Presentation, management, and outcome of out of hospital cardiopulmonary arrest: comparison by underlying aetiology

Sudden death in young South European population: a cross-sectional study of postmortem cases

To describe the annual incidence and the leading causes of sudden non-cardiac and cardiac death (SCD) in children and young adult Portuguese population. We retrospectively reviewed autopsy of sudden unexpected deaths reports from the Portuguese National Institute of Legal Medicine and Forensic Sciences' database, between 2012 and 2016, for the central region of Portugal, Azores and Madeira (ages 1-40: 26% of the total population). During a 5-year period, 159 SD were identified, corresponding to an annual incidence of 2,4 (95%confidence interval, 1,5-3,6) per 100.000 people-years. Victims had a mean age of 32 ± 7 years-old, and 72,3% were male. There were 70,4% cardiac, 16,4% respiratory and 7,5% neurologic causes of SD. The most frequent cardiac anatomopathological diagnosis was atherosclerotic coronary artery disease (CAD) (33,0%). There were 15,2% victims with left ventricular hypertrophy, with a diagnosis of hypertrophic cardiomyopathy only possible in 2,7%. The prevalence of cardiac pathological findings of uncertain significance was 30,4%. In conclusion, the annual incidence of SD was low. Atherosclerotic CAD was diagnosed in 33,0% victims, suggesting the need to intensify primary prevention measures in the young. The high prevalence of pathological findings of uncertain significance emphasizes the importance of molecular autopsy and screening of first-degree relatives.

Predicting neurological outcome after cardiac arrest by combining computational parameters extracted from standard and deviant responses from auditory evoked potentials

Background

Despite multimodal assessment (clinical examination, biology, brain MRI, electroencephalography, somatosensory evoked potentials, mismatch negativity at auditory evoked potentials), coma prognostic evaluation remains challenging.

Methods

We present here a method to predict the return to consciousness and good neurological outcome based on classification of auditory evoked potentials obtained during an oddball paradigm. Data from event-related potentials (ERPs) were recorded noninvasively using four surface electroencephalography (EEG) electrodes in a cohort of 29 post-cardiac arrest comatose patients (between day 3 and day 6 following admission). We extracted retrospectively several EEG features (standard deviation and similarity for standard auditory stimulations and number of extrema and oscillations for deviant auditory stimulations) from the time responses in a window of few hundreds of milliseconds. The responses to the standard and the deviant auditory stimulations were thus considered independently. By combining these features, based on machine learning, we built a two-dimensional map to evaluate possible group clustering.

Results

Analysis in two-dimensions of the present data revealed two separated clusters of patients with good versus bad neurological outcome. When favoring the highest specificity of our mathematical algorithms (0.91), we found a sensitivity of 0.83 and an accuracy of 0.90, maintained when calculation was performed using data from only one central electrode. Using Gaussian, K-neighborhood and SVM classifiers, we could predict the neurological outcome of post-anoxic comatose patients, the validity of the method being tested by a cross-validation procedure. Moreover, the same results were obtained with one single electrode (Cz).

Conclusion

statistics of standard and deviant responses considered separately provide complementary and confirmatory predictions of the outcome of anoxic comatose patients, better assessed when combining these features on a two-dimensional statistical map. The benefit of this method compared to classical EEG and ERP predictors should be tested in a large prospective cohort. If validated, this method could provide an alternative tool to intensivists, to better evaluate neurological outcome and improve patient management, without neurophysiologist assistance.

The Dance of Death: Cardiac Arrest, Mitral and Tricuspid Valve Prolapses, and Biannular Disjunctions

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Valvular heart disease is an uncommon but important cause of cardiac arrests.

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TAD is also often seen with MAD.

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High-risk features on echo include bileaflet MVP, MAD, and systolic curling.

Computed-Tomography as First-line Diagnostic Procedure in Patients With Out-of-Hospital Cardiac Arrest

Background

Mortality after out-of-hospital cardiac arrest (OHCA) with return of spontaneous circulation (ROSC) remains high despite numerous efforts to improve outcome. For patients with suspected coronary cause of arrest, coronary angiography is crucial. However, there are other causes and potentially life-threatening injuries related to cardiopulmonary resuscitation (CPR), which can be detected by routine computed tomography (CT).

Materials and Methods

At Hannover Medical School, rapid coronary angiography and CT are performed in successfully resuscitated OHCA patients as a standard of care prior to admission to intensive care. We analyzed all patients who received CT following OHCA with ROSC over a three-year period.

Results

There were 225 consecutive patients with return of spontaneous circulation following out-of-hospital cardiac arrest. Mean age was 64 ± 13 years, 75% were male. Of them, 174 (77%) had witnessed arrest, 145 (64%) received bystander CPR, and 123 (55%) had a primary shockable rhythm. Mean time to ROSC was 24 ± 20 min. There were no significant differences in CT pathologies in patients with or without ST-segment elevations in the initial ECG. Critical CT findings qualifying as a potential cause for cardiac arrest were intracranial bleeding (N = 6), aortic dissection (N = 5), pulmonary embolism (N = 17), pericardial tamponade (N = 3), and tension pneumothorax (N = 11). Other pathologies were regarded as consequences of CPR and relevant for further treatment: aspiration (N = 62), rib fractures (N = 161), sternal fractures (N = 50), spinal fractures (N = 11), hepatic bleeding (N = 12), and intra-abdominal air (N = 3).

Conclusion

Early CT fallowing OHCA uncovers a high number of causes and consequences of OHCA and CPR. Those are relevant for post-arrest care and are frequently life-threatening, suggesting that CT can contribute to improving prognosis following OHCA.

Cardiac Arrest during Interventional Radiology Procedures: A 7-Year Single-Center Retrospective Study

An intervention radiology (IR) unit collected cardiac arrest data between January 2014 and July 2020. Of 344,600 procedures, there were 23 cardiac arrest patients (0.0067%). The patient data was compared to a representative sample (N = 400) of the IR unit to evaluate the incidence and factors associated with cardiac arrest during IR procedures. Age, procedure urgency, American Society of Anesthesiologists (ASA) physical status, procedure type, and underlying medical conditions were identified as valuable predictors of a patient’s susceptibility to cardiac arrest during an IR procedure. The proportion of pediatrics was higher for cardiac arrest patients, and most required immediate procedures. The distribution of high ASA physical status (III or greater) was skewed compared to that of the non-cardiac arrest patients. Vascular procedures were associated with higher risk than non-vascular procedures. The patients who underwent non-transarterial chemoembolization arterial procedures demonstrated relative risks of 4.4 and 11.7 for cardiac arrest compared to biliary procedures and percutaneous catheter drainage, respectively. In addition, the six patients (26.1%) who died before discharge all underwent vascular procedures. Relative to patients with acute kidney injury, patients with malignancy, hypertension, and diabetes mellitus demonstrated relative risks of 3.3, 3.4, and 4.8 for cardiac arrest, respectively.

