Factors affecting outcome following cardiopulmonary resuscitation

Emergency Medical Services Handoff of Patients in Cardiac Arrest in the Emergency Department: A Retrospective Video Review Study of Duration and Details of Handoff

STUDY OBJECTIVES

We aimed to evaluate the duration and frequency of communication between EMS (Emergency Medical Services) and ED (Emergency Department) staff during handoff and the subsequent time to critical cardiac care (rhythm determination, defibrillation) using CA (cardiac arrest) video review.

METHODS

A single-center retrospective study of video-recorded adult CAs between August 2020 and December 2022 was performed. Two investigators assessed the communication of 17 data points, time intervals, EMS initiation of handoff, and type of EMS agency. Median times from initiation of handoff to first ED rhythm determination and defibrillation were compared between the groups above versus below the median number of data points communicated.

RESULTS

Overall, 95 handoffs were reviewed. The handoff was initiated in a median of 2 seconds (interquartile range (IQR) 0-10) after arrival. EMS initiated handoff in 65 (69.2%) patients. The median number of data points communicated was 9 and median duration was 66 seconds (IQR 50-100). Age, location of arrest, estimated down time, and medications administered were communicated >80% of the time, initial rhythm 79%, and bystander cardiopulmonary resuscitation and witnessed arrest <50%. The median times from initiation of handoff to first ED rhythm determination and defibrillation were 188 (IQR 106-256) and 392 (IQR 247-725) seconds, though not statistically different between handoffs with <9 vs. ≥9 data points communicated (p>0.40).

CONCLUSION

There is no standardization for handoff reports from EMS to ED staff for CA patients. Using video review, we demonstrated the variable communication during handoff. Improvements to this process could reduce the time to critical interventions.

End-Tidal Hypocapnia Under Anesthesia Predicts Postoperative Delirium

Background: Postoperative delirium (POD) might be associated with anesthetic management, but research has focused on choice or dosage of anesthetic drugs. We examined potential contributions of intraoperative ventilatory and hemodynamic management to POD.

Methods: This was a sub-study of the ENGAGES-Canada trial (NCT02692300) involving non-cardiac surgery patients enrolled in Winnipeg, Canada. Patients received preoperative psychiatric and cognitive assessments, and intraoperatively underwent high-fidelity data collection of blood pressure, end-tidal respiratory gases and anesthetic agent concentration. POD was assessed by peak and mean POD scores using the Confusion Assessment Method-Severity (CAM-S) tool. Bivariate and multiple linear regression models were constructed controlling for age, psychiatric illness, and cognitive dysfunction in the examination of deviations in intraoperative end-tidal carbon dioxide (areas over (AOC) and under the curve (AUC)) on POD severity scores.

Results: A total of 101 subjects [69 (6) years of age] were studied; 89 had comprehensive intraoperative hemodynamic and end-tidal gas measurements (data recorded at 1 Hz). The incidence of POD was 11.9% (12/101). Age, cognitive dysfunction, anxiety, depression, and intraoperative end-tidal CO₂ (AUC) were significant correlates of POD severity. In the multiple regression model, cognitive dysfunction and AUC end-tidal CO₂ (0.67 kPa below median intra-operative value) were the only independent significant predictors across both POD severity (mean and peak) scores. There was no association between cumulative anesthetic agent exposure and POD.

Conclusions: POD was associated with intraoperative ventilatory management, reflected by low end-tidal CO₂ concentrations, but not with cumulative anesthetic drug exposure. These findings suggest that maintenance of intraoperative normocapnia might benefit patients at risk of POD.

Out-of-hospital cardiac arrest patients treated with cardiopulmonary resuscitation using extracorporeal membrane oxygenation: focus on survival rate and neurologic outcome

Background

Extracorporeal membrane oxygenation (ECMO) is a useful treatment for refractory out-of-hospital cardiac arrest (OHCA). However, little is known about the predictors of survival and neurologic outcome after ECMO. We analyzed our institution’s experience with ECMO for refractory OHCA and evaluated the predictors of survival and neurologic outcome after ECMO.

Methods

This was a retrospective review of the medical records of 23 patients who were treated with ECMO due to OHCA that was unresponsive to conventional cardiopulmonary resuscitation, between January 2009 and January 2014.

