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Bachista KM, Moore JC, Labarère J, Crowe RP, Emanuelson LD, Lick CJ, Debaty GP, Holley JE, Quinn RP, Scheppke KA, Pepe PE. Survival for Nonshockable Cardiac Arrests Treated With Noninvasive Circulatory Adjuncts and Head/Thorax Elevation. Crit Care Med 2024; 52:170-181. [PMID: 38240504 DOI: 10.1097/ccm.0000000000006055] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
OBJECTIVES Cardiac arrests remain a leading cause of death worldwide. Most patients have nonshockable electrocardiographic presentations (asystole/pulseless electrical activity). Despite well-performed basic and advanced cardiopulmonary resuscitation (CPR) interventions, patients with these presentations have always faced unlikely chances of survival. The primary objective was to determine if, in addition to conventional CPR (C-CPR), expeditious application of noninvasive circulation-enhancing adjuncts, and then gradual elevation of head and thorax, would be associated with higher likelihoods of survival following out-of-hospital cardiac arrest (OHCA) with nonshockable presentations. DESIGN Using a prospective observational study design (ClinicalTrials.gov NCT05588024), patient data from the national registry of emergency medical services (EMS) agencies deploying the CPR-enhancing adjuncts and automated head/thorax-up positioning (AHUP-CPR) were compared with counterpart reference control patient data derived from the two National Institutes of Health clinical trials that closely monitored quality CPR performance. Beyond unadjusted comparisons, propensity score matching and matching of time to EMS-initiated CPR (TCPR) were used to assemble cohorts with corresponding best-fit distributions of the well-established characteristics associated with OHCA outcomes. SETTING North American 9-1-1 EMS agencies. PATIENTS Adult nontraumatic OHCA patients receiving 9-1-1 responses. INTERVENTIONS In addition to C-CPR, study patients received the CPR adjuncts and AHUP (all U.S. Food and Drug Administration-cleared). MEASUREMENTS AND MAIN RESULTS The median TCPR for both AHUP-CPR and C-CPR groups was 8 minutes. Median time to AHUP initiation was 11 minutes. Combining all patients irrespective of lengthier response intervals, the collective unadjusted likelihood of AHUP-CPR group survival to hospital discharge was 7.4% (28/380) vs. 3.1% (58/1,852) for C-CPR (odds ratio [OR], 2.46 [95% CI, 1.55-3.92]) and, after propensity score matching, 7.6% (27/353) vs. 2.8% (10/353) (OR, 2.84 [95% CI, 1.35-5.96]). Faster AHUP-CPR application markedly amplified odds of survival and neurologically favorable survival. CONCLUSIONS These findings indicate that, compared with C-CPR, there are strong associations between rapid AHUP-CPR treatment and greater likelihood of patient survival, as well as survival with good neurological function, in cases of nonshockable OHCA.
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Affiliation(s)
- Kerry M Bachista
- Department of Emergency Medicine, Mayo Clinic Alix School of Health Sciences, Mayo Clinic in Florida, Jacksonville, FL
| | - Johanna C Moore
- Hennepin Healthcare, Department of Emergency Medicine, University of Minnesota School of Medicine, Minneapolis, MN
| | - José Labarère
- Quality of Care Unit, Université Grenoble Alpes, Grenoble, France
| | | | - Lauren D Emanuelson
- Division of Quality Improvement and Compliance, Advanced Medical Transport of Central Illinois, Peoria, IL
| | - Charles J Lick
- Division of Emergency Medical Services, Allina Health, Minneapolis, MN
| | - Guillaume P Debaty
- Department of Emergency Medicine, University Hospital of Grenoble Alpes, Grenoble, France
| | - Joseph E Holley
- Memphis Fire Department, City of Memphis, TN
- Division of Emergency Medical Services, State of Tennessee Department of Health, Nashville, TN
| | - Ryan P Quinn
- EMS Division, City of Edina Fire Department, Edina, MN
| | - Kenneth A Scheppke
- Florida Department of Health, Tallahassee, FL
- Office of the Medical Director, Palm Beach County Fire Rescue, West Palm Beach, FL
| | - Paul E Pepe
- Department of Emergency Medicine, Mayo Clinic Alix School of Health Sciences, Mayo Clinic in Florida, Jacksonville, FL
- Emergency Medical Services Division, St. Johns County Fire Rescue, St. Augustine, FL
- Hennepin Healthcare, Department of Emergency Medicine, University of Minnesota School of Medicine, Minneapolis, MN
- Quality of Care Unit, Université Grenoble Alpes, Grenoble, France
- Clinical and Operational Research, ESO, Austin, TX
- Division of Quality Improvement and Compliance, Advanced Medical Transport of Central Illinois, Peoria, IL
- Division of Emergency Medical Services, Allina Health, Minneapolis, MN