Machine Learning Models for Survival and Neurological Outcome Prediction of Out-of-Hospital Cardiac Arrest Patients

Background

Out-of-hospital cardiac arrest (OHCA) is a major health problem worldwide, and neurologic injury remains the leading cause of morbidity and mortality among survivors of OHCA. The purpose of this study was to investigate whether a machine learning algorithm could detect complex dependencies between clinical variables in emergency departments in OHCA survivors and perform reliable predictions of favorable neurologic outcomes.

Methods

This study included adults (≥18 years of age) with a sustained return of spontaneous circulation after successful resuscitation from OHCA between 1 January 2004 and 31 December 2014. We applied three machine learning algorithms, including logistic regression (LR), support vector machine (SVM), and extreme gradient boosting (XGB). The primary outcome was a favorable neurological outcome at hospital discharge, defined as a Glasgow-Pittsburgh cerebral performance category of 1 to 2. The secondary outcome was a 30-day survival rate and survival-to-discharge rate.

Results

The final analysis included 1071 participants from the study period. For neurologic outcome prediction, the area under the receiver operating curve (AUC) was 0.819, 0.771, and 0.956 in LR, SVM, and XGB, respectively. The sensitivity and specificity were 0.875 and 0.751 in LR, 0.687 and 0.793 in SVM, and 0.875 and 0.904 in XGB. The AUC was 0.766 and 0.732 in LR, 0.749 and 0.725 in SVM, and 0.866 and 0.831 in XGB, for survival-to-discharge and 30-day survival, respectively.

Conclusions

Prognostic models trained with ML technique showed appropriate calibration and high discrimination for survival and neurologic outcome of OHCA without using prehospital data, with XGB exhibiting the best performance.

Different forms of bystander cardiopulmonary resuscitation in out-of-hospital cardiac arrest

Out-of-hospital cardiac arrest (OHCA) is a major cause of death in the Western world with an estimated number of 275 000 treated with resuscitation attempts by the Emergency Medical Services (EMS) in Europe each year. Overall survival rates remain low, and most studies indicate that around 1 out 10 will survive to 30 days. Amongst the strongest factors associated with survival in OHCA is first recorded rhythm amendable to defibrillation, early defibrillation and prompt initiation of cardiopulmonary resuscitation (CPR). Overall, CPR started prior to EMS arrival has repeatedly been shown to be associated with survival rates 2-3 times higher compared with no such initiation. The primary goal of CPR is to generate sufficient blood flow to vital organs, mainly the brain and heart, until restoration of spontaneous circulation can be achieved. Barriers to the initiation of CPR by bystanders in OHCA include fear of being incapable, causing harm, and transmission of infectious diseases. Partly due to these barriers, and low rates of CPR, the concept of CPR with compression only was proposed as a simpler form of resuscitation with the aim to be more widely accepted by the public in the 1990s. But how reliable is the evidence supporting this simpler form of CPR, and are the outcomes after CO-CPR comparable to standard CPR?

Feasibility and beneficial effects of an early goal directed therapy after cardiac arrest: evaluation by conductance method

Although beneficial effects of an early goal directed therapy (EGDT) after cardiac arrest and successful return of spontaneous circulation (ROSC) have been described, clinical implementation in this period seems rather difficult. The aim of the present study was to investigate the feasibility and the impact of EGDT on myocardial damage and function after cardiac resuscitation. A translational pig model which has been carefully adapted to the clinical setting was employed. After 8 min of cardiac arrest and successful ROSC, pigs were randomized to receive either EGDT (EGDT group) or therapy by random computer-controlled hemodynamic thresholds (noEGDT group). Therapeutic algorithms included blood gas analysis, conductance catheter method, thermodilution cardiac output and transesophageal echocardiography. Twenty-one animals achieved successful ROSC of which 13 pigs survived the whole experimental period and could be included into final analysis. cTnT and LDH concentrations were lower in the EGDT group without reaching statistical significance. Comparison of lactate concentrations between 1 and 8 h after ROSC exhibited a decrease to nearly baseline levels within the EGDT group (1 h vs 8 h: 7.9 vs. 1.7 mmol/l, P < 0.01), while in the noEGDT group lactate concentrations did not significantly decrease. The EGDT group revealed a higher initial need for fluids (P < 0.05) and less epinephrine administration (P < 0.05) post ROSC. Conductance method determined significant higher values for preload recruitable stroke work, ejection fraction and maximum rate of pressure change in the ventricle for the EGDT group. EGDT after cardiac arrest is associated with a significant decrease of lactate levels to nearly baseline and is able to improve systolic myocardial function. Although the results of our study suggest that implementation of an EGDT algorithm for post cardiac arrest care seems feasible, the impact and implementation of EGDT algorithms after cardiac arrest need to be further investigated.

Post resuscitation electrocardiogram for coronary angiography indication after out-of-hospital cardiac arrest

BACKGROUND

Coronary angiography is the standard of care after Out-of-Hospital Cardiac Arrest (OHCA), but its benefit for patients without persistent ST-segment elevation (STE) remains controversial.

METHODS

All patients admitted for coronary angiography after a resuscitated OHCA were consecutively included in this prospective study. Three patient groups were defined according to post-resuscitation ECG: STE or new left bundle branch block (LBBB) (group 1); other ST/T repolarization disorders (group 2) and no repolarisation disorders (group 3). The proportion and predictive factors of an acute coronary lesion, defined by acute coronary occlusion or thrombotic lesion or lesion associated with flow impairment, were evaluated according to different groups as well as thirty-day mortality.

RESULTS

Among 129 consecutive patients: 62 (48.1%), 30 (23.3%) and 30 (23.3%) patients were included in groups 1, 2 and 3 respectively. An acute coronary lesion was observed in 43% (n = 55) of patients, mainly in group 1 (n = 44, 70.9%). Initial coronary TIMI 0/1 flow was more frequently observed in group 1 than in group 2 (n = 25, 40.3% vs n = 1, 3.3%) and never in group 3. Chest pain and STE or new LBBB were independently associated with an acute coronary lesion (adj. OR = 7.14 [1.85-25.00]; p = 0.004 and adj. OR = 11.10 [3.70-33.33]; p < 0.001 respectively). In absence of any repolarization disorders, acute coronary lesion or occlusion were excluded with negative predictive values of 93.3% and 100% respectively. The one-month survival rate was 38.8% and was better in patients among the group 1 compared to those from the 2 other groups (n = 28, 45.2% vs n = 21, 35%, respectively; p = 0.014).

