at high risk of CA.

Methods:

This project occurred in a 26-bed pediatric CICU of a tertiary care children’s hospital. Statistical process control methodology tracked changes in CA rates over time. The global aim was to reduce CICU mortality; the smart aim was to reduce the CA rate by 50% over 12 months. Interprofessional development and implementation of a QI bundle included visual cues to identify high-risk patients, risk mitigation strategies, a new rounding paradigm, and defined escalation algorithms. Additionally, weekly event and long-term data reviews, arrest debriefs, and weekly unit-wide dissemination of key findings supported a culture change.

Results:

After bundle implementation, CA rates decreased by 68% compared to baseline and 45% from the historical baseline. Major complications decreased from 17.1% to 12.6% (P < 0.001) and mortality decreased from 5.7% to 5.0% (P = 0.048). These results were sustained for 30 months.

Conclusions:

Cardiac arrest is a modifiable, rather than inevitable, metric in the CICU. Reduction is achievable through the interprofessional implementation of bundled interventions targeting proactive CA prevention. Once incorporated into widespread efforts to engage multidisciplinary CICU stakeholders, these patient-focused interventions resulted in sustained improvement.

Paramedic Rhythm Interpretation Misclassification is Associated with Poor Survival from Out-of-Hospital Cardiac Arrest

BACKGROUND

Early recognition and rapid defibrillation of shockable rhythms is strongly associated with survival in out of hospital cardiac arrest (OHCA). Little is known about the accuracy of paramedic rhythm interpretation and its impact on survival. We hypothesized that inaccurate paramedic interpretation of initial rhythm would be associated with worse survival.

METHODS

This is a retrospective cohort analysis of prospectively collected OHCA data over a nine-year period within a single, urban, fire-based EMS system that utilizes manual defibrillators equipped with rhythm-filtering technology. We compared paramedic-documented initial rhythm with a reference standard of post-event physician interpretation to estimate sensitivity and specificity of paramedic identification of and shock delivery to shockable rhythms. We assessed the association between misclassification of initial rhythm and neurologically intact survival to hospital discharge using multivariable logistic regression.

RESULTS

A total of 863 OHCA cases were available for analysis with 1,756 shocks delivered during 542 (63%) resuscitation attempts. Eleven percent of shocks were delivered to pulseless electrical activity (PEA). Sensitivity and specificity for paramedic initial rhythm interpretation were 176/197 (0.89, 95% CI 0.84-0.93) and 463/504 (0.92, 95% CI 0.89-0.94) respectively. No patient survived to hospital discharge when paramedics misclassified the initial rhythm.

CONCLUSIONS

Paramedics achieved high sensitivity for shock delivery to shockable rhythms, but with an 11% shock delivery rate to PEA. Misclassification of initial rhythm was associated with poor survival. Technologies that assist in rhythm identification during CPR, rapid shock delivery, and minimal hands-off time may improve outcomes.

Impediments to and impact of checklists on performance of emergency interventions in primary care: an in situ simulation-based randomized controlled trial

OBJECTIVE

Medical crises occur rather seldom in the primary care setting, but when they do, initial management impacts on morbidity and mortality. Factors that impede the performance of emergency interventions in primary care have not been studied through in-situ simulation. Checklists reportedly improve crisis management.

DESIGN

This randomized controlled trial evaluated emergency intervention performance during two scenarios (hypoglycemia-coma and anaphylaxis-cardiac arrest) simulated at primary care centers, and whether checklist access improved performance.

SETTING

Twenty-two primary care centers in Southern Sweden participated in the study.

SUBJECTS

A total of 347 personnel performed 100 simulations, 45 with and 55 without checklist access.

MAIN OUTCOME MEASURES

Time and impediments to performance of five emergency interventions in each scenario.

RESULTS

On 28 of the 37 occasions when the adrenalin auto-injector was employed, the administration technique was incorrect. In 9 of 49 scenarios, teams had trouble locating the 30% glucose solution. Median time to supplemental oxygen administration during the first scenario was 186 s compared with 96 s during the second scenario (p < 0.001). Checklist access had no significant impact on time to performance of emergency interventions, aside from shorter time to adequate glucose or glucagon administration (median times 632 s with, 756 s without checklist access; p = 0.03).

CONCLUSION

Unfamiliarity with local emergency equipment impedes the performance of emergency interventions during crises simulated in the primary care setting. Simply providing checklist access does not improve the performance of emergency interventions.KEY POINTSLittle is known about the factors that affect the performance of emergency interventions in the primary care setting.Unfamiliarity with local emergency equipment impedes the performance of emergency interventions during crises simulated in the primary care setting.Simply providing crisis checklist access does not improve the performance of emergency interventions in the primary care setting.