- Department of Emergency Medicine, University Hospital of Grenoble Alpes, Grenoble, France
- Memphis Fire Department, City of Memphis, TN
- Division of Emergency Medical Services, State of Tennessee Department of Health, Nashville, TN
- EMS Division, City of Edina Fire Department, Edina, MN
- Florida Department of Health, Tallahassee, FL
- Office of the Medical Director, Palm Beach County Fire Rescue, West Palm Beach, FL
- Department of Management, Policy and Community Health, University of Texas Health Sciences Center, Houston, School of Public Health, Houston, TX
- Dallas County Fire Rescue Department, Dallas County, Dallas, TX
- Executive Offices, Metropolitan EMS Medical Directors Global Alliance, Fort Lauderdale, FL
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Manning JE, Morrison JJ, Pepe PE. Prehospital Resuscitation: What Should It Be? Adv Surg 2023; 57:233-256. [PMID: 37536856 DOI: 10.1016/j.yasu.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Prehospital resuscitation is a dynamic field now being energized by new technologies and a shift in thinking regarding intravascular resuscitation. Growing evidence discourages use of intravenous (IV) crystalloid and colloid solutions in trauma, whereas blood products, particularly whole blood, are becoming preferred. Although randomized clinical trials validating definitive resuscitative protocols are still lacking, most preclinical and clinical indicators support this approach. In addition, emerging technologies such as external and endovascular hemorrhage control devices and extracorporeal perfusion are now being used routinely, even in the prehospital setting in many countries, generating new lines of emerging investigations for trauma specialists.
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Affiliation(s)
- James E Manning
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, 170 Manning Drive, CB# 7594, Chapel Hill, NC 27599-7594, USA.
| | - Jonathan J Morrison
- Division of Vascular and Endovascular Surgery, Mayo Clinic, 200 First Street, Rochester, MN 55905, USA
| | - Paul E Pepe
- University of Miami, Miller School of Medicine, Miami, FL, USA; Dallas County Public Safety, Emergency Medical Services, Dallas, TX, USA; Global Emergency Medical Services, Suite 307 Point of Americas One, 2100 South Ocean Lane, Fort Lauderdale, FL 33316-3823, USA
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Moore JC, Pepe PE, Scheppke KA, Lick C, Duval S, Holley J, Salverda B, Jacobs M, Nystrom P, Quinn R, Adams PJ, Hutchison M, Mason C, Martinez E, Mason S, Clift A, Antevy PM, Coyle C, Grizzard E, Garay S, Crowe RP, Lurie KG, Debaty GP, Labarère J. Head and thorax elevation during cardiopulmonary resuscitation using circulatory adjuncts is associated with improved survival. Resuscitation 2022; 179:9-17. [PMID: 35933057 DOI: 10.1016/j.resuscitation.2022.07.039] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/25/2022] [Accepted: 07/28/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND Survival after out-of-hospital cardiac arrest (OHCA) remains poor. A physiologically distinct cardiopulmonary resuscitation (CPR) strategy consisting of (1) active compression-decompression CPR and/or automated CPR, (2) an impedance threshold device, and (3) automated controlled elevation of the head and thorax (ACE) has been shown to improve neurological survival significantly versus conventional (C) CPR in animal models. This resuscitation device combination, termed ACE-CPR, is now used clinically. OBJECTIVES To assess the probability of OHCA survival to hospital discharge after ACE-CPR versus C-CPR. METHODS As part of a prospective registry study, 227 ACE-CPR OHCA patients were enrolled 04/2019-07/2020 from 6 pre-hospital systems in the United States. Individual C-CPR patient data (n = 5196) were obtained from three large published OHCA randomized controlled trials from high-performing pre-hospital systems. The primary study outcome was survival to hospital discharge. Secondary endpoints included return of spontaneous circulation (ROSC) and favorable neurological survival. Propensity-score matching with a 1:4 ratio was performed to account for imbalances in baseline characteristics. RESULTS Irrespective of initial rhythm, ACE-CPR (n = 222) was associated with higher adjusted odds ratios (OR) of survival to hospital discharge relative to C-CPR (n = 860), when initiated in <11 min (3.28, 95 % confidence interval [CI], 1.55-6.92) and < 18 min (1.88, 95 % CI, 1.03-3.44) after the emergency call, respectively. Rapid use of ACE-CPR was also associated with higher probabilities of ROSC and favorable neurological survival. CONCLUSIONS Compared with C-CPR controls, rapid initiation of ACE-CPR was associated with a higher likelihood of survival to hospital discharge after OHCA.
