The role of adrenaline in cardiopulmonary resuscitation

A novel copper ion enhanced electrochemical DNA biosensor for the determination of epinephrine

A novel electrochemical biosensor was developed for the detection of epinephrine (EP) by immobilizing double-strand DNA (dsDNA) bound with copper ions on a gold electrode (Cu2+/dsDNA/MCH/AuE). The electrochemical behavior of EP at Cu2+/dsDNA/MCH/AuE was examined, and the results demonstrated a significant enhancement in the electrocatalytic oxidation peak current of EP due to the formation of a stable G-Cu(II)-G sandwich structure between Cu2+ and guanine at the modified electrode. The modification process of the electrode was characterized by scanning electron microscopy, infrared spectroscopy, electrochemical impedance spectroscopy, and differential pulse voltammetry. A study on the effect of pH in phosphate buffer solution on the electrochemical oxidation of EP indicated that the catalytic oxidation process was pH-dependent. A plot of catalytic current versus EP concentration exhibited a dual-linear relationship within two ranges: 1.0-12.5 μM and 12.5-1000.0 μM, with correlation coefficients of 0.995 and 0.997, respectively. The limit of detection was determined to be 47 nM (S/N = 3). According to the calculated Hill coefficient (0.99), it can be concluded that the electrocatalytic process followed the Michaelis-Menten kinetic mechanism. The maximum catalytic current Im was 25 μA, while the apparent Michaelis-Menten constant Km was 1.425 mM. These findings indicated excellent electrocatalytic activity of the modified electrode towards oxidation of EP. The developed biosensor successfully detected EP in spiked mouse serum as well as epinephrine hydrochloride injection with high selectivity, sensitivity, stability, and accuracy.

Molecular mechanism of Danxiong Tongmai Granules in treatment of coronary heart disease

BACKGROUND

Danxiong Tongmai Granules (DXTMG) are widely utilized in treating coronary heart disease (CHD) in China. This study aims to explore the molecular mechanisms underlying the therapeutic effects of DXTMG on CHD by employing a network pharmacology approach, complemented with experimental validation.

METHODS

Traditional Chinese Medicine (TCM) compounds and targets were identified via searches in the BATMAN-TCM database, and the GeneCards database was used to obtain the main target genes involved in CHD. We combined disease targets with the drug targets to identify common targets. The "TCM-compound-target" network was plotted using Cytoscape 3.7.2 software and a protein-protein interaction (PPI) network was constructed using the STRING database from which core targets were obtained. Gene ontology (GO) function analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis were performed for common drug-disease targets using R Version 4.0.4 (64 bit) software. Molecular docking of core protein-small molecule ligand interaction was modeled using AutoDock software. A molecular dynamics simulation was conducted on the optimal protein-small molecule complex identified through molecular docking, using Amber18 software. The rat model for myocardial ischemia was established through pre-gavage administration of DXTMG, followed by dorsal hypodermic injection of isoprenaline. Myocardial tissues from the rats were analyzed using hematoxylin and eosin (HE) staining and Masson's trichrome staining. Relevant targets were validated by enzyme-linked immunosorbent assay (ELISA) and immunohistochemistry.

RESULTS

162 potential targets of DXTMG involved in CHD were identified. These included INS, ALB, IL-6 and TNF according to PPI network studies. GO enrichment analysis identified a total of 3365 GO pathways, including 3049 biological process pathways (BP) concerned with the heart and circulatory system; 109 cellular component (CC) pathways, including cation channels and membrane rafts and 207 molecular function (MF) pathways related to receptor ligands and activators. KEGG analysis revealed a total of 137 pathways (P < 0.05), including those related to AGE-RAGE signaling associated with diabetic complications, fluid shear stress and atherosclerosis. The results of molecular docking and molecular dynamics simulations demonstrated the robust binding affinity between the compounds and target proteins. Animal experiment findings indicated that, compared with the model group, the DXTMG group effectively ameliorated inflammation and fibrosis in rat myocardial tissues, reduced LDH, cTn-I, and MDA levels (P < 0.05, P < 0.01), elevated SOD and GSH-PX levels (P < 0.05), and reduced the percentage of positive area for IL-6 and TNF-α (P < 0.05).

CONCLUSION

This study preliminarily suggests that DXTMG can modulate oxidative stress, inflammation response, and cardiomyocyte regulation, thereby mitigating the onset and progression of CHD.

Risk factors of 30-day and long-term mortality and outcomes in open repair of thoracoabdominal aortic aneurysm

BACKGROUND

Open repair of thoracoabdominal aortic aneurysm (TAAA) was characterized by significant risk of postoperative mortality and morbidity. The aim of this study was to determine the perioperative predictors of early and long-term mortality in patients undergoing open repair of TAAA. Besides, the postoperative outcomes in patients with open repair of TAAA were described.

METHODS

This is a single-center retrospective study, and 146 patients with open repair of TAAA from January 4, 2011, to November 22, 2018 was involved. Categorical variables were analyzed by the Chi-square test or Fisher's exact test, and continuous variables were analyzed by the independent sample t-test and the WilCoxon rank-sum test. Multivariate Logistic regression and Cox regression were applied to identify the predictors of 30-day and long-term mortality, respectively. The Kaplan Meier curves were used to illustrate survival with the Log-rank test.

RESULTS

The 30-day mortality was 9.59% (n = 14). Older than 50 years, the intraoperative volume of red blood cell (RBC) and epinephrine use were independently associated with postoperative 30-day mortality in open repair of TAAA. Long-term mortality was 17.12% (n = 25) (median of 3.5 years (IQR = 2-5 years) of follow-up). Prior open thoracoabdominal aortic aneurysm (TAAA) repair, aortic cross-clamping (ACC) time, intraoperative volume of RBC and use of epinephrine were independently correlated with long-term mortality.

CONCLUSIONS

Identifying perioperative risk factors of early and long-term mortaliy is crucial for surgeons. Intraoperative volume of RBC and use of epinephrine were predictors of both early and long-term mortality. In addition, patients of advanced age, prior open repair of TAAA and prolonged ACC time should be paid more attention.

Methylene blue as an adjuvant during cardiopulmonary resuscitation: an experimental study in rats

INTRODUCTION

Methylene Blue (MB) has been shown to attenuate oxidative, inflammatory, myocardial, and neurological lesions during ischemia-reperfusion and has great potential during cardiac arrest. This study aimed to determine the effects of MB combined with epinephrine during cardiac arrest on myocardial and cerebral lesions.

METHOD

Thirty-eight male Wistar rats were randomly assigned to four groups: the sham group (SH, n = 5), and three groups subjected to cardiac arrest (n = 11/group) and treated with EPI 20 µg.kg-1 (EPI), EPI 20 µg.kg-1 + MB 2 mg.kg-1 (EPI + MB), or saline 0.9% 0.2 ml (CTL). Ventricular fibrillation was induced by direct electrical stimulation in the right ventricle for 3 minutes, and anoxia was maintained for 5 minutes. Cardiopulmonary Resuscitation (CPR) consisted of medications, ventilation, chest compressions, and defibrillation. After returning to spontaneous circulation, animals were observed for four hours. Blood gas, troponin, oxidative stress, histology, and TUNEL staining measurements were analyzed. Groups were compared using generalized estimating equations.

RESULTS

No differences in the Returning of Spontaneous Circulation (ROSC) rate were observed among the groups (EPI: 63%, EPI + MB: 45%, CTL: 40%, p = 0.672). The mean arterial pressure immediately after ROSC was higher in the EPI+MB group than in the CTRL group (CTL: 30.5 [5.8], EPI: 63 [25.5], EPI+MB: 123 [31] mmHg, p = 0.007). Serum troponin levels were high in the CTL group (CTL: 130.1 [333.8], EPI: 3.70 [36.0], EPI + MB: 43.7 [116.31] ng/mL, p < 0.05).