CONCLUSION

Considering the high negative predictive value of post-resuscitation ECG to exclude acute coronary lesion and occlusion after OHCA, a delayed coronary angiography appears a reliable alternative for patients without repolarization disorders.

Hydrogen Inhalation is Superior to Mild Hypothermia for Improving Neurological Outcome and Survival in a Cardiac Arrest Model of Spontaneously Hypertensive Rat

BACKGROUND

Postcardiac arrest syndrome is the consequence of whole-body ischemia-reperfusion events that lead to multiple organ failure and eventually to death. Recent animal studies demonstrated that inhalation of hydrogen greatly mitigates postresuscitation myocardial dysfunction and brain injury. However, the influence of underlying heart disease on the efficacy of hydrogen is still unknown. In the present study, we investigated the effects of hydrogen inhalation on neurological outcome and survival in a cardiac arrest model of spontaneously hypertensive rat (SHR).

METHODS

Cardiopulmonary resuscitation was initiated after 4 min of untreated ventricular fibrillation in 40 SHRs. Immediately after successful resuscitation, animals were randomized to be ventilated with 98% oxygen and 2% nitrogen under normothermia (Ctrl), 2% nitrogen under hypothermia (TH), 2% hydrogen under normothermia (H2), or 2% hydrogen under hypothermia (H2+TH) for 2 h. Hypothermia was maintained at 33°C for 2 h. Animals were observed up to 96 h for assessment of survival and neurologic recovery.

RESULTS

No statistical differences in baseline measurements were observed among groups and all the animals were successfully resuscitated. Compared with Ctrl, serum cardiac troponin T measured at 5 h and myocardial damage score measured at 96 h after resuscitation were markedly reduced in H2, TH, and H2+TH groups. Compared with Ctrl and TH, astroglial protein S100 beta measured during the earlier postresuscitation period, and neurological deficit score and neuronal damage score measured at 96 h were considerably lower in both H2 and H2+TH groups. Ninety-six hours survival rates were significantly higher in the H2 (80.0%) and H2+TH (90.0%) groups than TH (30.0%) and to Ctrl (30.0%).

CONCLUSIONS

Hydrogen inhaling was superior to mild hypothermia for improving neurological outcome and survival in cardiac arrest and resuscitation model of systemic hypertension rats.

Role of coronary angiography in patients with a non-diagnostic electrocardiogram following out of hospital cardiac arrest: Rationale and design of the multicentre randomized controlled COUPE trial

BACKGROUND

Coronary artery disease (CAD) is a major cause of out-of-hospital cardiac arrest (OHCA). The role of emergency coronary angiography (CAG) and percutaneous coronary intervention (PCI) following cardiac arrest in patients without ST-segment elevation myocardial infarction (STEMI) remains unclear.

AIMS

We aim to assess whether emergency CAG and PCI, when indicated, will improve survival with good neurological outcome in post-OHCA patients without STEMI who remain comatose.

METHODS

COUPE is a prospective, multicentre and randomized controlled clinical trial. A total of 166 survivors of OHCA without STEMI will be included. Potentially non-cardiac aetiology of the cardiac arrest will be ruled out prior to randomization. Randomization will be 1:1 for emergency (within 2 h) or deferred (performed before discharge) CAG. Both groups will receive routine care in the intensive cardiac care unit, including therapeutic hypothermia. The primary efficacy endpoint is a composite of in-hospital survival free of severe dependence, which will be evaluated using the Cerebral Performance Category Scale. The safety endpoint will be a composite of major adverse cardiac events including death, reinfarction, bleeding and ventricular arrhythmias.

CONCLUSIONS

This study will assess the efficacy of an emergency CAG versus a deferred one in OHCA patients without STEMI in terms of survival and neurological impairment.

Resuscitation room management of critically ill nontraumatic patients in a German emergency department (OBSERvE-study)

BACKGROUND

Management of critically ill nontrauma (CINT) patients in the resuscitation room (RR) of the emergency department (ED) is very challenging. Detailed data describing the characteristics and management of this population are lacking. This observational study describes the epidemiology, management and outcome in CINT ED patients in the RR.

PATIENTS AND METHODS

From September 2014 to August 2015, data were collected prospectively on adult CINT patients admitted to the RR of a single German University ED. Patient characteristics, out-of-hospital/in-hospital treatment, admission-related diseases, time intervals for diagnostics and interventions plus outcome were recorded using a self-developed questionnaire.

RESULTS

A total of 34 303 patients were admitted to the ED; of these 21 074 patients were admitted for nontrauma emergencies and because of acute life-threatening problems. Five hundred and thirty-two CINT patients were admitted to the RR (median age: 71 years, 58.3% men). The main problems on admission were obstructed airway (3.8%, A), respiratory insufficiency (26.5%, B), shock (35.5%, C), unconsciousness (33.3%, D) or other (0.9%, E). Out-of-hospital and in-hospital management included intravenous access (96.8 vs. 76.9%), 12-lead ECG (50.0 vs. 86.5%), invasive airway management (30.1 vs. 27.1%), noninvasive and invasive ventilation (7.0 vs. 16.4% and 30.1 vs. 57.2%), catecholamines (16.2 vs. 24.1%), arterial line (0.2 vs. 58.1%) and cardiopulmonary resuscitation (18.4 vs. 12.2%). The mean length of stay was 34±24 min. At day 30, all-cause mortality was 34.2% (patients with and without cardiopulmonary resuscitation: 72.7 vs. 24.0%, P<0.001).

CONCLUSION

Observation of critically ill patients in the resuscitation room of the Emergency Department shows the challenge of care for CINT patients in the ED. With high levels of mortality, there is an urgent need for structured ED management guidelines.