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Affiliation(s)
- Johanna C Moore
- Hennepin Healthcare, Minneapolis, MN, USA; University of Minnesota, Minneapolis, MN, USA; Hennepin Healthcare Research Institute, Minneapolis, MN, USA.
| | - Paul E Pepe
- Dallas County Fire Rescue, University of Texas Health Sciences Center, Houston, TX, USA
| | | | - Charles Lick
- Allina Emergency Medical Services, Minneapolis, MN, USA
| | - Sue Duval
- University of Minnesota, Minneapolis, MN, USA
| | - Joseph Holley
- University of Tennessee Health Science Center- Memphis, Memphis, TN, USA
| | - Bayert Salverda
- Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Michael Jacobs
- Alameda County Emergency Medical Services, San Leandro, CA, USA
| | - Paul Nystrom
- Hennepin Healthcare, Minneapolis, MN, USA; Edina Fire, Edina, MN, USA
| | | | | | - Mack Hutchison
- Metropolitan Emergency Medical Services, Little Rock, AR, USA
| | - Charles Mason
- Metropolitan Emergency Medical Services, Little Rock, AR, USA
| | | | | | | | | | - Charles Coyle
- Palm Beach County Fire Rescue, West Palm Beach, FL, USA
| | | | | | | | - Keith G Lurie
- Hennepin Healthcare, Minneapolis, MN, USA; University of Minnesota, Minneapolis, MN, USA; Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Guillaume P Debaty
- Department of Emergency Medicine, University Grenoble Alps/CNRS/TIMC UMR 5525, Grenoble, France
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Han MX, Yeo ANWT, Ong MEH, Smith K, Lim YL, Lin NH, Tan B, Arulanandam S, Ho AFW, Ng QX. Cardiac Arrest Occurring in High-Rise Buildings: A Scoping Review. J Clin Med 2021; 10:jcm10204684. [PMID: 34682806 PMCID: PMC8539960 DOI: 10.3390/jcm10204684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/05/2021] [Accepted: 10/08/2021] [Indexed: 11/16/2022] Open
Abstract
Out-of-hospital cardiac arrests (OHCAs) occurring in high-rise buildings are a challenge to Emergency Medical Services (EMS). Contemporary EMS guidelines lack specific recommendations for systems and practitioners regarding the approach to these patients. This scoping review aimed to map the body of literature pertaining to OHCAs in high-rise settings in order to clarify concepts and understanding and to identify knowledge gaps. Databases were searched from inception through to 6 May 2021 including OVID Medline, PubMed, Embase, CINAHL, and Scopus. Twenty-three articles were reviewed, comprising 8 manikin trials, 14 observational studies, and 1 mathematical modelling study. High-rise settings commonly have lower availability of bystanders and automatic external defibrillators (AEDs), while height constraints often lead to delays in EMS interventions and suboptimal cardiopulmonary resuscitation (CPR), scene access, and extrication. Four studies found return of spontaneous circulation (ROSC) rates to be significantly poorer, while seven studies found rates of survival-to-hospital discharge (n = 3) and neurologically favourable survival (n = 4) to be significantly lower in multistorey settings. Mechanical chest compression devices, transfer sheets, and strategic defibrillator placement were suggested as approaches to high-rise OHCA management. A shift to maximising on-scene treatment time, along with bundling novel prehospital interventions, could ameliorate some of these difficulties and improve clinical outcomes for patients.