CONCLUSION

The coadministration of MB and epinephrine failed to yield enhancements in cardiac or brain lesions in a rodent model of cardiac arrest.

Research progress on microcirculatory disorders in septic shock: A narrative review

Hemodynamic coherence plays a critical role in the outcomes of septic shock. Due to the potential negative consequences of microcirculatory disorders on organ failure and clinical outcomes, the maintenance of a balance between the macrocirculation and microcirculation is a topic of significant research focus. Although physical methods and specialized imaging techniques are used in clinical practice to assess microcirculation, the use of monitoring devices is not widespread. The integration of microcirculation research tools into clinical practice poses a significant challenge for the future. Consequently, this review aims to evaluate the impact of septic shock on the microcirculation, the methods used to monitor the microcirculation and highlight the importance of microcirculation in the treatment of critically ill patients. In addition, it proposes an evaluation framework that integrates microcirculation monitoring with macrocirculatory parameters. The optimal approach should encompass dynamic, multiparametric, individualized, and continuous monitoring of both the macrocirculation and microcirculation, particularly in cases of hemodynamic separation.

Cumulative dose of epinephrine and mode of death after non-shockable out-of-hospital cardiac arrest: a registry-based study

BACKGROUND

Epinephrine increases the chances of return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA), especially when the initial rhythm is non-shockable. However, this drug could also worsen the post-resuscitation syndrome (PRS). We assessed the association between epinephrine use during cardiopulmonary resuscitation (CPR) and subsequent intensive care unit (ICU) mortality in patients with ROSC after non-shockable OHCA.

METHODS

We used data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (capturing OHCA data located in the Greater Paris area, France) between May 2011 and December 2021. All adults with ROSC after medical, cardiac and non-cardiac causes, non-shockable OHCA admitted to an ICU were included. The mode of death in the ICU was categorized as cardiocirculatory, neurological, or other.

RESULTS

Of the 2,792 patients analyzed, there were 242 (8.7%) survivors at hospital discharge, 1,004 (35.9%) deaths from cardiocirculatory causes, 1,233 (44.2%) deaths from neurological causes, and 313 (11.2%) deaths from other etiologies. The cardiocirculatory death group received more epinephrine (4.6 ± 3.8 mg versus 1.7 ± 2.8 mg, 3.2 ± 2.6 mg, and 3.5 ± 3.6 mg for survivors, neurological deaths, and other deaths, respectively; p < 0.001). The proportion of cardiocirculatory death increased linearly (R2 = 0.92, p < 0.001) with cumulative epinephrine doses during CPR (17.7% in subjects who did not receive epinephrine and 62.5% in those who received > 10 mg). In multivariable analysis, a cumulative dose of epinephrine was strongly associated with cardiocirculatory death (adjusted odds ratio of 3.45, 95% CI [2.01-5.92] for 1 mg of epinephrine; 12.28, 95% CI [7.52-20.06] for 2-5 mg; and 23.71, 95% CI [11.02-50.97] for > 5 mg; reference 0 mg; population reference: alive at hospital discharge), even after adjustment on duration of resuscitation. The other modes of death (neurological and other causes) were also associated with epinephrine use, but to a lesser extent.

CONCLUSIONS

In non-shockable OHCA with ROSC, the dose of epinephrine used during CPR is strongly associated with early cardiocirculatory death. Further clinical studies aimed at limiting the dose of epinephrine during CPR seem warranted. Moreover, strategies for the prevention and management of PRS should take this dose of epinephrine into consideration for future trials.

Comparative Analysis of Perfusion Index and End-Tidal Carbon Dioxide in Cardiac Arrest Patients: Implications for Hemodynamic Monitoring and Resuscitation Outcomes

BACKGROUND

During cardiopulmonary resuscitation (CPR), some parameters (e.g., intraarterial pressure measurement and end-tidal carbon dioxide (EtCO2)) indicate the quality and outcome of resuscitation. These parameters are generally based on monitoring the hemodynamic status. Perfusion index (PI) is a calculation from the photoplethysmography (PPG) signal and displays the proportion of pulsatile to non-pulsatile light absorption or reflection in the PPG signal. It helps to evaluate cardiac output and tissue perfusion in the care of a critical patient. Its most important advantages are that it can be easily measured with a pulse oximeter probe attached to the finger (non-invasive), can be objectively repeated, can be applied quickly, and is inexpensive. Normal PI values range from 0.2% to 20%. Despite being recognized as a valuable indicator of hemodynamics, there is limited information regarding its relevance in patients experiencing cardiac arrest. Although the PI is known to be a valuable parameter to indicate hemodynamics, information about its value in cardiac arrest patients is limited. This study aims to evaluate the performance of PI and EtCO2 in predicting the return of spontaneous circulation (ROSC) among cardiac arrest patients.

METHODS

This was a single-center, prospective, observational clinical study including both out-of-hospital and in-hospital adult cardiac arrest patients. The study was conducted from November 1, 2018 to April 30, 2019 at the Emergency Department (ED) of the Hacettepe University Hospital, Ankara, Turkey. The EtCO2 values of the patients were recorded at the time they were intubated (t0) and every five minutes (t5, t10, t15...) during CPR. Along with these measurements, PI values were measured with the Masimo Signal Extraction Technology device (Masimo, California, United States). The study's primary outcome was PI's performance in predicting the ROSC among cardiac arrest patients. The secondary outcomes of the study were the performance of EtCO2 in predicting the ROSC among cardiac arrest patients and the association between PI and EtCO2 values.

RESULTS

We included a total of 100 cases. The mean age of patients was 70.4 ± 13.4 years, and 65% were male. The ROSC was achieved in 29 patients. There was no statistical difference in PI values between the ROSC (+) and ROSC (-) groups at any minute. However, in the ROSC (+) group, EtCO2 values were observed to be high starting from the fifth minute (t5, p=0.010; t10, p<0.001; t15, p=0.014; t20, p=0.033; t25, p=0.003, respectively). There was no correlation between the PI and EtCO2 values at 0, 5, 10, 15, 20, and 25 minutes (t0, p=0.436; t5, p=0.154; t10, p=0.557; t15, p=0.740; t20 p=0.241; t25 p=0.201, respectively).

CONCLUSION

Measuring PI values during resuscitation in intubated cardiac arrest patients does not help clinicians predict the outcome. In addition, no correlation was found with EtCO2 values. However, EtCO2 values remained high in patients with the ROSC from the fifth minute onward. Further larger-scale studies are needed regarding the optimal use of PI in cardiac arrest patients.

Association of intraosseous and intravenous access with patient outcome in out-of-hospital cardiac arrest

Here we report the results of a study on the association between drug delivery via intravenous route or intraosseous route in out-of-hospital cardiac arrest. Intraosseous drug delivery is considered an alternative option in resuscitation if intravenous access is difficult or impossible. Intraosseous uptake of drugs may, however, be compromised. We have performed a retrospective cohort study of all Danish patients with out-of-hospital cardiac arrest in the years 2016-2020 to investigate whether mortality is associated with the route of drug delivery. Outcome was 30-day mortality, death at the scene, no prehospital return of spontaneous circulation, and 7- and 90-days mortality. 17,250 patients had out-of-hospital cardiac arrest. 6243 patients received no treatment and were excluded. 1908 patients had sustained return of spontaneous circulation before access to the vascular bed was obtained. 2061 patients were unidentified, and 286 cases were erroneously registered. Thus, this report consist of results from 6752 patients. Drug delivery by intraosseous route is associated with increased OR of: No spontaneous circulation at any time (OR 1.51), Death at 7 days (OR 1.94), 30 days (2.02), and 90 days (OR 2.29). Intraosseous drug delivery in out-of-hospital cardiac arrest is associated with overall poorer outcomes than intravenous drug delivery.