Protective effects of nicorandil against cerebral injury in a swine cardiac arrest model

The present study investigated the effects of nicorandil on cerebral injury following cardiopulmonary resuscitation (CPR) in a swine model of cardiac arrest. CPR was performed on swine following 4 min induced ventricular fibrillation. Surviving animals were randomly divided into 3 groups: A nicorandil group (n=8), a control group (n=8) and a sham group (n=4). The sham group underwent the same surgical procedure to imitate cardiac arrest, but ventricular fibrillation was not induced. When the earliest observable return of spontaneous circulation (ROSC) was detected, the nicorandil and control groups received injections of nicorandil and saline, respectively. Swine serum was collected at baseline and 5 min, 0.5, 3 and 6 h following ROSC. Serum levels of neuron-specific enolase (NSE), S100β, tumor necrosis factor α (TNF-α) and interleukin 6 (IL-6) were measured using ELISA. Animals were euthanized and brain tissue samples were collected and assessed using light and electron microscopy 6 h following ROSC. The expression of aquaporin-4 (AQP-4) in the brain tissue was measured using western blotting. Malondialdehyde (MDA) and glutathione (GSH) levels in the brain tissue were determined using thiobarbituric acid and thiobenzoic acid colorimetric methods, respectively. Serum NSE and S100β were significantly higher in the nicorandil and control groups following CPR, compared with baseline (P<0.05). Additionally, NSE and S100β levels were significantly lower in the nicorandil group compared with the control (P<0.05). Pathological examinations and electron microscopy indicated that nicorandil reduced brain tissue damage. TNF-α and IL-6 levels were significantly decreased in the nicorandil group compared with the control group (P<0.05). Furthermore, AQP-4 expression in brain tissue 6 h following ROSC was significantly lower in the nicorandil group compared with the control group (P<0.05). MDA and GSH levels in swine brain tissue decreased and increased, respectively, in the nicorandil group compared with the control group (P<0.05). The results of the present study demonstrate that nicorandil exerts a protective effect against brain injury following cardiac arrest by reducing oxidative damage, inflammatory responses and brain edema post-ROSC.

Poisoning-induced Out-of-Hospital Cardiac Arrest and Outcomes according to Poison Agent

It is unclear whether specific agent groups are associated with outcomes in cases of poisoning-induced out-of-hospital cardiac arrest (P-OHCA). The study population comprised cases of confirmed P-OHCA drawn from the national out-of-hospital cardiac arrest (OHCA) registry (2008-2013). Exposures were categorized into five groups according to the International Classification of Disease, 10th version: group 1, prescribed drugs; group 2, vapors and gases; group 3, pesticides; group 4, alcohol and organic solvents; and group 5, other poisons. The outcome was survival to discharge and good neurological recovery. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated to test the association between specific groups and outcomes. A total of 2,083 patients were analyzed; group 1 (10.3%), group 2 (23.6%), group 3 (52.9%), group 4 (1.4%), and group 5 (13.2%). The survival to discharge and good neurological recovery rates were 3.3%/1.3% for all patients, 10.3%/5.6% (group 1), 6.9%/3.4% (group 2), 2.4%/0.4% (group 3), 2.2%/1.0% (group 4), and 3.3%/2.4% (group 5) (all P < 0.001). The aORs (95% CIs) of groups 2-5 compared with group 1 for survival to discharge were 0.47 (0.09-2.51), 0.34 (0.17-0.68), 0.33 (0.14-0.77), and 0.31 (0.13-0.77), respectively. The odds ratios (95% CIs) for good neurological recovery were significant only in group 1, the pesticides group (0.07 [0.02-0.26]) and were not significant in the other groups. P-OHCA outcomes differed significantly among the poisoning agent groups. The pesticides group showed the worst outcomes, followed by the group of vapors or gases.

Effects of extracorporeal cardiopulmonary resuscitation on neurological and cardiac outcome after ischaemic refractory cardiac arrest

BACKGROUND

Extracorporeal cardiopulmonary resuscitation is increasingly recognised as a rescue therapy for refractory cardiac arrest, nevertheless data are scanty about its effects on neurologic and cardiac outcome. The aim of this study is to compare clinical outcome in patients with cardiac arrest of ischaemic origin (i.e. critical coronary plaque during angiography) and return of spontaneous circulation during conventional cardiopulmonary resuscitation vs refractory cardiac arrest patients needing extracorporeal cardiopulmonary resuscitation. Moreover, we tried to identify predictors of survival after successful cardiopulmonary resuscitation.

METHODS

We enrolled 148 patients with ischaemic cardiac arrest admitted to our hospital from 2011-2015. We compared clinical characteristics, cardiac arrest features, neurological and echocardiographic data obtained after return of spontaneous circulation (within 24 h, 15 days and six months).

RESULTS

Patients in the extracorporeal cardiopulmonary resuscitation group ( n=63, 43%) were younger (59±9 vs 63±8 year-old, p=0.02) with lower incidence of atherosclerosis risk factors than those with conventional cardiopulmonary resuscitation. In the extracorporeal cardiopulmonary resuscitation group, left ventricular ejection fraction was lower than conventional cardiopulmonary resuscitation at early echocardiography (19±16% vs 37±11 p<0.01). Survivors in both groups showed similar left ventricular ejection fraction 15 days and 4-6 months after cardiac arrest (46±8% vs 49±10, 47±11% vs 45±13%, p not significant for both), despite a major extent and duration of cardiac ischaemia in extracorporeal cardiopulmonary resuscitation patients. At multivariate analysis, the total cardiac arrest time was the only independent predictor of survival.

CONCLUSIONS

Extracorporeal cardiopulmonary resuscitation patients are younger and have less comorbidities than conventional cardiopulmonary resuscitation, but they have worse survival and lower early left ventricular ejection fraction. Survivors after extracorporeal cardiopulmonary resuscitation have a neurological outcome and recovery of heart function comparable to subjects with return of spontaneous circulation. Total cardiac arrest time is the only predictor of survival after cardiopulmonary resuscitation in both groups.

Variation in emergency percutaneous coronary intervention in ventilated patients in the UK: Insights from a national database

AIMS

Pre-procedural ventilation is a marker of high risk in PCI patients. Causes include out-of-hospital cardiac arrest (OHCA) and cardiogenic shock. OHCA occurs in approximately 60,000 patients in the UK per annum. No consensus exists regarding the need/timing of coronary angiography ± revascularization without ST elevation. The aim was to describe the national variation in the rate of emergency PCI in ventilated patients.

METHODS AND RESULTS

Using the UK national database for PCI in 2013, we identified all procedures performed as 'emergency' or 'salvage' for whom ventilation had been initiated before the PCI. Of the 92,589 patients who underwent PCI, 1342 (5.5%) fulfilled those criteria. There was wide variation in practice. There was no demonstrable relationship between the number of emergency PCI patients with pre-procedure ventilation per annum and (i) total number of PPCIs in a unit (r=-0.186), and (ii) availability of 24h PCI, (iii) on-site surgical cover.

CONCLUSION

We demonstrated a wide variation in practice across the UK in rates of pre-procedural ventilation in emergency PCI. The majority of individuals will have suffered an OHCA. In the absence of a plausible explanation for this discrepant practice, it is possible that (a) some patients presenting with OHCA that may benefit from revascularization are being denied treatment and (b) procedures may be being undertaken that are futile. Further prospective data are needed to aid in production of guidelines aiming at standardized care in OHCA.