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Affiliation(s)
- Ming Xuan Han
- Emergency Medical Services Department, Singapore Civil Defence Force, Singapore 408827, Singapore; (M.X.H.); (Y.L.L.); (B.T.); (S.A.)
| | - Amelia Natasha Wen Ting Yeo
- Engineering Product Development Pillar, Singapore University of Technology and Design, Singapore 487372, Singapore;
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore 169608, Singapore; (M.E.H.O.); (A.F.W.H.)
- SingHealth Emergency Medicine Academic Clinical Programme, Duke-National University of Singapore Medical School, Singapore 169857, Singapore
| | - Karen Smith
- Department of Community Emergency Health and Paramedic Practice, Monash University, Clayton, VIC 3800, Australia;
| | - Yu Liang Lim
- Emergency Medical Services Department, Singapore Civil Defence Force, Singapore 408827, Singapore; (M.X.H.); (Y.L.L.); (B.T.); (S.A.)
- MOH Holdings Pte Ltd., Singapore 099253, Singapore;
| | | | - Bobo Tan
- Emergency Medical Services Department, Singapore Civil Defence Force, Singapore 408827, Singapore; (M.X.H.); (Y.L.L.); (B.T.); (S.A.)
| | - Shalini Arulanandam
- Emergency Medical Services Department, Singapore Civil Defence Force, Singapore 408827, Singapore; (M.X.H.); (Y.L.L.); (B.T.); (S.A.)
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore 169608, Singapore; (M.E.H.O.); (A.F.W.H.)
- SingHealth Emergency Medicine Academic Clinical Programme, Duke-National University of Singapore Medical School, Singapore 169857, Singapore
| | - Qin Xiang Ng
- Emergency Medical Services Department, Singapore Civil Defence Force, Singapore 408827, Singapore; (M.X.H.); (Y.L.L.); (B.T.); (S.A.)
- MOH Holdings Pte Ltd., Singapore 099253, Singapore;
- Correspondence: ; Tel.: +65-6794-5502
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5
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McVaney KE, Pepe PE, Maloney LM, Bronsky E, Crowe RP, Augustine JJ, Gilliam SO, Asaeda GH, Eckstein M, Mattu A, Fumagalli R, Aufderheide TP, Osterholm MT. The relationship of large city out-of-hospital cardiac arrests and the prevalence of COVID-19. EClinicalMedicine 2021; 34:100815. [PMID: 33997730 PMCID: PMC8102707 DOI: 10.1016/j.eclinm.2021.100815] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/04/2021] [Accepted: 03/15/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Though variable, many major metropolitan cities reported profound and unprecedented increases in out-of-hospital cardiac arrest (OHCA) in early 2020. This study examined the relative magnitude of those increases and their relationship to COVID-19 prevalence. METHODS EMS (9-1-1 system) medical directors for 50 of the largest U.S. cities agreed to provide the aggregate, de-identified, pre-existing monthly tallies of OHCA among adults (age >18 years) occurring between January and June 2020 within their respective jurisdictions. Identical comparison data were also provided for corresponding time periods in 2018 and 2019. Equivalent data were obtained from the largest cities in Italy, United Kingdom and France, as well as Perth, Australia and Auckland, New Zealand. FINDINGS Significant OHCA escalations generally paralleled local prevalence of COVID-19. During April, most U.S. cities (34/50) had >20% increases in OHCA versus 2018-2019 which reflected high local COVID-19 prevalence. Thirteen observed 1·5-fold increases in OHCA and three COVID-19 epicenters had >100% increases (2·5-fold in New York City). Conversely, cities with lesser COVID-19 impact observed unchanged (or even diminished) OHCA numbers. Altogether (n = 50), on average, OHCA cases/city rose 59% during April (p = 0·03). By June, however, after mitigating COVID-19 spread, cities with the highest OHCA escalations returned to (or approached) pre-COVID OHCA numbers while cities minimally affected by COVID-19 during April (and not experiencing OHCA increases), then had marked OHCA escalations when COVID-19 began to surge locally. European, Australian, and New Zealand cities mirrored the U.S. experience. INTERPRETATION Most metropolitan cities experienced profound escalations of OHCA generally paralleling local prevalence of COVID-19. Most of these patients were pronounced dead without COVID-19 testing. FUNDING No funding was involved. Cities provided de-identified aggregate data collected routinely for standard quality assurance functions.