Skeletal muscle oxygenation during cardiopulmonary resuscitation as a predictor of return of spontaneous circulation: a pilot study

BACKGROUND

Near-infrared spectroscopy (NIRS) provides regional tissue oxygenation (rSO2) even in pulseless states, such as out-of-hospital cardiac arrest (OHCA). Brain rSO2 seems to be important predictor of return of spontaneous circulation (ROSC) during cardiopulmonary resuscitation (CPR). Aim of our study was to explore feasibility for monitoring and detecting changes of skeletal muscle rSO2 during resuscitation.

METHODS

Skeletal muscle and brain rSO2 were measured by NIRS (SenSmart Model X-100, Nonin, USA) during CPR in adult patient with OHCA. Start (basal) rSO2, maximal during CPR (maximal) and difference between maximal-minimal rSO2 (delta-rSO2), were recorded. Patients were divided into ROSC and NO-ROSC group.

RESULTS

20 patients [age: 66.0ys (60.5-79.5), 65% male] with OHCA [50% witnessed, 70% BLS, time to ALS 13.5 min (11.0-19.0)] were finally analyzed. ROSC was confirmed in 5 (25%) patients. Basal and maximal skeletal muscle rSO2 were higher in ROSC compared to NO-ROSC group [49.0% (39.7-53.7) vs. 15.0% (12.0-25.2), P =  0.006; 76.0% (52.7-80.5) vs. 34.0% (18.0-49.5), P =  0.005, respectively]. There was non-linear cubic relationship between time of collapse and basal skeletal muscle rSO2 in witnessed OHCA and without BLS (F-ratio = 9.7713, P =  0.0261). There was correlation between maximal skeletal muscle and brain rSO2 (n = 18, rho: 0.578, P =   0.0121).

CONCLUSIONS

Recording of skeletal muscle rSO2 during CPR in patients with OHCA is feasible. Basal and maximal skeletal muscle rSO2 were higher in ROSC compared to NO-ROSC group. Clinical trial registration number ClinicalTrials.gov, NCT04058925, registered on: 16th August 2019. URL of trial registry record: https://www.

CLINICALTRIALS

gov/ct2/show/NCT04058925?titles=Tissue+Oxygenation+During+Cardiopulmonary+Resuscitation+as+a+Predictor+of+Return+of+Spontaneous+Circulation&draw=2&rank=1 .

Non-shockable rhythms: A parametric model for the immediate probability of return of spontaneous circulation

BACKGROUND

Cardiac arrest can present with asystole, Pulseless Electrical Activity (PEA), or Ventricular Fibrillation/Tachycardia (VF/VT). We investigated the transition intensity of Return of spontaneous circulation (ROSC) from PEA and asystole during in-hospital resuscitation.

MATERIALS AND METHODS

We included 770 episodes of cardiac arrest. PEA was defined as ECG with >12 QRS complexes per min, asystole by an isoelectric signal >5 seconds. The observed times of PEA to ROSC transitions were fitted to five different parametric time-to-event models. At values ≤0.1, transition intensities roughly represent next-minute probabilities allowing for direct interpretation. Different entities of PEA and asystole, dependent on whether it was the primary or a secondary rhythm, were included as covariates.

RESULTS

The transition intensities to ROSC from primary PEA and PEA after asystole were unimodal with peaks of 0.12 at 3 min and 0.09 at 6 min, respectively. Transition intensities to ROSC from PEA after VF/VT, or following transient ROSC, exhibited high initial values of 0.32 and 0.26 at 3 minutes, respectively, but decreased. The transition intensity to ROSC from initial asystole and asystole after PEA were both about 0.01 and 0.02; while asystole after VF/VT had an intensity to ROSC of 0.15 initially which decreased. The transition intensity from asystole after temporary ROSC was constant at 0.08.

CONCLUSION

The immediate probability of ROSC develops differently in PEA and asystole depending on the preceding rhythm and the duration of the resuscitation attempt. This knowledge may aid simple bedside prognostication and electronic resuscitation algorithms for monitors/defibrillators.

Is epinephrine still the drug of choice during cardiac arrest in the emergency department of the hospital? A meta-analysis

Epinephrine is the first-line emergency drug for cardiac arrest and anaphylactic reactions but is reported to be associated with many challenges resulting in its under- or improper utilization. Therefore, in this meta-analysis, the efficacy and safety of epinephrine as a first-line cardiac emergency drug for both out-of-hospital and in-hospital patients was assessed. Pertinent articles were searched in central databases like PubMed, Scopus, and Web of Science, using appropriate keywords as per the PRISMA guidelines. Retrospective and prospective studies were included according to the predefined PICOS criteria. RevMan and MedCalc software were used and statistical parameters such as odds ratio and risk ratio were calculated. Twelve clinical trials with a total of 208,690 cardiac arrest patients from 2000 to 2022 were included, in accordance with the chosen inclusion criteria. In the present meta-analysis, a high odds ratio (OR) value of 3.67 (95 % CI 2.32-5.81) with a tau2 value of 0.64, a chi2 value of 12,446.86, df value of 11, I2 value of 100 %, Z-value 5.53, and a p-value < 0.00001 were reported. Similarly, the risk ratio of 1.89 (95 % CI 1.47-2.43) with a tau2 value of 0.19, chi2 value of 11,530.67, df value of 11, I2 value of 100 %, Z-value of 4.95, and p-value < 0.000001. The present meta-analysis strongly prefers epinephrine injection as the first cardiac emergency drug for both out-of-hospital and in-hospital patients during cardiac arrest.

The outcomes of cardiopulmonary resuscitation and their predictors during the coronavirus 2019 pandemic in Iran

BACKGROUND

Coronavirus disease 2019 (COVID-19) can negatively affect different healthcare-related outcomes. Nonetheless, there is limited information about its effects on different healthcare-related outcomes. This study aimed at evaluating the outcomes of cardiopulmonary resuscitation (CPR) and their predictors during the COVID-19 pandemic in Iran.

METHODS

This cross-sectional study was conducted on 1253 patients who had undergone CPR in the emergency wards of teaching hospitals in the west of Iran from the beginning of the first wave to the end of the third epidemic wave of COVID-19 in Iran, between February 20, 2020, and January 20, 2021. Data were collected using the National CPR Documentation Forms developed based on the Utstein Style and routinely used for all patients with cardiac arrest (CA). The SPSS (v. 20.0) program was used to analyze the data through the Chi-square, Fisher's exact, and Mann-Whitney U tests and logistic regression analysis.

RESULTS

Participants' age mean was 64.62 ± 17.54 years. Age mean among participants with COVID-19 was eight years more than other participants. Most participants were male (64.09%) and had at least one underlying disease (64.99%). The total rates of the return of spontaneous circulation (ROSC) and CPR-discharge survival were respectively 15.3% and 3.8% among all participants, 20.25% and 5.17% among participants without COVID-19, and 8.96% and 2.04% among participants with COVID-19. The significant predictors of ROSC were age, affliction by COVID-19, affliction by underlying diseases, baseline rhythm, delay in epinephrine administration, and epinephrine administration time interval, while the significant predictors of CPR-discharge survival were age and baseline rhythm.

CONCLUSIONS

The total rates of ROSC and CPR-discharge survival were respectively 15.3% and 3.8% among all participants. The rates of ROSC and CPR to discharge survival among patients without COVID-19 are respectively 2.26 and 2.53 times more than the rates among patients with COVID-19.

Epinephrine in Out-of-Hospital Cardiac Arrest: A Network Meta-analysis and Subgroup Analyses of Shockable and Nonshockable Rhythms

BACKGROUND

Epinephrine is the most commonly used drug in out-of-hospital cardiac arrest (OHCA) resuscitation, but evidence supporting its efficacy is mixed.

RESEARCH QUESTION

What are the comparative efficacy and safety of standard dose epinephrine, high-dose epinephrine, epinephrine plus vasopressin, and placebo or no treatment in improving outcomes after OHCA?