Comparison of two strategies for managing in-hospital cardiac arrest

In-hospital cardiac arrest (IHCA) is associated with poor outcomes. There are currently no standards for cardiac arrest teams in terms of member composition and task allocation. Here we aimed to compare two different cardiac arrest team concepts to cover IHCA management in terms of survival and neurological outcomes. This prospective study enrolled 412 patients with IHCA from general medical wards. From May 2014 to April 2016, 228 patients were directly transferred to the intensive care unit (ICU) for ongoing resuscitation. In the ICU, resuscitation was extended to advanced cardiac life support (ACLS) (Load-and-Go [LaG] group). By May 2016, a dedicated cardiac arrest team provided by the ICU provided ACLS in the ward. After return of spontaneous circulation (ROSC), the patients (n = 184) were transferred to the ICU (Stay-and-Treat [SaT] group). Overall, baseline characteristics, aetiologies, and characteristics of cardiac arrest were similar between groups. The time to endotracheal intubation was longer in the LaG group than in the SaT group (6 [5, 8] min versus 4 [2, 5] min, p = 0.001). In the LaG group, 96% of the patients were transferred to the ICU regardless of ROSC achievement. In the SaT group, 83% of patients were transferred to the ICU (p = 0.001). Survival to discharge did not differ between the LaG (33%) and the SaT (35%) groups (p = 0.758). Ultimately, 22% of patients in the LaG group versus 21% in the SaT group were discharged with good neurological outcomes (p = 0.857). In conclusion, we demonstrated that the cardiac arrest team concepts for the management of IHCA did not differ in terms of survival and neurological outcomes. However, a dedicated (intensive care) cardiac arrest team could take some load off the ICU.

Cerebral oximetry: a developing tool for monitoring cerebral oxygenation during cardiopulmonary resuscitation

Despite improvements in cardiopulmonary resuscitation (CPR), survival and neurologic recovery after cardiac arrest remain very poor because of the impact of severe ischemia and subsequent reperfusion injury. As the likelihood of survival and favorable neurologic outcome decreases with increasing severity of ischemia during CPR, developing methods to measure the magnitude of ischemia during resuscitation, particularly cerebral ischemia, is critical for improving overall outcomes. Cerebral oximetry, which measures regional cerebral oxygen saturation (rSO₂ ) by near-infrared spectroscopy, has emerged as a potentially beneficial marker of cerebral ischemia during CPR. In numerous preclinical and clinical studies, higher rSO₂ during CPR has been associated with improved cardiac arrest survival and neurologic outcome. In this narrative review, we summarize the scientific rationale and validation of cerebral oximetry across populations and pathophysiologic states, discuss the evidence surrounding its use to predict return of spontaneous circulation, rearrest, and neurologic outcome, and provide suggestions for incorporation of cerebral oximetry into CPR practice.

Are there disparities in the location of automated external defibrillators in England?

Background

Early defibrillation is an essential element of the chain of survival for out-of-hospital cardiac arrest (OHCA). Public access defibrillation (PAD) programmes aim to place automated external defibrillators (AED) in areas with high OHCA incidence, but there is sometimes a mismatch between AED density and OHCA incidence.

Objectives

This study aimed to assess whether there were any disparities in the characteristics of areas that have an AED and those that do not in England.

Methods

Details of the location of AEDs registered with English Ambulance Services were obtained from individual services or internet sources. Neighbourhood characteristics of lower layer super output areas (LSOA) were obtained from the Office for National Statistics. Comparisons were made between LSOAs with and without a registered AED.

Results

AEDs were statistically more likely to be in LSOAs with a lower residential but higher workplace population density, with people predominantly from a white ethnic background and working in higher socio-economically classified occupations (p < 0.05). There was a significant correlation between AED coverage and the LSOA Index of Multiple Deprivation (IMD) (r = 0.79, p = 0.007), with only 27.4% in the lowest IMD decile compared to about 45% in highest. AED density varied significantly across the country from 0.82/km² in the north east to 2.97/km² in London.

Conclusions

In England, AEDs were disproportionately placed in more affluent areas, with a lower residential population density. This contrasts with locations where OHCAs have previously occurred. Future PAD programmes should give preference to areas of higher deprivation and be tailored to the local community.

Awareness and attitude about basic life support among medical school students in Jeddah University, 2019: A cross-sectional study

Objectives:

To measure the level of knowledge and awareness towards basic life support (BLS) among students in preclinical years at Jeddah University (JU), and to determine their willingness to participate in BLS training in the near future.