Results

Our ECMO team was activated within 10 min for refractory OHCA, and the 30-day survival rate was 43.5 %. In a multivariate analysis that evaluated independent factors contributing to mortality, urine output  ≤ 0.5 mL · kg⁻¹ · h⁻¹ (defined as oliguria) during the 24 h after ECMO was statistically significant (OR, 32.271; 95 % CI, 1.379–755.282; p = 0.031). Just after ECMO implantation, 6 of the 9 patients (66.7 %) who had normal findings on brain computed tomography (CT) survived with a cerebral performance category (CPC) of grade 1. However, only 3 of the 11 patients (27 %) who had evidence of hypoxic brain damage on initial brain CT survived (their CPC grade was 4).

Conclusions

Based on our findings, the survival rate can be improved by rapid implantation of ECMO, and oliguria seen during the first 24 h after ECMO may be an independent predictor of mortality. Furthermore, findings on brain CT just after ECMO and subsequent images may represent an important predictor for neurologic outcome after ECMO.

Benefits of thrombolytics in prolonged cardiac arrest and hypothermia over its bleeding risk

A 52-year-old non-smoking Caucasian male, who was admitted to our emergency room after he was found unconscious in the bathroom, went into cardiac arrest requiring prolonged cardiopulmonary resuscitation (CPR) and hypothermia therapy. Cardiac catheterization showed non-obstructive coronary arteries and further bedside echocardiogram suggested probable pulmonary embolism (PE) as an underlying cause of cardiac arrest. Although thrombolytic therapy is an effective therapy for PE, it is not routinely given during prolonged CPR for its life- threatening bleeding complications. Many reported cases have suggested a beneficial effect of empiric thrombolytic in cardiac arrest, but unrelated to duration of resuscitation and adjuvant treatments that imposes bleeding risk. We suspect that tissue plasminogen activator (tPA) should be promptly given to prolonged cardiac arrest patients, even when bleeding risk is high with the concurrent hypothermia treatment, keeping the benefits over risk strategy. Our patient received thrombolytic, tPA and showed remarkable clinical, physiological and radiographical improvement.

Cardiac arrest in the operating room requiring prolonged resuscitation

PURPOSE

Prolonged cardiopulmonary resuscitation (CPR) is often associated with limited success and poor long-term outcomes. The purpose of this report is to present the case of a patient who suffered an unanticipated cardiac arrest in the operating room and survived following a prolonged period of CPR.

CLINICAL FEATURES

A previously healthy 53-yr-old male with inflammatory bowel disease was diagnosed with a perforated bowel and underwent emergency exploratory laparotomy under general anesthesia. Approximately two hours after induction of anesthesia, the patient experienced cardiac arrest, and for 55 min, he underwent CPR and defibrillation according to the Advanced Cardiac Life Support (ACLS) protocols. As the decision to terminate CPR was being considered, a return of spontaneous circulation was detected 56 min after the onset of cardiac arrest. The patient survived with no major organ failure or adverse neurological outcome. No definitive cause of cardiac arrest was diagnosed in the postoperative period. At the follow-up 14 months after the event, the patient had returned to the pre-arrest level of functioning. The results of our literature search showed that no upper limit for the duration of CPR has been defined. Good outcomes after prolonged CPR depend on the patient's pre-arrest condition and the etiology of the cardiac arrest.

CONCLUSION

Perioperative cardiac arrests are rare events, and there is little evidence to suggest an upper limit for the duration of resuscitation. Unknown etiologies and the presence of good patient predictors may support the continuation of prolonged CPR with good outcomes.

Modifications to advanced life support in renal failure

The outcome of cardiopulmonary resuscitation (CPR) has been reported to be worse in patients with renal failure compared with those with normal renal function. It is likely that this increased mortality may be at least partly attributable to sub-optimal and highly variable treatment strategies used in cardiac arrest in patients with renal failure, but this issue has not previously been explored. Such patients undoubtedly pose a challenge to advanced life support (ALS) providers, and renal unit staff are not trained to provide specialist advice after a patient has sustained a cardiac arrest. There are few studies investigating the epidemiology, safety or outcome of cardiac arrest in patients with renal failure and there are no generally accepted resuscitation guidelines for this special circumstance. In this article we discuss the unique problems of resuscitating patients with renal failure and propose a suitable management strategy.

Outcome after heroin overdose and cardiopulmonary resuscitation

BACKGROUND

The survival of heroin overdose patients resuscitated from cardiac arrest is reported to be poor. The aim of our study was to investigate the outcome and characteristics of survivors after cardiac arrest caused by heroin overdose.