STUDY DESIGN AND METHODS

In this systematic review and network meta-analysis of randomized controlled trials, we searched six databases from inception through June 2022 for randomized controlled trials evaluating epinephrine use during OHCA resuscitation. We performed frequentist random-effects network meta-analysis and present ORs and 95% CIs. We used the the Grading of Recommendations, Assessment, Development, and Evaluation approach to rate the certainty of evidence. Outcomes included return of spontaneous circulation (ROSC), survival to hospital admission, survival to discharge, and survival with good functional outcome.

RESULTS

We included 18 trials (21,594 patients). Compared with placebo or no treatment, high-dose epinephrine (OR, 4.27; 95% CI, 3.68-4.97), standard-dose epinephrine (OR, 3.69; 95% CI, 3.32-4.10), and epinephrine plus vasopressin (OR, 3.54; 95% CI, 2.94-4.26) all increased ROSC. High-dose epinephrine (OR, 3.53; 95% CI, 2.97-4.20), standard-dose epinephrine (OR, 3.00; 95% CI, 2.66-3.38), and epinephrine plus vasopressin (OR, 2.79; 95% CI, 2.27-3.44) all increased survival to hospital admission as compared with placebo or no treatment. However, none of these agents may increase survival to discharge or survival with good functional outcome as compared with placebo or no treatment. Compared with placebo or no treatment, standard-dose epinephrine improved survival to discharge among patients with nonshockable rhythm (OR, 2.10; 95% CI, 1.21-3.63), but not in those with shockable rhythm (OR, 0.85; 95% CI, 0.39-1.85).

INTERPRETATION

Use of standard-dose epinephrine, high-dose epinephrine, and epinephrine plus vasopressin increases ROSC and survival to hospital admission, but may not improve survival to discharge or functional outcome. Standard-dose epinephrine improved survival to discharge among patients with nonshockable rhythm, but not those with shockable rhythm.

TRIAL REGISTRY

Center for Open Science: https://osf.io/arxwq.

Is 1:1000 adrenaline as a topical haemostat an effective alternative to control bleeding in dentistry and oral surgery?

Minor oral surgery can give rise to bleeding intra- and post-operatively. This can be minimal in most patients; however, it can be more problematic in patients with impaired clotting disorders, liver disease, or taking any form of anticoagulation therapy. Haemostatic agents are available to overcome such bleeding risks. The topical application of 1:1000 adrenaline used in medicine can be considered for use in dentistry. Adrenaline is widely used within medicine, surgery and dentistry. Examples include its use in local anaesthetic agents, in the management of anaphylaxis and as part of the cardiopulmonary resuscitation algorithm. 1:1000 adrenaline used topically for ear, nose and throat surgeries has shown improved visual fields during surgery with better surgical outcomes. It is relatively safe, but in patients with cardiovascular comorbidities, it should be practised with caution. This has precipitated the idea for its use within oral surgical procedures, including canine exposures, third molar surgery, root displacement into the antrum and periapical surgery. The haemostatic effect of 1:1000 adrenaline as an alternative should be considered in operative dentistry and oral surgery to aid in haemostasis and improve intra-operative visualisation, reducing the risk of iatrogenic damage and bleeding, thereby improving treatment outcomes.

Changes in pre- and in-hospital management and outcomes among children with out-of-hospital cardiac arrest between 2012 and 2017 in Kanto, Japan

Previously, the SOS-KANTO 2012 studies, conducted in the Kanto area of Japan, reported a summary of outcomes in patients with out-of-hospital cardiac arrest (OHCA). This sub-analysis of the SOS-KANTO study 2017 aimed to evaluate the neurological outcomes of paediatric OHCA patients, by comparing the SOS-KANTO 2012 and 2017 studies. All OHCA patients, aged < 18 years, who were transported to the participating hospitals by EMS personnel were included in both SOS-KANTO studies (2012 and 2017). The number of survival patients with favourable neurological outcomes (paediatric cerebral performance category 1 or 2) at 1 month did not improve between 2012 and 2017. There was no significant difference in achievement of pre-hospital return of spontaneous circulation (ROSC) [odds ratio (OR): 2.00, 95% confidence interval (95% CI): 0.50-7.99, p = 0.50] and favourable outcome at 1 month [OR: 0.67, 95% CI: 0.11-3.99, p = 1] between the two studies, matched by age, witnessed arrest, bystander CPR, aetiology of OHCA, and time from call to EMS arrival. Multivariable logistic regression showed no significant difference in the achievement of pre-hospital ROSC and favourable outcomes at 1 month between the two studies.

Determination of Exogenous Adrenaline Levels in Patients Undergoing Cardiopulmonary Resuscitation

Core-shell quantum dot ZnS/CdSe screen-printed electrodes were used to electrochemically measure human blood plasma levels of exogenous adrenaline administered to cardiac arrest patients. The electrochemical behavior of adrenaline on the modified electrode surface was investigated using differential pulse voltammetry (DPV), cyclic voltammetry, and electrochemical impedance spectroscopy (EIS). Under optimal conditions, the linear working ranges of the modified electrode were 0.001-3 μM (DPV) and 0.001-300 μM (EIS). The best limit of detection for this concentration range was 2.79 × 10^-8 μM (DPV). The modified electrodes showed good reproducibility, stability, and sensitivity and successfully detected adrenaline levels.

Association between Conversion to Shockable Rhythms and Survival with Favorable Neurological Outcomes for Out-of-Hospital Cardiac Arrests

BACKGROUND

The initial cardiac rhythm in out-of-hospital cardiac arrest (OHCA) portends different prognoses and affects treatment decisions. Initial shockable rhythms are associated with good survival and neurological outcomes but there is conflicting evidence for those who initially present with non-shockable rhythms. The aim of this study is to evaluate if OHCA with conversion from non-shockable (i.e., asystole and pulseless electrical activity) rhythms to shockable rhythms compared to OHCA remaining in non-shockable rhythms is associated with better survival and neurological outcomes.

METHOD

OHCA cases from the Pan-Asian Resuscitation Outcomes Study registry in 13 countries between January 2009 and February 2018 were retrospectively analyzed. Cases with missing initial rhythms, age <18 years, presumed non-medical cause of arrest, and not conveyed by emergency medical services were excluded. Multivariable logistic regression analysis was performed to evaluate the relationship between initial and subsequent shockable rhythm, survival to discharge, and survival with favorable neurological outcomes (cerebral performance category 1 or 2).

RESULTS

Of the 116,387 cases included. 11,153 (9.6%) had initial shockable rhythms and 9,765 (8.4%) subsequently converted to shockable rhythms. Japan had the lowest proportion of OHCA patients with initial shockable rhythms (7.3%). For OHCA with initial shockable rhythm, the adjusted odds ratios (aOR) for survival and good neurological outcomes were 8.11 (95% confidence interval [CI] 7.62-8.63) and 15.4 (95%CI 14.1-16.8) respectively. For OHCA that converted from initial non-shockable to shockable rhythms, the aORs for survival and good neurological outcomes were 1.23 (95%CI 1.10-1.37) and 1.61 (95%CI 1.35-1.91) respectively. The aORs for survival and good neurological outcomes were 1.48 (95%CI 1.22-1.79) and 1.92 (95%CI 1.3 - 2.84) respectively for initial asystole, while the aOR for survival in initial pulseless electrical activity patients was 0.83 (95%CI 0.71-0.98). Prehospital adrenaline administration had the highest aOR (2.05, 95%CI 1.93-2.18) for conversion to shockable rhythm.

CONCLUSION

In this ambidirectional cohort study, conversion from non-shockable to shockable rhythm was associated with improved survival and neurologic outcomes compared to rhythms that continued to be non-shockable. Continued advanced resuscitation may be beneficial for OHCA with subsequent conversion to shockable rhythms.

Preclinical evaluation of triiodothyronine nanoparticles as a novel therapeutic intervention for resuscitation from cardiac arrest

BACKGROUND

Given emerging evidence of rapid non-genomic cytoprotective effects of triiodothyronine (T3), we evaluated the resuscitative efficacy of two nanoparticle formulations of T3 (T3np) designed to prolong cell membrane receptor-mediated signaling.