Subjects and Methods:

A cross-sectional study was conducted among first-, second-, and third-year medical students of JU. A 27-item questionnaire measured the level of awareness and knowledge about BLS, including: 1) basic Information (seven items); 2) rescue reflex (eight items); and 3) CPR technique and process (12 items). Demographic and academic data, experience and exposure to BLS, and attitude regarding BLS (six items) were analysed as factors of adequate knowledge.

Results:

One hundred and four male students participated and 65 (62.5%) of them were in the second academic year. The correct answers varied from 10.6% to 67.3%, with eight items having <30% correct answers; and seven items showed >50% correct answers. Mean (SD) and median (P75) overall knowledge scores were 37.86 (13.92) and 37.04 (44.44) out of 100, respectively. Twenty-four (23.11%) participants attended a training course in BLS and 13 (12.5%) have ever performed BLS, either voluntarily or not voluntarily, and 18 (17.3%) felt that their current knowledge was sufficient. Knowledge level showed no statistically significant association with any of the investigated factors.

Conclusion:

There is an urgent need to integrate BLS courses to medical students to enrich their knowledge and improve resuscitation skills and ensure implementation of correct resuscitation techniques.

Cerebrospinal fluid is a significant fluid source for anoxic cerebral oedema

Cerebral edema develops after anoxic brain injury. In two models of asphyxial and asystolic cardiac arrest without resuscitation, we found that edema develops shortly after anoxia secondary to terminal depolarizations and the abnormal entry of cerebrospinal fluid (CSF). Edema severity correlated with the availability of CSF with the age-dependent increase in CSF volume worsening the severity of edema. Edema was identified primarily in brain regions bordering CSF compartments in mice and humans. The degree of ex vivo tissue swelling was predicted by an osmotic model suggesting that anoxic brain tissue possesses a high intrinsic osmotic potential. This osmotic process was temperature-dependent, proposing an additional mechanism for the beneficial effect of therapeutic hypothermia. These observations show that CSF is a primary source of edema fluid in anoxic brain. This novel insight offers a mechanistic basis for the future development of alternative strategies to prevent cerebral edema formation after cardiac arrest.

Intramuscular adrenaline for out-of-hospital cardiac arrest is associated with faster drug delivery: A feasibility study

BACKGROUND

Early adrenaline administration is associated with return of spontaneous circulation (ROSC) and survival in out-of-hospital cardiac arrest (OHCA). Animal data demonstrate a similar rate of ROSC when early intramuscular (IM) adrenaline is given compared to early intravenous (IV) adrenaline.

AIM

To evaluate the feasibility of protocolized first-dose IM adrenaline in OHCA and it's effect on time from Public Safety Access Point (PSAP) call receipt to adrenaline administration when compared to IO and IV administration.

METHODS

This is a before-and-after feasibility study of adult OHCAs in a single EMS service following adoption of a protocol for first-dose IM adrenaline. Time from PSAP call to administration and outcomes were compared to 674 historical controls (from January 1, 2013-February 8, 2021) who received at least one dose of adrenaline by IV or IO routes.

RESULTS

During the study period, first-dose IM adrenaline was administered to 99 patients (December 1, 2019-February 8, 2021). IM adrenaline was given a median of 12.2 min (95% CI 11.4-13.1 min) after the PSAP call receipt compared to 15.3 min for the IV route (95% CI 14.6-16.0 min) and 15.3 min for the IO route (95% CI 14.9-15.7 min) with a time savings of 3 min (95% CI 2-4 min). Rates of survival to hospital discharge appeared similar between groups: 10% for IM, 8% for IV and 7% for IO. However, results related to survival were underpowered for statistical comparison.

CONCLUSIONS

Within the limitations of a small sample size and before-and-after design, first-dose IM adrenaline was feasible and reduced the time to adrenaline administration.

Singapore Advanced Cardiac Life Support Guidelines 2021

Advanced cardiac life support (ACLS) emphasises the use of advanced airway management and ventilation, circulatory support and the appropriate use of drugs in resuscitation, as well as the identification of reversible causes of cardiac arrest. Extracorporeal cardiopulmonary resuscitation and organ donation, as well as special circumstances including drowning, pulmonary embolism and pregnancy are addressed. Resuscitation does not end with ACLS but must continue in post-resuscitation care. ACLS also covers the recognition and management of unstable pre-arrest tachy- and bradydysrhythmias that may deteriorate further.