METHODS

This was a retrospective study in a medium-sized city (population, 560,000). Between 1 January 1997 and 31 December 2000, there were 94 combined cardiac arrests caused by acute drug poisonings. The main outcome measure was survival to discharge.

RESULTS

Cardiopulmonary resuscitation was attempted in 19 heroin overdose patients (group A) and in 53 patients with cardiac arrest caused by other poisonings (group B). Three (16%) vs. six (11%) patients were discharged alive (group A vs. B, respectively). The survivors in group A had an Emergency Medical Service (EMS)-witnessed cardiac arrest or the Emergency Dispatching Centre was called before the arrest occurred. There was no statistically significant difference between the two groups in terms of survival. Survivors in both groups suffered from acute renal failure (two), hypoglycaemia (four) and hypothermia (three).

CONCLUSION

Survival after cardiac arrest caused by heroin overdose is possible if the arrest is EMS witnessed or the Emergency Dispatching Centre is called before the cardiac arrest occurs. In comparison with cardiac arrests caused by other poisonings, there was no difference in survival. The incidence and mechanism of hypoglycaemia should be examined in further studies.

Prolonged cardiopulmonary resuscitation with preservation of cerebral function in an elderly patient with asystole after electroconvulsive therapy

This case report describes a patient who became asystolic after electroconvulsive therapy. The report describes the prolonged resuscitative events that lasted 54 minutes and discusses the effectiveness of chest compressions and the importance of monitoring the acid-base balance. The report also stresses the importance of being able to establish effective cardiac pacing in this patient. The updated resuscitation guidelines published by the American Heart Association are also discussed.

The effect of differing support surfaces on the efficacy of chest compressions using a resuscitation manikin model

AIM

External chest compression (ECC) efficacy is influenced by factors including the surface supporting the patient. Air-filled support surfaces are deflated for cardiopulmonary resuscitation, with little evidence to substantiate this. We investigated the effect that differing support surfaces had on ECC efficacy using a CPR manikin model.

METHODOLOGY

Four participants carried out four cycles of ECC with an assistant ventilating. The subjects were blinded to the seven support surfaces and the order was randomised. For each participant/surface combination, ECC variables and the participants' perceptions were measured.

RESULTS

Participants produced effective ECC with the manikin on the floor (mean proportion correct, 94.5%; mean depth, 42.5 mm). Compared with the floor: the proportion of correct ECC was less for the overlay inflated (P<0.05); the depth of ECC was less effective (30-37 mm) for the overlay inflated/deflated and low-air-loss inflated and foam mattresses (P<0.05). The foam mattress, overlay inflated/deflated, and low-air-loss inflated were perceived as being less stable and as having reduced ECC efficacy compared with the floor. There was no difference or agreement, regarding subjects' perceptions or ECC variables, between the support surfaces or between inflated/deflated air-filled support surfaces.

CONCLUSION

The efficacy of ECC is affected by the support surfaces. There seems little evidence to substantiate deflating all air-filled support surfaces for CPR.

A review of nurses' performance of cardiopulmonary resuscitation at cardiac arrests

This study investigated nurses' ability to initiate and maintain effective cardiopulmonary resuscitation (CPR) in actual cardiac arrests (n = 50). Results indicated that in the majority of cases nurses effectively managed all components of CPR. These results are in direct contrast to the current accepted body of knowledge related to deficits in nurses' CPR performance. In particular the results suggest that nurses' actual management of cardiac arrests in a contextual environment differs markedly from results shown by research using simulated settings. Research findings suggest the need for an evaluation of the use and effects of cognitive and metacognitive instructional strategies in CPR training courses on transfer of skills and knowledge to practice.

Forebrain ischemia: effect on pharmacologically induced seizure thresholds in the rat

Seizures are common after severe cerebral ischemia. To examine the mechanisms underlying these seizures, we determined the impact of prior forebrain ischemia on the seizure thresholds of four convulsants with differing modes of action: lidocaine, pentylenetetrazol (PTZ), N-methyl-D-aspartate (NMDA), and picrotoxin. Anesthetized Sprague-Dawley rats were chronically instrumented with screw electrodes and vascular catheters, and then subjected to 10 min of forebrain ischemia, produced by carotid occlusion and hypotension (mean arterial pressure to 30 mmHg). Animals were then awakened. 6, 24 or 48 h later, groups of awake animals received intravenous infusions of the four drugs. The total dose of drug infused prior to either electrical seizures (lidocaine, PTZ, and picrotoxin) or tonic-clonic convulsions (all drugs) were noted. For each drug, a group of Sham animals (no ischemia) served as controls. There were markedly different patterns of changes in the convulsant thresholds for the drugs. For example, at 6 h post-ischemia, rats treated with lidocaine died before convulsing, while the threshold for PTZ increased by 86%. There was no change in the picrotoxin threshold at 6 h, but the dose of NMDA needed to induce tonic-clonic seizure activity was reduced by 70%. By 48 h, lidocaine and PTZ thresholds had returned to values similar to those in Shams, but the NMDA threshold had now increased to a value 62% greater than Sham. Ten minutes of cerebral ischemia is followed by a complex and changing pattern of susceptibility to chemical convulsants. Finding suggests that early post-ischemic seizures may be related to increased NMDA receptor sensitivity.