METHODS

Swine (n = 40) were randomized to intravenous vehicle (empty np), EPI (0.015 mg/kg), T3np (0.125 mg/kg), or T3np loaded with phosphocreatine (T3np + PCr; 0.125 mg/kg) during CPR following 7-min cardiac arrest (n = 10/group). Hemodynamics and biomarkers of heart (cardiac troponin I; cTnI) and brain (neuron-specific enolase; NSE) injury were assessed for up to 4-hours post-ROSC, at which time the heart and brain were collected for post-mortem analysis.

RESULTS

Compared with vehicle (4/10), the rate of ROSC was higher in swine receiving T3np (10/10; p < 0.01), T3np + PCr (8/10; p = 0.08) or EPI (10/10; p < 0.01) during CPR. Although time to ROSC and survival duration were comparable between groups, EPI was associated with a ∼2-fold higher post-ROSC concentration of cTnI vs T3np and T3np + PCr and the early post-ROSC rise in NSE and neuronal injury were attenuated in T3np-treated vs EPI-treated animals. Analysis of hippocampal ultrastructure revealed deterioration of mitochondrial integrity, reduced active zone length, and increased axonal vacuolization in EPI-treated animals vs controls. However, the frequency of these abnormalities was diminished in animals resuscitated with T3np.

CONCLUSIONS

T3np achieved a ROSC rate and post-ROSC survival that was superior to vehicle and comparable to EPI. The attenuation of selected biomarkers of cardiac and neurologic injury at individual early post-ROSC timepoints in T3np-treated vs EPI-treated animals suggests that T3np administration during CPR may lead to more favorable outcomes in cardiac arrest.

Application and investigation of thrombopoiesis-stimulating agents in the treatment of thrombocytopenia

Platelets, derived from a certain subpopulation of megakaryocytes, are closely related to hemostasis, coagulation, metastasis, inflammation, and cancer progression. Thrombopoiesis is a dynamic process regulated by various signaling pathways in which thrombopoietin (THPO)-MPL is dominant. Thrombopoiesis-stimulating agents could promote platelet production, showing therapeutic effects in different kinds of thrombocytopenia. Some thrombopoiesis-stimulating agents are currently used in clinical practices to treat thrombocytopenia. The others are not in clinical investigations to deal with thrombocytopenia but have potential in thrombopoiesis. Their potential values in thrombocytopenia treatment should be highly regarded. Novel drug screening models and drug repurposing research have found many new agents and yielded promising outcomes in preclinical or clinical studies. This review will briefly introduce thrombopoiesis-stimulating agents currently or potentially valuable in thrombocytopenia treatment and summarize the possible mechanisms and therapeutic effects, which may enrich the pharmacological armamentarium for the medical treatment of thrombocytopenia.

Rat model of asphyxia-induced cardiac arrest and resuscitation

Neurologic injury after cardiopulmonary resuscitation is the main cause of the low survival rate and poor quality of life among patients who have experienced cardiac arrest. In the United States, as the American Heart Association reported, emergency medical services respond to more than 347,000 adults and more than 7,000 children with out-of-hospital cardiac arrest each year. In-hospital cardiac arrest is estimated to occur in 9.7 per 1,000 adult cardiac arrests and 2.7 pediatric events per 1,000 hospitalizations. Yet the pathophysiological mechanisms of this injury remain unclear. Experimental animal models are valuable for exploring the etiologies and mechanisms of diseases and their interventions. In this review, we summarize how to establish a standardized rat model of asphyxia-induced cardiac arrest. There are four key focal areas: (1) selection of animal species; (2) factors to consider during modeling; (3) intervention management after return of spontaneous circulation; and (4) evaluation of neurologic function. The aim was to simplify a complex animal model, toward clarifying cardiac arrest pathophysiological processes. It also aimed to help standardize model establishment, toward facilitating experiment homogenization, convenient interexperimental comparisons, and translation of experimental results to clinical application.

Augmented-Medication CardioPulmonary Resuscitation Trials in out-of-hospital cardiac arrest: a pilot randomized controlled trial

BACKGROUND

Previously conducted physician-centered trials on the usefulness of vasopressin have yielded negative results; thus, patient-oriented trials have been warranted. We hypothesize that Augmented-Medication CardioPulmonary Resuscitation could be helpful for selected patients with out-of-hospital cardiac arrest (OHCA).

METHODS

This is a double-blind, single-center, randomized, placebo-controlled trial conducted in the emergency department in a tertiary, university-affiliated hospital in Seoul, Korea. A total of 148 adults with non-traumatic OHCA who had initial diastolic blood pressure (DBP) < 20 mm Hg via invasive arterial monitoring during the early cardiac compression period were randomly assigned to two groups. Patients received a dose of 40 IU of vasopressin or placebo with initial epinephrine. The primary endpoint was a sustained return of spontaneous circulation. Secondary endpoints were survival discharge, and neurologic outcomes at discharge.

RESULTS

Of the 180 included patients, 32 were excluded, and 148 were enrolled in the trial. A sustained return of spontaneous circulation was achieved by 27 patients (36.5%) in the vasopressin group and 24 patients (32.4%) in the control group (risk difference, 4.1%; P = .60). Survival discharge and good neurologic outcomes did not differ between groups. The trial group had significantly higher median DBPs during resuscitation than the control group (16.0 vs. 14.5 mm Hg, P < 0.01). There was no difference in end-tidal carbon dioxide, acidosis, and lactate levels at baseline, 10 min, and end-time.

CONCLUSION

Among patients with refractory vasodilatory shock in OHCA, administration of vasopressin, compared with placebo, did not significantly increase the likelihood of return of spontaneous circulation.

Is there an association between 30-day mortality and adrenaline infusion rates in post-ROSC patients? A retrospective observational analysis

Introduction

Revised guidelines for the management of cardiac arrest have placed greater emphasis on early defibrillation and closed chest compressions; subsequently there has been a significant rise in the number of patients gaining a return of spontaneous circulation (ROSC). As a consequence, emergency medical services have realised the importance of therapies delivered during this phase of care. In some Trusts this includes the use of inotropic agents to augment the cardiovascular system and maintain adequate cerebral and coronary perfusion pressures to mitigate the effects of post-cardiac arrest syndrome. Currently, limited evidence exists with regards to the efficacy of such treatments in the pre-hospital phase.

Methods

Retrospective observational analysis of out-of-hospital cardiac arrest patients who received an adrenaline infusion by critical care paramedics. Infusion rates, time of call (ToC) to ROSC and 30-day mortality were compared.

Results

Over a 2-year period, 202 patients were recorded as having an adrenaline infusion commenced. Of these, 25 were excluded as they did not meet criteria or had incomplete data and 22 were excluded as the infusion was stopped at scene; 155 patients were admitted to hospital. There were no survivors in the non-shockable group and three survivors in the shockable group at 30 days. A rare events analysis found no relationship between infusion rate, ToC to ROSC and 30-day mortality (Wald chi2, 1.37).

Conclusion

Commencement of adrenaline infusions in post-ROSC was associated with significant 30-day mortality, especially in non-shockable rhythms. Further research is needed to elucidate whether this intervention has any benefit in the post-ROSC patient.

Characteristics and outcome of traumatic cardiac arrest at a level 1 trauma centre over 10 years in Sweden

Background

Historically, resuscitation in traumatic cardiac arrest (TCA) has been deemed futile. However, recent literature reports improved but varying survival. Current European guidelines emphasise the addressing of reversible aetiologies in TCA and propose that a resuscitative thoracotomy may be performed within 15 min from last sign of life. To improve clinician understanding of which patients benefit from resuscitative efforts we aimed to describe the characteristics and 30-day survival for traumatic cardiac arrest at a Swedish trauma centre with a particular focus on resuscitative thoracotomy.