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Affiliation(s)
- Kevin E. McVaney
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver, CO, USA
- Denver Health and Hospital Authority, Denver, CO, USA
| | - Paul E. Pepe
- Dallas County Emergency Medical Services and County Public Safety Agencies, Dallas, TX, USA
- Broward Sheriff's Office, Ft. Lauderdale, FL, USA
- Palm Beach County Fire Rescue, West Palm Beach, FL, USA
- Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Sciences Center, Houston, TX, USA
- Metropolitan EMS Medical Directors Global Alliance, Dallas, TX, USA
- Corresponding author.
| | - Lauren M. Maloney
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | | | | | | | - Sheaffer O. Gilliam
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver, CO, USA
- Denver Health and Hospital Authority, Denver, CO, USA
| | | | - Marc Eckstein
- Los Angeles Fire Department, Los Angeles, CA, USA
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Amal Mattu
- University of Maryland, Baltimore, MD, USA
| | - Roberto Fumagalli
- Niguarda Hospital, University of Milano-Bicocca, Milan, Italy
- Agenzia Regionale Emergenza Urgenza (AREU), Lombardy, Italy
| | - Tom P. Aufderheide
- Resuscitation Research Center, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael T. Osterholm
- University of Minnesota Center for Infectious Disease Research and Policy, Minneapolis, MN, USA
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6
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van Schuppen H, Boomars R, Kooij FO, den Tex P, Koster RW, Hollmann MW. Optimizing airway management and ventilation during prehospital advanced life support in out-of-hospital cardiac arrest: A narrative review. Best Pract Res Clin Anaesthesiol 2020; 35:67-82. [PMID: 33742579 DOI: 10.1016/j.bpa.2020.11.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/03/2020] [Accepted: 11/06/2020] [Indexed: 12/20/2022]
Abstract
Airway management and ventilation are essential components of cardiopulmonary resuscitation to achieve oxygen delivery in order to prevent hypoxic injury and increase the chance of survival. Weighing the relative benefits and downsides, the best approach is a staged strategy; start with a focus on high-quality chest compressions and defibrillation, then optimize mask ventilation while preparing for advanced airway management with a supraglottic airway device. Endotracheal intubation can still be indicated, but has the largest downsides of all advanced airway techniques. Whichever stage of airway management, ventilation and chest compression quality should be closely monitored. Capnography has many advantages and should be used routinely. Optimizing ventilation strategies, harmonizing ventilation with mechanical chest compression devices, and implementation in complex and stressful environments are challenges we need to face through collaborative innovation, research, and implementation.
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Affiliation(s)
- Hans van Schuppen
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Meibergdreef 9, Amsterdam, the Netherlands.
| | - René Boomars
- Regional Ambulance Service Utrecht (RAVU), Jan van Eijcklaan 6, Bilthoven, the Netherlands
| | - Fabian O Kooij
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, Helicopter Mobile Medical Team (MMT), De Boelelaan 1117, Amsterdam, the Netherlands
| | - Paul den Tex
- University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Rudolph W Koster
- Amsterdam UMC, University of Amsterdam, Amsterdam Resuscitation Studies (ARREST), Meibergdreef 9, Amsterdam, the Netherlands
| | - Markus W Hollmann
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Meibergdreef 9, Amsterdam, the Netherlands
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