Neurologic complications in the intensive care unit

Neurologic complications resulting from critical illness and intensive care unit therapies are common, but frequently unrecognized because these patients are often intubated, sedated, and, occasionally, receiving neuromuscular blocking agents. Neurologic complications are associated with an increased intensive care unit mortality. This article discusses central nervous system complications that are secondary to critical illness or to therapeutic interventions in the critically ill patient.

Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest

The effects of mild hypothermia (MH) were investigated. From 1995 to 1996, 28 adult patients with out-of-hospital cardiopulmonary arrest (CPA) had return of spontaneous circulation and survived for more than two days. Thirteen patients were in the MH group. In the MH group, core temperature was maintained between 33 and 34 degrees C for 48 h, and then re-warmed to a temperature of 37 degrees C, at a rate of no greater than 1 degrees C per day. Fifteen patients, admitted before the MH protocol was instituted, were in the control group. Despite the fact that the number of witnessed arrests in the control group were greater than in the MH group, there were both more survivors (7/13 vs. 5/15) and more fully recovered patients (3/13 vs. 1/15) in the MH vs Control groups. Eleven of 13 MH patients, as compared to 6/15 controls developed pneumonia. Our study, although preliminary, suggests that MH might confer improved outcome, as has been shown in animal models, after CPA. This treatment is associated with an increase in pneumonic complications.

Accuracy and impact of presumed cause in patients with cardiac arrest

BACKGROUND

International guidelines recommend differentiation between cardiac and noncardiac causes of cardiac arrest. The aim of this study was to find the rate of agreement between primarily postulated and definitive causes of cardiac arrest.

METHODS AND RESULTS

We retrospectively analyzed the primarily presumed cause of cardiac arrest as determined by the emergency room physician on admission in all patients admitted to the emergency department of one urban tertiary care hospital. This was compared with the definitive cause as established by clinical evidence or autopsy. Within 4 years, the initially presumed cause was unclear in 24 (4%) of 593 patients. In the remaining 569 patients, the presumed cause was correct in 509 (89%) and wrong in 60 (11%) cases. Cardiac origin was presumed in 421 (71%) and the definitive cause in 408 (69%) cases. Noncardiac origin was presumed in 148 (25%) and the definitive cause in 185 (31%) patients. Presumed cardiac cause was sensitive (96%) but less specific (77%). Noncardiac causes such as pulmonary embolism, cerebral disorders, or exsanguination were those most frequently overlooked. Asystole occurred significantly more often in patients in whom presumed cause remained undetermined or differed from the definitive cause.

CONCLUSIONS

Cause of cardiac arrest is not as easily recognized as anticipated, especially when the initial rhythm is different from ventricular fibrillation. This might affect comparability of study results, therapeutic strategies, prognosis, and outcome. Patients in whom the presumed cause was confirmed as being correct had significantly better survival and neurological outcome.

Cardiac arrest associated with sulprostone use during caesarean section

Sulprostone, a synthetic prostaglandin with potent uterotonic action, has been shown to have a low complication rate in a large series. We present a case in which a bolus intravenous injection of sulprostone 30 micrograms was administered to treat postpartum haemorrhage during caesarean section. The 38-year-old patient with no previous cardiac or smoking history developed complete heart block, ventricular fibrillation and subsequent asystole. Cardiopulmonary resuscitation was successful after 45 minutes. Post resuscitation there was no myocardial infarction and she had complete neurological recovery. We postulate that the bolus of sulprostone resulted in possible coronary spasm that resulted in cardiac arrest.