Methods

Retrospective cohort study of adult patients (≥ 15 years) with TCA managed at Karolinska University Hospital Solna between 2011 and 2020. Trauma demographics, intra-arrest factors, lab values and procedures were compared between survivors and non-survivors.

Results

Among the 284 included patients the median age was 38 years, 82.2% were male and 60.5% were previously healthy. Blunt trauma was the dominant injury in 64.8% and median Injury Severity Score (ISS) was 38. For patients with a documented arrest rhythm, asystole was recorded in 39.2%, pulseless electric activity in 24.8% and a shockable rhythm in 6.8%. Thirty patients (10.6%) survived to 30 days with a Glasgow Outcome Scale score of 3 (n = 23) or 4 (n = 7). The most common causes of death were haemorrhagic shock (50.0%) and traumatic brain injury (25.5%). Survivors had a lower ISS (P < 0.001), more often had reactive pupils (P < 0.001) and a shockable rhythm (P = 0.04). In the subset of prehospital TCA, survivors less frequently received adrenaline (epinephrine) (P < 0.001) and in lower amounts (P = 0.02). Of patients that underwent resuscitative thoracotomy (n = 101), survivors (n = 12) had a shorter median time from last sign of life to thoracotomy (P = 0.03), however in four of these survivors the time exceeded 15 min.

Conclusion

Survival after TCA is possible. Determining futility in TCA is difficult and this study demonstrates survivors outside of recent guidelines.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-022-01039-9.

Studies on the mechanism of energy metabolism via AMPK/PGC-1α signaling pathway induced by compatibility of Ligusticum chuanxiong Hort and Gastrodia

AMP-activated protein kinase (AMPK) regulates overall energy consumption and energy intake through cytokines. Ligusticum striatum DC (CX) combined with Gastrodia elata Blume (TM) has been used for migraine treatment for millennia. When used alone in clinical practice, CX causes symptoms of thirst, irritability, and yellow urine and has influenced the levels of cytokines such as AMP that activate the AMPK pathway of energy metabolism. However, relationships between this compatibility prescription, integral biological energy metabolism, and the AMPK pathway remain unclear. Studies were performed by treating normal rats with physiological saline, CX extract, CX coupled TM extract, and TM extracts separately for 4 weeks. Food intake, water intake, urine output, stool output, and body weight were monitored once a week by the metabolic cage method. Values of FBG, BUN, TP, TC and TG in blood samples were detected approaching the whole blood automatic detector from 1 to 4 weeks. Na+ -K+ -ATPase, Ca2+ -Mg2+ -ATPase, cAMP, and cGMP activity were determined by the enzyme-linked immunosorbent assay (ELISA); the biological samples that were obtained at 1, 2, 3, and 4 weeks after drug administration were tested by GC-TOF-MS. Then real-time PCR and Western Blot were applied to detect changes in expression of some substances involved in energy metabolism. The results demonstrated that administering CX alone increased energy input, mobility, and respiratory exchange ratio, accelerated energy consumption, and caused inflammatory infiltration in the liver. CX coupled with TM led to lower energy metabolism and liver damage in comparison with CX used alone. Moreover, CX-treated rats harbored higher levels of differential metabolites (including pyrophosphate, oxaloacetic acid, and galactinol). Glycerophospholipid metabolism and the citrate cycle are closely related to the differential metabolites above. In addition, CX-induced unbalanced energy metabolism depends on cAMP activation mediated by the AMPK/PGC-1α pathway in rats. Our findings suggest that CX-induced energy metabolism imbalance was corrected after coupling with TM by mediating the AMPK/PGC-1α pathway.

Intra-Arrest Therapeutic Hypothermia and Neurologic Outcome in Patients Admitted after Out-of-Hospital Cardiac Arrest: A Post Hoc Analysis of the Princess Trial

Background: Despite promising results, the role of intra-arrest hypothermia in out-of-hospital cardiac arrest (OHCA) remains controversial. The aim of this study was to assess the effects of trans-nasal evaporative cooling (TNEC) during resuscitation on neurological recovery in OHCA patients admitted alive to the hospital. Methods: A post hoc analysis of the PRINCESS trial, including only patients admitted alive to the hospital, either assigned to TNEC or standard of care during resuscitation. The primary endpoint was favorable neurological outcome (FO) defined as a Cerebral Performance Category (CPC) of 1–2 at 90 days. The secondary outcomes were overall survival at 90 days and CPC 1 at 90 days. Subgroup analyses were performed according to the initial cardiac rhythm. Results: A total of 149 patients in the TNEC and 142 in the control group were included. The number of patients with CPC 1–2 at 90 days was 56/149 (37.6%) in the intervention group and 45/142 (31.7%) in the control group (p = 0.29). Survival and CPC 1 at 90 days was observed in 60/149 patients (40.3%) vs. 52/142 (36.6%; p = 0.09) and 50/149 (33.6%) vs. 35/142 (24.6%; p = 0.11) in the two groups. In the subgroup of patients with an initial shockable rhythm, the number of patients with CPC 1 at 90 days was 45/83 (54.2%) in the intervention group and 27/78 (34.6%) in the control group (p = 0.01). Conclusions: In this post hoc analysis of admitted OHCA patients, no statistically significant benefits of TNEC on neurological outcome at 90 days was found. In patients with initial shockable rhythm, TNEC was associated with increased full neurological recovery.

The first case series analysis on efficacy of esmolol injection for in-hospital cardiac arrest patients with refractory shockable rhythms in China

Background: This study assessed the effects of esmolol injection in patients with in-hospital cardiac arrest (IHCA) with refractory ventricular fibrillation (VF)/pulseless ventricular tachycardia (pVT).

Methods: From January 2018 to December 2021, 29 patients with IHCA with refractory shockable rhythm were retrospectively reviewed. Esmolol was administered after advanced cardiovascular life support (ACLS)-directed procedures, and outcomes were assessed.

Results: Among the 29 cases, the rates of sustained return of spontaneous circulation (ROSC), 24-h ROSC, and 72-h ROSC were 79%, 62%, and 59%, respectively. Of those patients, 59% ultimately survived to discharge. Four patients with cardiac insufficiency died. The duration from CA to esmolol infusion was significantly shorter for patients in the survival group (SG) than for patients in the dead group (DG) (12 min, IQR: 8.5–19.5 vs. 23.5 min, IQR: 14.4–27 min; p = 0.013). Of those patients, 76% (22 of 29) started esmolol administration after the second dose of amiodarone. No significant difference was observed in the survival rate between this group and groups administered an esmolol bolus simultaneously or before the second dose of amiodarone (43% vs. 64%, p = 0.403). Of those patients, 31% (9 of 29) were administered an esmolol bolus for defibrillation attempts ≤ 5, while the remaining 69% of patients received an esmolol injection after the fifth defibrillation attempt. No significant differences were observed in the rates of ≥ 24-h ROSC (67% vs. 60%, p = 0.73), ≥ 72-h ROSC (67% vs. 55%, p = 0.56), and survival to hospital discharge (67% vs. 55%, p = 0.56) between the groups administered an esmolol bolus for defibrillation attempts ≤ 5 and defibrillation attempts > 5.

Conclusion: IHCA patients with refractory shockable rhythms receiving esmolol bolus exhibited a high chance of sustained ROSC and survival to hospital discharge. Patients with end-stage heart failure tended to have attenuated benefits from beta-blockers. Further large-scale, prospective studies are necessary to determine the effects of esmolol in patients with IHCA with refractory shockable rhythms.