Safety and feasibility of the RhinoChill immediate transnasal evaporative cooling device during out-of-hospital cardiopulmonary resuscitation: A single-center, observational study

We investigated feasibility and safety of the RhinoChill (RC) transnasal cooling system initiated before achieving a protected airway during cardiopulmonary resuscitation (CPR) in a prehospital setting.In out-of-hospital cardiac arrest (OHCA), transnasal evaporative cooling was initiated during CPR, before a protected airway was established and continued until either the patient was declared dead, standard institutional systemic cooling methods were implemented or cooling supply was empty. Patients were monitored throughout the hypothermia period until either death or hospital discharge. Clinical assessments and relevant adverse events (AEs) were documented over this period of time.In total 21 patients were included. Four were excluded due to user errors or meeting exclusion criteria. Finally, 17 patients (f = 6; mean age 65.5 years, CI95%: 57.7-73.4) were analyzed. Device-related AEs, like epistaxis or nose whitening, occurred in 2 patients. They were mild and had no consequence on the patient's outcome. According to the field reports of the emergency medical services (EMS) personnel, no severe technical problems occurred by using the RC device that led to a delay or the impairment of quality of the CPR.Early application of the RC device, during OHCA is feasible, safe, easy to handle, and does not delay or hinder CPR, or establishment of a secure intubation. For efficacy and further safety data additional studies will be needed.

Predictors of inhospital mortality following out-of-hospital cardiac arrest: Insights from a single-centre consecutive case series

PURPOSE OF THE STUDY

Out-of-hospital cardiac arrest (OHCA) has a poor prognosis despite bystander resuscitation and rapid transfer to hospital. Optimal management of patients after arrival to hospital continues to be contentious, especially the timing of emergency coronary angiography±revascularisation. Robust predictors of inhospital outcome would be of clinical value for initial decision-making.

STUDY DESIGN

A retrospective analysis of consecutive patients who presented to a university hospital following OHCA over a 70-month period (2008-2013). Patients were identified from the emergency department electronic patient registration and coding system. For those patients who underwent emergency percutaneous coronary intervention, details were crosschecked with national databases.

RESULTS

We identified 350 consecutive patients who were brought to our hospital following OHCA. Return of spontaneous circulation (ROSC) for >20 min was achieved either before arrival or inhospital in 196 individuals. From the 350 subjects, 114 (32.6%) survived to hospital discharge. When sustained ROSC was achieved, either before or inhospital, survival to discharge was 58.2% (114 of 196). Non-shockable rhythm, absence of bystander cardiopulmonary resuscitation, 'downtime' >15 min and initial pH ≤7.11 were predictors of inhospital death. 12% patients who underwent angiography in the presence of ST elevation had no acute coronary occlusion. 21% patients with acute coronary occlusion at angiography did not have ST elevation.

CONCLUSIONS

In our cohort of patients with OHCA, those who achieve ROSC had a survival-to-discharge rate of 58.2%. We identified four predictors of inhospital death, which are readily available at the time of patient presentation. Reliance on ST elevation to decide about coronary angiography and revascularisation may be flawed. More data are required.

Sudden cardiac arrest in people with epilepsy in the community: Circumstances and risk factors

OBJECTIVE

To ascertain whether characteristics of ventricular tachycardia/fibrillation (VT/VF) differed between people with epilepsy and those without and which individuals with epilepsy were at highest risk.

METHODS

We ascertained 18 people with active epilepsy identified in a community-based registry of sudden cardiac arrest (SCA) with ECG-confirmed VT/VF (cases). We compared them with 470 individuals with VT/VF without epilepsy (VT/VF controls) and 54 individuals with epilepsy without VT/VF (epilepsy controls). Data on comorbidity, epilepsy severity, and medication use were collected and entered into (conditional) logistic regression models to identify determinants of VT/VF in epilepsy.

RESULTS

In most cases, there was an obvious (10/18) or presumed cardiovascular cause (5/18) in view of preexisting heart disease. In 2 of the 3 remaining events, near-sudden unexpected death in epilepsy (SUDEP) was established after successful resuscitation. Cases had a higher prevalence of congenital/inherited heart disease (17% vs 1%, p = 0.002), and experienced VT/VF at younger age (57 vs 64 years, p = 0.023) than VT/VF controls. VT/VF in cases occurred more frequently at/near home (89% vs 58%, p = 0.009), and was less frequently witnessed (72% vs 89%, p = 0.048) than in VT/VF controls. Cases more frequently had clinically relevant heart disease (50% vs 15%, p = 0.005) and intellectual disability (28% vs 1%, p < 0.001) than epilepsy controls.

CONCLUSION

Cardiovascular disease rather than epilepsy characteristics is the main determinant of VT/VF in people with epilepsy in the community. SCA and SUDEP are partially overlapping disease entities.

Hospital costs of out-of-hospital cardiac arrest patients treated in intensive care; a single centre evaluation using the national tariff-based system

OBJECTIVES

There is a scarcity of literature reporting hospital costs for treating out of hospital cardiac arrest (OOHCA) survivors, especially within the UK. This is essential for assessment of cost-effectiveness of interventions necessary to allow just allocation of resources within the National Health Service. We set out primarily to calculate costs stratified against hospital survival and neurological outcomes. Secondarily, we estimated cost effectiveness based on estimates of survival and utility from previous studies to calculate costs per quality adjusted life year (QALY).

SETTING

We performed a single centre (London) retrospective review of in-hospital costs of patients admitted to the intensive care unit (ICU) following return of spontaneous circulation (ROSC) after OOHCA over 18 months from January 2011 (following widespread introduction of targeted temperature management and primary percutaneous intervention).

PARTICIPANTS

Of 69 successive patients admitted over an 18-month period, survival and cerebral performance category (CPC) outcomes were obtained from review of databases and clinical notes. The Trust finance department supplied ICU and hospital costs using the Payment by Results UK system.

RESULTS

Of those patients with ROSC admitted to ICU, survival to hospital discharge (any CPC) was 33/69 (48%) with 26/33 survivors in CPC 1-2 at hospital discharge. Cost per survivor to hospital discharge (including total cost of survivors and non-survivors) was £50,000, cost per CPC 1-2 survivor was £65,000. Cost and length of stay of CPC 1-2 patients was considerably lower than CPC 3-4 patients. The majority of the costs (69%) related to intensive care. Estimated cost per CPC 1-2 survivor per QALY was £16,000.