Epidemiology and survival rate of out-of-hospital cardiac arrest in north-east Italy: The F.A.C.S. study. Friuli Venezia Giulia Cardiac Arrest Cooperative Study

The results of the first epidemiological, prospective, multicentric study on cardiac arrest in a geographical Italian region are reported. On 708 consecutive cardiac arrests, 438 underwent cardiopulmonary resuscitation (CPR). Of these, 344 were identified of cardiac aetiology. The underlying initial rhythm was: 166 asystole (48.3%), 104 ventricular fibrillation (30.2%), 74 pulseless electrical activity (21.5%). The best outcome occurred in patients whose cardiac arrest was witnessed by the EMS (49% return of spontaneous circulation (ROSC), 21% hospital discharge). When cardiac arrest was witnessed by lay people, 20.5% had ROSC and 4.4% were discharged alive from the hospital. When it was unwitnessed ROSC and hospital discharge were 8.6 and 1.7%, respectively. Ventricular fibrillation was highly predictive of outcome. Both ROSC and hospital discharge correlated inversely with the delay of the first defibrillation. Overall, the highest probability of survival was achieved when CPR interventions were started within the first minutes after collapse. Basic Life Support (BLS) manoeuvres began after 9 min of untreated cardiac arrest were still followed by a ROSC, but none of these patients survived. The incidence of prehospital cardiac arrest in our population was estimated to be in proportion of 0.95/1000 per year with a survival rate of 6.7%.

The role of nurses in cardiopulmonary resuscitation and defibrillation

Cardiac [corrected] arrest outcome studies have identified early defibrillation (among other variables) as a strong predictor of survival--with the emphasis placed on minimal delay between arrest and 'shock'. Nurses play a key role in the management of in-hospital cardiac arrest. Often they are first on the scene of an arrest--initiating cardiopulmonary resuscitation (CPR) as well as summoning assistance from the 'advanced life support'/'arrest' team. Thus it is argued that nurses should be willing (and able) to perform defibrillation when required. Notwithstanding this, the community has an expectation (rightly or wrongly) that all nurses are able to appropriately manage a collapse situation. However, research clearly demonstrates that not all nurses are competent in CPR. There is obviously a mismatch between community expectations and reality, which nursing needs to address. Nurses can contribute to the prevention of cardiac arrest in the community by promoting the importance of seeking medical care in the event of chest pain. Furthermore, skilled clinical assessment and recognition of the prodromes of cardiorespiratory collapse may reduce the incidence of in-hospital cardiac arrests.

Activation of blood coagulation after cardiac arrest is not balanced adequately by activation of endogenous fibrinolysis

BACKGROUND

Animal studies have demonstrated that hemostatic disorders occurring after cardiac arrest affect outcome. We investigated hemostatic changes during and after cardiopulmonary resuscitation (CPR) in humans.

METHODS AND RESULTS

The prospective study included 23 patients (29 to 86 years) who underwent out-of-hospital CPR for nontraumatic causes. Blood samples were drawn immediately and 15 and 30 minutes after initiation of CPR. In the case of restoration of spontaneous circulation (ROSC; n = 7), additional blood samples were taken immediately, 30 minutes, and 2, 8, 24, 48, and 72 hours after ROSC. A marked activation of blood coagulation was found in all patients. The specific markers of activated blood coagulation and fibrin formation, thrombin-antithrombin complex (TAT; median during CPR, 260 micrograms/L; median after ROSC, 57 micrograms/L; normal range, 1.0 to 4.1 micrograms/L), and fibrin monomers (FM; median during CPR, 34.3 micrograms/mL; median after ROSC, 65.4 micrograms/mL; normal range, 0 to 3.6 micrograms/mL) were markedly increased during and in the early phase after CPR. When patients survived for 48 hours, TAT and FM values returned to the normal range. In most patients, the plasma levels of D-dimer, an indicator of endogenous fibrinolytic activity, were not markedly increased during CPR (median, < 0.25 microgram/mL; normal range, < 0.25 microgram/mL) but increased moderately after ROSC (median, 0.56 microgram/mL). Levels of plasminogen activator inhibitor type 1 (normal range, 0.3 to 3.5 U/mL), a marker for endogenous inhibition of fibrinolytic activity, were moderately increased in most patients (median during CPR, 4.22 U/mL; median after ROSC, 8.08 U/mL).

CONCLUSIONS

Our data clearly demonstrate that there is a marked activation of blood coagulation and fibrin formation after prolonged cardiac arrest and CPR in humans that is not balanced adequately by concomitant activation of endogenous fibrinolysis. These changes may contribute to reperfusion disorders, such as the cerebral "no-reflow" phenomenon, by inducing fibrin deposition and formation of microthrombi.