Bone Regeneration in Rat using Polycaprolactone/Gelatin/Epinephrine Scaffold

Solid supports like the extracellular matrix network are necessary for bone cell attachment and start healing in the damaged bone. Scaffolds which are made of different materials are widely used as a supportive structure in bone tissue engineering. In the current study, a 3-D Polycaprolactone/Gelatin bone scaffold was developed by blending electrospinning and freeze-drying techniques for bone tissue engineering. To improve the efficiency of the scaffold, different concentrations of epinephrine due to its effect on bone healing were loaded. Fabricated scaffolds were characterized by different tests such as surface morphology, FTIR, porosity, compressive strength, water contact angle, degradation rate. The interaction between prepared scaffolds and blood and cells was evaluated by hemolysis, and MTT test, respectively, and bone healing was evaluated by a rat calvaria defect model. Based on the results, the porosity of scaffolds was about 75% and by adding epinephrine, mechanical strength decreased while due to the hydrophilic properties of it, degradation rate increased. In vivo and in vitro studies showed the best cell proliferation and bone healing were in PCL/Gelatin/Epinephrine1%-treated group. These results showed the positive effect of fabricated scaffold on osteogenesis and bone healing and the possibility of using it in clinical trials.

A Clinical Practice Guideline for the Emergency Management of Anaphylaxis (2020)

Background: For anaphylaxis, a life-threatening allergic reaction, the incidence rate was presented to have increased from the beginning of the 21st century. Underdiagnosis and undertreatment of anaphylaxis are public health concerns. Objective: This guideline aimed to provide high-quality and evidence-based recommendations for the emergency management of anaphylaxis. Method: The panel of health professionals from fifteen medical areas selected twenty-five clinical questions and formulated the recommendations with the supervision of four methodologists. We collected evidence by conducting systematic literature retrieval and using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Results: This guideline made twenty-five recommendations that covered the diagnosis, preparation, emergency treatment, and post-emergency management of anaphylaxis. We recommended the use of a set of adapted diagnostic criteria from the American National Institute of Allergy and Infectious Diseases and the Food Allergy and Anaphylaxis Network (NIAID/FAAN), and developed a severity grading system that classified anaphylaxis into four grades. We recommended epinephrine as the first-line treatment, with specific doses and routes of administration for different severity of anaphylaxis or different conditions. Proper dosage is critical in the administration of epinephrine, and the monitor is important in the IV administration. Though there was only very low or low-quality evidence supported the use of glucocorticoids and H1 antagonists, we still weakly recommended them as second-line medications. We could not make a well-directed recommendation regarding premedication for preventing anaphylaxis since it is difficult to weigh the concerns and potential effects. Conclusion: For the emergency management of anaphylaxis we conclude that: • NIAID/FAAN diagnostic criteria and the four-tier grading system should be used for the diagnosis • Prompt and proper administration of epinephrine is critical.

Ischemic injury of the upper gastrointestinal tract after out-of-hospital cardiac arrest: a prospective, multicenter study

Background

The consequences of cardiac arrest (CA) on the gastro-intestinal tract are poorly understood. We measured the incidence of ischemic injury in the upper gastro-intestinal tract after Out-of-hospital CA (OHCA) and determined the risk factors for and consequences of gastrointestinal ischemic injury according to its severity.

Methods

Prospective, non-controlled, multicenter study in nine ICUs in France and Belgium conducted from November 1, 2014 to November 30, 2018. Included patients underwent an esophago-gastro-duodenoscopy 2 to 4 d after OHCA if still intubated and the presence of ischemic lesions of the upper gastro-intestinal tract was determined by a gastroenterologist. Lesions were a priori defined as severe if there was ulceration or necrosis and moderate if there was mucosal edema or erythema. We compared clinical and cardiac arrest characteristics of three groups of patients (no, moderate, and severe lesions) and identified variables associated with gastrointestinal ischemic injury using multivariate regression analysis. We also compared the outcomes (organ failure during ICU stay and neurological status at hospital discharge) of the three groups of patients.

Results

Among the 214 patients included in the analysis, 121 (57%, 95% CI 50–63%) had an upper gastrointestinal ischemic lesion, most frequently on the fundus. Ischemic lesions were severe in 55/121 (45%) patients. In multivariate regression, higher adrenaline dose during cardiopulmonary resuscitation (OR 1.25 per mg (1.08–1.46)) was independently associated with increased odds of severe upper gastrointestinal ischemic lesions; previous proton pump inhibitor use (OR 0.40 (0.14–1.00)) and serum bicarbonate on day 1 (OR 0.89 (0.81–0.97)) were associated with lower odds of ischemic lesions. Patients with severe lesions had a higher SOFA score during the ICU stay and worse neurological outcome at hospital discharge.

Conclusions

More than half of the patients successfully resuscitated from OHCA had upper gastrointestinal tract ischemic injury. Presence of ischemic lesions was independently associated with the amount of adrenaline used during resuscitation. Patients with severe lesions had higher organ failure scores during the ICU stay and a worse prognosis.

Clinical Trial RegistrationNCT02349074.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-03939-9.

High dose of epinephrine does not improve survival of children with out-of-hospital cardiac arrest: Results from the French National Cardiac Arrest Registry

OBJECTIVES

The pediatric resuscitation guidelines recommend the use of 0. 01 mg kg^-1 epinephrine during a cardiac arrest; an epinephrine dose higher than that is not recommended. The first aim of this study was to determine the administration rate of high epinephrine dose during pediatric out-of-hospital cardiac arrest. The second aim was to compare the survival status in patients who received high or standard doses of epinephrine.

METHODS

This was a multicenter comparative post-hoc study conducted between January 2011 and July 2021 based on the French National Cardiac Arrest Registry data. All prepubescent (boys < 12 years old, girls < 10 years old) victims of an out-of-hospital cardiac arrest were included. To compare survival status and control bias, patients who received a high epinephrine dose were matched with those who received a standard epinephrine dose using propensity score matching.

RESULTS

The analysis included 755 patients; 400 (53%) received a high dose and 355 (47%) received a standard dose of epinephrine. The median dose (mg kg^-1) per bolus was higher in the high-dose group than that in the standard dose group (0.04 vs. 0.01 mg kg^-1, P < 0.001). Before matching, there was no between-group difference in the 30-day survival rate or survival status at hospital discharge. Matching yielded 288 pairs; there was no between-group difference in the 30-day survival rate or survival at hospital discharge (High dose, n = 5; standard dose, n = 12; Odds ratios: 2.40, 95% confidence interval: 0.85-6.81). Only 2 patients in the standard dose group had a good neurological outcome.

CONCLUSION

More than 50% of the patients did not receive the recommended epinephrine dose during resuscitation. There was no association between patients receiving a high dose or standard dose of epinephrine with the 30-day survival or survival status at hospital discharge. Collaboration across multiple cardiac arrest registries is needed to study the application of pediatric guidelines.

Emergencies in obese patients: a narrative review

Obesity is associated to an increased risk of morbidity and mortality due to respiratory, cardiovascular, metabolic, and neoplastic diseases. The aim of this narrative review is to assess the physio-pathological characteristics of obese patients and how they influence the clinical approach during different emergency settings, including cardiopulmonary resuscitation. A literature search for published manuscripts regarding emergency and obesity across MEDLINE, EMBASE, and Cochrane Central was performed including records till January 1, 2021. Increasing incidence of obesity causes growth in emergency maneuvers dealing with airway management, vascular accesses, and drug treatment due to both pharmacokinetic and pharmacodynamic alterations. Furthermore, instrumental diagnostics and in/out-hospital transport may represent further pitfalls. Therefore, people with severe obesity may be seriously disadvantaged in emergency health care settings, and this condition is enhanced during the COVID-19 pandemic, when obesity was stated as one of the most frequent comorbidity. Emergency in critical obese patients turns out to be an intellectual, procedural, and technical challenge. Organization and anticipation based on the understanding of the physiopathology related to obesity are very important for the physician to be mentally and physically ready to face the associated issues.

Monitoring Mitochondrial Partial Oxygen Pressure During Cardiac Arrest and Extracorporeal Cardiopulmonary Resuscitation. An Experimental Pilot Study in a Pig Model

Introduction: Ischemia and reperfusion are crucial in determining the outcome after cardiac arrest and can be influenced by extracorporeal cardiopulmonary resuscitation (ECPR). The effect of ECPR on the availability and level of oxygen in mitochondria remains unknown. The aim of this study was to find out if skin mitochondrial partial oxygen pressure (mitoPO₂) measurements in cardiac arrest and ECPR are feasible and to investigate its course.