CONCLUSIONS

The costs of in-hospital patient care for ICU admissions following ROSC after OOHCA are considerable but within a reasonable threshold when assessed from a QALY perspective.

[Epidemiological characteristics of out-of-hospital cardiorespiratory arrest recorded by the 061 emergencies system (SAMU) in the Balearic Islands (Spain), 2009-2012]

OBJECTIVE

To describe the epidemiology of out-of-hospital cardiorespiratory arrest (OHCA) and identify factors associated with recovery of spontaneous circulation (ROSC).

DESIGN

Observational study of OHCA registered on a continuous basis in the Emergency Medical Services (EMS) database during 2009-2012.

SETTING

The islands of Mallorca, Ibiza, Menorca and Formentera (Balearic Islands, Spain).

PATIENTS

OHCA in patients ≥ 18 years of age. The main variables were: Patient sex, age, probable cause, place of arrest, bystander, witnessed, basic life support (BLS), shockable rhythm, intervention time, semi-automatic defibrillator (AED), duration of cardiopulmonary arrest (CA), and ROSC. Independent variables were defined according to the Utstein protocol, and the dependent variable was defined as ROSC.

RESULTS

The EMS treated 1170 OHCAs (28/100,000 persons-year). We included 1130 CA. The mean age was 61.4 years (73.4% males). Most CA (72.3%) were of cardiac etiology, and 84.7% were witnessed. A total of 840 (74.3%) received BLS and 400 (47.6%) did so before arrival of the EMS (45 by bystander relatives). AED was available in 330 cases CA (29.2%) (96 with shockable rhythm). The interval between emergency call and BLS and between emergency call and advanced life support was 8.4 and 15.8min, respectively. Shockable rhythm was monitored in 257 CAs (22.7%). ROSC occurred in 261 (23.1%). Factors associated with ROSC were age, shockable rhythm, BLS before EMS arrival, and CA duration less than 30min.

CONCLUSION

The incidence rate of the OHCA is low. The proportion of patients receiving BLS from relatives was low. Age, shockable rhythm and BSL before EMS arrival were associated with ROSC.

["Bridge to recovery"- implantation of an Impella® CP in infarct-related cardiogenic shock]

We present the case of a 43-year-old man with the diagnosis of a posterior and anterior wall infarction who was taken to our institution after prolonged cardioplumonary resuscitation. Cardiac catheterization showed thrombotic occlusion of the LAD and a subtotal stenosis of the right coronary artery. Both lesions were revascularized by PCI. Despite catecholamine infusion, the patient developed severe cardiogenic shock with multiorgan dysfunction syndrome under therapeutic hypothermia. Thus, an Impella® CP, a percutaneous left ventricular assist device (LVAD), was implanted. Due to effective LVAD support, it was possible to wean and remove the device after 75 h of support. The impaired left ventricular ejection fraction and wall-motion abnormalities which were present on day 1 achieved complete recuperation on day 14. The patient was discharged without any neurological deficits.

Therapeutic temperature management after cardiac arrest and the risk of bleeding: systematic review and meta-analysis

AIM

Prognosis after cardiac arrest in the era of modern critical care is still poor with a high mortality of approximately 90%. Around 30% of the survivors have neurological impairments. Targeted temperature management (TTM) is the only treatment option which can improve mortality and neurological outcome. It is so far unclear if bleeding complications occur more often in patients undergoing TTM treatment.

METHODS

We conducted a systematic literature research in September 2013 including three major databases i.e. MEDLINE, EMBASE and CENTRAL. All studies were rated in respect to the ILCOR Guidelines and concerning their level of evidence and quality. We then performed a meta-analysis on bleeding disposition under TTM.

RESULTS

We initially found 941 studies out of which 34 matched our requirements and were thus included in our overview. Five studies including 599 patients were summarized in a meta-analysis concerning bleeding complications of all severities. There was a trend toward higher bleeding in patients treated with TTM (RR: 1.30, 95% CI: 0.97-1.74) which did not reach significance (p=0.085). Seven studies with an overall 599 patients were included in our meta-analysis on bleeding requiring transfusion. There was no significant difference in the incidence of severe bleeding with a risk ratio of 0.97 (95% CI: 0.61-1.56, p=0.909).

CONCLUSIONS

The data included in our meta-analysis indicate that, concerning the risk of bleeding, TTM is a safe method for patients after cardiac arrest. We did not observe a significantly higher risk for bleeding in patients undergoing TTM.

Hypothermia after cardiac arrest as a novel approach to increase survival in cardiopulmonary cerebral resuscitation: a review

Context:

The aim of this review study was to evaluate therapeutic mild hypothermia, its complications and various methods for induced mild hypothermia in patients following resuscitation after out-of-hospital cardiac arrest.

Evidence Acquisition:

Studies conducted on post-cardiac arrest cares, history of induced hypothermia, and therapeutic hypothermia for patients with cardiac arrest were included in this study. We used the valid databases (PubMed and Cochrane library) to collect relevant articles.

Results:

According to the studies reviewed, induction of mild hypothermia in patients after cardiopulmonary resuscitation would lead to increased survival and better neurological outcome; however, studies on the complications of hypothermia or different methods of inducing hypothermia were limited and needed to be studied further.

Conclusions:

This study provides strategic issues concerning the induction of mild hypothermia, its complications, and different ways of performing it on patients; using this method helps to increase patients’ neurological survival rate.

Favourable 5-year postdischarge survival of comatose patients resuscitated from out-of-hospital cardiac arrest, managed with immediate coronary angiogram on admission

AIMS

On-admission coronary angiogram (CA) with angioplasty (percutaneous coronary intervention, PCI) may improve survival in patients resuscitated from out-of-hospital cardiac arrest (OHCA), but long-term survival data are scarce. We assessed long-term survival in OHCA patients managed with on-admission CA and PCI if indicated and compared survival rates in patients with/without acute coronary syndrome (ACS).

METHODS

Retrospective single-centre study including patients aged ≥18 years resuscitated from an OHCA without noncardiac cause, with sustained return of spontaneous circulation, undergoing on-admission CA with PCI if indicated. ACS was diagnosed angiographically. Survival was recorded at hospital discharge and at 5-year follow up. Survival probability was estimated by Kaplan-Meier survival curves.

RESULTS

A total of 300 comatose patients aged 56 years (IQR 48-67 years) were included, 36% with ST-segment elevation. All had on-admission CA; 31% had ACS. PCI was attempted in 91% of ACS patients and was successful in 93%. Hypothermia was performed in 84%. Survival to discharge was 32.3%. After discharge, 5-year survival was 81.7 ± 5.4%. Survival from admission to 5 years was 26.2 ± 2.8%. ACS patients had better survival to discharge (40.8%) compared with non-ACS patients (28.5%, p=0.047). After discharge, 5-year survival was 92.2 ± 5.4% for patients with ACS and 73.4 ± 8.6% without ACS (hazard ratio, HR, 2.7, 95% CI 0.8-8.9, p=0.1). Survival from admission to 5 years was 37.4 ± 5.2% for ACS patients, 20.7 ± 3.0%, for non-ACS patients (HR 1.5, 95% CI 1.12-2.0, p=0.0067).

CONCLUSIONS

OHCA patients undergoing on-admission CA had a very favourable postdischarge survival. Patients with OHCA due to ACS had better survival to discharge at 5-year follow up than patients with OHCA due to other causes.

A 6-year experience of CPR outcomes in an emergency department in Thailand

Purpose

Sudden cardiac arrest is a common emergency condition found in the emergency department of the hospital. The survival rate of out-of-hospital cardiac arrest patients is 2.0%–10.0% and 7.4%–27.0% percent for in-hospital cardiac arrest patients. The factors for survival outcome are divided into three main groups: patient characteristics, pre-hospital factors, and resuscitated information. The objective of this study was to evaluate the related factors, outcome, and survival rate in patients with cardiac arrest who received cardiopulmonary resuscitation (CPR) at Ramathibodi Emergency Medicine Department. There are limited data for this issue in Thailand and other Asian countries.

Methods

This retrospective study included all patients who were older than 15 years with sudden cardiac arrest and who were resuscitated in the emergency room between January 2005 and December 2010. Descriptive analytic statistics and logistic regressions were used to analyze factors that related to the sustained return of spontaneous circulation (ROSC) and survival at discharge.

Results

There were 181 patients enrolled. The overall sustained ROSC rate was 34.8% and the survival rate at discharge was 11.1%. There were 145 out-of-hospital cardiac arrest patients, in whom the survival rate was 52.4% and the survival to discharge rate was 7.6%. For inhospital cardiac arrest, there were 36 patients with a survival rate of 86.1% and the survival to discharge rate was 25.0%. Statistically significant factors related to sustained ROSC were good and moderate cerebral performance, in-hospital cardiac arrest, beginning of CPR in less than 30 minutes, and cardiopulmonary cause of arrest. The factors influencing survival to discharge were cardiopulmonary causes of cardiac arrest.

Conclusion

Factors associated with sustained ROSC were functional status before cardiac arrest, location of cardiac arrest, duration of CPR, and cause of cardiac arrest. Survival rate was related to the cause of cardiac arrest.

Emergency coronary angiography in comatose cardiac arrest patients: do real-life experiences support the guidelines?

AIMS

To describe the use of emergency coronary angiography (CAG) and primary percutaneous coronary intervention (PCI) and the association with short- and long-term survival in consecutive comatose survivors after out-of-hospital cardiac arrest (OHCA).

METHODS

In the period 2004-10, a total of 479 consecutive patients with OHCA of suspected cardiac cause were referred to a tertiary cardiac centre, 360 patients were comatose and admitted to the ICU for post-resuscitative care. The population was stratified in two groups according to the pattern of the first ECG obtained after re-established circulation; ST-segment elevation (STEMI, n=116) and ECG without STEMI pattern (No-STEMI, n=244). Emergency CAG (≤12 hours after OHCA) was performed at the discretion of the attending cardiologist. Primary outcome was 30-day and 1-year survival.

RESULTS

Emergency CAG was performed in all patients in the STEMI group compared to 82 (34%) in the group without STEMI pattern (p<0.0001) with significant coronary lesions found in 108 (93%) compared to 43 (52%) patients, respectively (p<0.0001). Survival at 30 day according to emergency CAG vs. no emergency CAG was 65% in the STEMI group compared to 66% and 54% in the group without STEMI pattern (p log-rank=0.11). The use of emergency CAG in the group without STEMI pattern was not associated with reduced mortality (HRadjusted=0.69, 95% CI 0.4-1.2, p=0.18).

CONCLUSIONS

In comatose survivors of OHCA presenting with STEMI, a high prevalence of coronary disease and culprit lesions suitable for emergency PCI was found, whereas in patients without STEMI pattern, significant coronary stenosis was less frequent. Clinical benefits of emergency CAG/PCI in comatose survivors of OHCA presenting without STEMI could not be identified.

Etiology of out-of-hospital cardiac arrest diagnosed via detailed examinations including perimortem computed tomography

CONTEXT

The spectrum of the etiology of out-of-hospital cardiopulmonary arrest (OHCPA) has not been established. We have performed perimortem computed tomography (CT) during cardiopulmonary resuscitation.

AIMS

To clarify the incidence of non-cardiac etiology (NCE), actual distribution of the causes of OHCPA via perimortem CT and its usefulness.

SETTINGS AND DESIGN

Population-based observational case series study.

MATERIALS AND METHODS

We reviewed the medical records of 1846 consecutive OHCPA cases and divided them into two groups: 370 showing an obvious cause of OHCPA with NCE (trauma, neck hanging, terminal stage of malignancy, and gastrointestinal bleeding) and others.

RESULTS

Of a total OHCPA, perimortem CT was performed in 57.5% and 62.5% were finally diagnosed as NCE: Acute aortic dissection (AAD) 8.07%, pulmonary thrombo-embolization (PTE) 1.46%, hypoxia due to pneumonia 5.25%, asthma and acute worsening of chronic obstructive pulmonary disease 2.06%, cerebrovascular disorder (CVD) 4.48%, airway obstruction 7.64%, and submersion 5.63%. The rates of patients who survived to hospital discharge were 6-14% in patients with NCE. Out of the 1476 cases excluding obvious NCE of OHCPA, 66.3% underwent perimortem CT, 14.6% of cases without obvious NCE and 22.1% of cases with perimortem CT were confirmed as having some NCE.

CONCLUSIONS

Of the total OHCPA the incidences of NCE was 62.5%; the leading etiologies were AAD, airway obstruction, submersion, hypoxia and CVD. The rates of cases converted from cardiac etiology to NCE using perimortem CT were 14.6% of cases without an obvious NCE.

Factors associated with mortality in out-of-hospital cardiac arrests attended in basic life support units in the Basque Country (Spain)

INTRODUCTION AND OBJECTIVES

To describe the epidemiological characteristics of cardiac arrests attended in basic life support units in the Basque Country (Spain) and look for factors associated with failure of cardiopulmonary resuscitation.

METHODS

We conducted an observational study during 18 months, including all out-of-hospital cardiopulmonary resuscitation provided by basic life support units. The variables defined in the Utstein-style were considered as independent and mortality as the dependent variable. We applied descriptive and analytical statistics and evaluated the magnitude of the association using a logistic regression model, which included variables with P<.05 in the bivariate analysis.

RESULTS

Of 1050 cardiac arrests attended, 15.7% of patients were revived in situ. The presumed etiology was cardiac in 55.3% of cases and 71.4% occurred at home. Cardiopulmonary resuscitation was started before the arrival of the ambulance in 22.9% of cases and in 18.2% the rhythm of presentation was shockable. Variables associated with lower mortality were: shockable rhythms (relative risk=0.44; P=.003), patient aged<65 years (relative risk=0.44; P=.002), time to cardiopulmonary resuscitation<8 min (relative risk=0.56; P=.039), and out-of-home events (relative risk=0.55; P=.031).

CONCLUSIONS

Cardiac arrest survival was low. Cardiopulmonary resuscitation before the arrival of the ambulance was rare. A shockable rhythm, age younger than 65 years, early cardiopulmonary resuscitation efforts, and a location away from home were associated with longer survival. It is necessary to develop strategies designed to reduce ambulance response time and educate the public in basic resuscitation.

Regional variation and outcome of out-of-hospital cardiac arrest (ohca) in Finland - the Finnresusci study

Background

Despite the efforts of the modern Emergency Medical Service Systems (EMS), survival rates for sudden out-of-hospital cardiac arrest (OHCA) have been poor as approximately 10% of OHCA patients survive hospital discharge. Many aspects of OHCA have been studied, but few previous reports on OHCA have documented the variation between different sizes of study areas on a regional scale. The aim of this study was to report the incidence, outcomes and regional variation of OHCA in the Finnish population.

Methods

From March 1st to August 31st, 2010, data on all OHCA patients in the southern, central and eastern parts of Finland was collected. Data collection was initiated via dispatch centres whenever there was a suspected OHCA case or if a patient developed OHCA before arriving at the hospital. The study area includes 49% of the Finnish population; they are served by eight dispatch centres, two university hospitals and six central hospitals.

Results

The study period included 1042 cases of OHCA. Resuscitation was attempted on 671 patients (64.4%), an incidence of 51/100,000 inhabitants/year. The initial rhythm was shockable for 211 patients (31.4%). The survival rate at one-year post-OHCA was 13.4%. Of the witnessed OHCA events with a shockable rhythm of presumed cardiac origin (n=140), 64 patients (45.7%) were alive at hospital discharge and 47 (33.6%) were still living one year hence. Surviving until hospital admission was more likely if the OHCA occurred in an urban municipality (41.5%, p=0.001).

Conclusions

The results of this comprehensive regional study of OHCA in Finland seem comparable to those previously reported in other countries. The survival of witnessed OHCA events with shockable initial rhythms has improved in urban Finland in recent decades.

Year in review 2011: Critical Care--Out-of-hospital cardiac arrest and trauma

In 2011, numerous studies were published in Critical Care focusing on out-of-hospital cardiac arrest, cardiopulmonary resuscitation, trauma, and some related airway, respiratory, and response time factors. In this review, we summarize several of these studies, including those that brought forth advances in therapies for the post-resuscitative period. These advances involved hypothesis-generating concepts in therapeutic hypothermia as well as the impact of early percutaneous coronary artery interventions and the potential utility of extracorporeal life support after cardiac arrest. There were also articles pertaining to the importance of timing in prehospital airway management, the outcome impact of hyperoxia, and the timing of end-tidal carbon dioxide measurements to predict futility in cardiac arrest resuscitation. In other articles, additional perspectives were provided on the classic correlations between emergency medical service response intervals and outcomes.

The effect of percutaneous coronary intervention in patients suffering from ST-segment elevation myocardial infarction complicated by out-of-hospital cardiac arrest on 30 days survival

AIM OF THE STUDY

To question the beneficial effects of the recommended early percutaneous coronary intervention (PCI) after out-of-hospital cardiac arrest on 30-day survival with favourable neurological outcome.

METHODS

Prospectively collected data of 1277 out of hospital cardiac arrest patients between 2005 and 2010 from a registry at a tertiary care university hospital were used for a cohort study.

RESULTS

In 494 (39%) arrest patients ST-segment elevation was identified in 249 (19%). Within 12h after restoration of spontaneous circulation catheter laboratory investigations were initiated in 197 (79%) and PCI in 183 (93%) (78% got PCI in less than 180 min). Adjustment for a cumulative time without chest compressions <2 min, initial shockable rhythm, cardiac arrest witnessed by healthcare professionals, and a higher core temperature at time of hospitalization reduced the effect of PCI on favourable neurological outcome at 30 days (OR 1.40; 95% CI, 0.53-3.7) compared to the univariate analysis (OR 2.52; 95% CI, 1.42-4.48).

CONCLUSION

This cohort study failed to demonstrate the beneficial effects of PCI as part of post-resuscitation care on 30-day survival with a favourable neurological outcome.

Cardiac arrest: a public health perspective

This article reviews out-of-hospital cardiac arrest from a public health perspective. Case definitions are discussed. Incidence, outcome, and fixed and modifiable risk factors for cardiac arrest are described. There is a large variation in survival between communities that is not explained by patient or community factors. Study of variation in outcome in other related conditions suggest that this is due to differences in organizational culture rather than processes of care. A public health approach to improving outcomes is recommended that includes ongoing monitoring and improvement of processes and outcome of care.

Vasoactive support in the optimization of post-cardiac arrest hemodynamic status: from pharmacology to clinical practice

As a critical component of post-resuscitation care, prompt optimization of hemodynamic status by means of targeted interventions is vital in order to maximize the likelihood of good outcome. Vasoactive agents play an essential role in the supportive care of post cardiac arrest patients. The administration of these agents is associated with serious side-effects and therefore they should be used in the minimal dose necessary to achieve low-normal mean arterial pressure and adequate systematic perfusion. Careful and frequent serial evaluation of the patient is important primarily to assess volume status and adequacy of circulatory support. Continuous monitoring of blood pressure and laboratory parameters is essential both to accurately titrate therapy and because inotropes and vasopressors have the potential to induce life-threatening side-effects. The clinical efficacy of inotropes and vasopressors has been largely investigated through examination of their impact on hemodynamic end points, and clinical practice has been driven in part by expert opinion, extrapolation from animal studies, and physician preference. Clearly these agents should all be considered as supportive measures to stabilize the patient prior to some form of definitive therapy.