Materials and Methods: We performed a feasibility test to determine if skin mitoPO₂ measurements in a pig are possible. Next, we aimed to measure skin mitoPO₂ in 10 experimental pigs. Measurements were performed using a cellular oxygen metabolism measurement monitor (COMET), at baseline, during cardiac arrest, and during ECPR using the controlled integrated resuscitation device (CIRD).

Results: The feasibility test showed continuous mitoPO₂ values. Nine experimental pigs could be measured. Measurements in six experimental pigs succeeded. Our results showed a delay until the initial spike of mitoPO₂ after ECPR initiation in all six experimental tests. In two experiments (33%) mitoPO₂ remained present after the initial spike. A correlation of mitoPO₂ with mean arterial pressure (MAP) and arterial partial oxygen pressure measured by CIRD (CIRD-PaO₂) seemed not present. One of the experimental pigs survived.

Conclusions: This experimental pilot study shows that continuous measurements of skin mitoPO₂ in pigs treated with ECPR are feasible. The delay in initial mitoPO₂ and discrepancy of mitoPO₂ and MAP in our small sample study could point to the possible value of additional measurements besides MAP to monitor the quality of tissue perfusion during cardiac arrest and ECPR.

Adrenaline improves regional cerebral blood flow, cerebral oxygenation and cerebral metabolism during CPR in a porcine cardiac arrest model using low-flow extracorporeal support

BACKGROUND

The effects of adrenaline on cerebral blood vessels during cardiopulmonary resuscitation (CPR) are not well understood. We developed an extracorporeal CPR model that maintains constant low systemic blood flow while allowing adrenaline-associated effects on cerebral vasculature to be assessed at different mean arterial pressure (MAP) levels independently of the effects on systemic blood flow.

METHODS

After eight minutes of cardiac arrest, low-flow extracorporeal life support (ECLS) (30 ml/kg/min) was started in fourteen pigs. After ten minutes, continuous adrenaline administration was started to achieve MAP values of 40 (n = 7) or 60 mmHg (n = 7). Measurements included intracranial pressure (ICP), cerebral perfusion pressure (CePP), laser-Doppler-derived regional cerebral blood flow (CBF), cerebral regional oxygen saturation (rSO₂), brain tissue oxygen tension (P_btO₂) and extracellular cerebral metabolites assessed by cerebral microdialysis.

RESULTS

During ECLS without adrenaline, regional CBF increased by only 5% (25th to 75th percentile: -3 to 14; p=0.2642) and P_btO₂ by 6% (0-15; p=0.0073) despite a significant increase in MAP to 28 mmHg (25-30; p<0.0001) and CePP to 10 mmHg (8-13; p<0.0001). Accordingly, cerebral microdialysis parameters showed a profound hypoxic-ischemic pattern. Adrenaline administration significantly improved regional CBF to 29±14% (p=0.0098) and 61±25% (p<0.001) and P_btO₂ to 15±11% and 130±82% (both p<0.001) of baseline in the MAP 40 mmHg and MAP 60 mmHg groups, respectively. Importantly, MAP of 60 mmHg was associated with metabolic improvement.

CONCLUSION

This study shows that adrenaline administration during constant low systemic blood flow increases CePP, regional CBF, cerebral oxygenation and cerebral metabolism.

Stress hormones kinetics in ventricular fibrillation cardiac arrest and resuscitation: Translational and therapeutic implications

BACKGROUND

Knowing the kinetics of endogenous stress hormones during cardiac arrest and cardiopulmonary resuscitation (CRP) will help to optimize personalized physiology-guided treatment. The aim of this study was to examine the dynamic changes in stress hormones in a swine model of ventricular fibrillation (VF) cardiac arrest.

METHODS

Ventricular fibrillation was induced in 10 healthy Landrace/Large White piglets, which were subsequently left untreated for 8 min. All animals were resuscitated according to the 2015 European Resuscitation Council guidelines. The concentration of adrenalin, noradrenalin, and cortisol was measured at baseline and at the 4th and 8th minute of VF-cardiac arrest, as well as at 30-min, 60-min, 24 h and 48 h post-ROSC.

RESULTS

By the end of the 4th min of VF, the animals of the ROSC group exhibited significantly higher adrenaline levels compared to those of the no-ROSC group (7264 pg/ml vs. 1648 pg/ml, p = 0.03). Noradrenaline was higher in the ROSC group at the 4th min of VF (3021 pg/ml vs. 1626 pg/ml, p = 0.02). Cortisol levels in the ROSC group were significantly lower by the end of the 8th min of VF [16.25 ng/ml vs. 92.82 ng/ml, p = 0.03]. With a cut-off point of 5970 pg/ml, adrenaline at the 4th min of VF exhibited 100% sensitivity and 80% specificity for predicting ROSC.

CONCLUSION

Higher endogenous adrenaline and lower endogenous cortisol levels were associated with ROSC.

Immediate intravenous epinephrine versus early intravenous epinephrine for in-hospital cardiopulmonary arrest

Background

Intravenous epinephrine has been a key treatment in cardiopulmonary arrest since the early 1960s. The ideal timing for the first dose of epinephrinee is uncertain. We aimed to investigate the association of immediate epinephrine administration (within 1-min of recognition of cardiac arrest) with return of spontaneous circulation (ROSC) up to 24-h.

Methods

This was a multicenter retrospective analysis of patients who underwent cardiopulmonary resuscitation. We included the following patients: 1) ≥18 years-old, 2) non-shockable rhythms, 3) received intravenous epinephrine during cardiopulmonary resuscitation, 4) witnessed in-hospital arrest and 5) first resuscitation attempt (for patients requiring more than one resuscitation attempt). We excluded patients who suffered from traumatic arrest, were pregnant, had shockable rhythms, arrested in the operating room, with Do-Not-Resuscitate (DNR) order, and patient aged 17 years-old or less.

Results

A total of 360 patients were included in the analysis. Median age was 62 years old and median epinephrine administration time was two minutes. We found that immediate epinephrine administration (within 1-min) is associated with higher rates of ROSC up to 24-h (OR = 1.25, 95% CI; [1.01–1.56]), compared with early epinephrine (≥2-min) administration. After adjusting for confounding covariates, earlier administration of epinephrine predicted higher rates of ROSC sustained for up to 24-h (OR 1.33 95%CI [1.13–1.55]).

Conclusions

Immediate administration of epinephrine in conjunction with high-quality CPR is associated with higher rates of ROSC.

Outcome Related to Level of Targeted Temperature Management in Postcardiac Arrest Syndrome of Low, Moderate, and High Severities: A Nationwide Multicenter Prospective Registry

OBJECTIVES

The optimal target temperature during targeted temperature management for patients after cardiac arrest remains under debate. The aim of this study was to evaluate the association between targeted temperature management at lower target temperatures and the neurologic outcomes among patients classified by the severity of postcardiac arrest syndrome.

DESIGN

A multicenter observational study from the out-of-hospital cardiac arrest registry of the Japanese Association for Acute Medicine, which is a nationwide prospective registry of out-of-hospital cardiac arrest patients.

SETTING

A total of 125 critical care medical centers or hospitals with an emergency care department across Japan.

PATIENTS

A total of 1,111 out-of-hospital cardiac arrest patients who had received targeted temperature management.

MEASUREMENTS AND MAIN RESULTS

We divided all 1,111 postcardiac arrest syndrome patients treated with targeted temperature management into two groups: those who received targeted temperature management at a lower target temperature (33-34°C) and those who received targeted temperature management at a higher target temperature (35-36°C). In regard to classification of the patients, we divided the patients into three categories of severity (low, moderate, and high severities) using the risk classification tool, post-Cardiac Arrest Syndrome for Therapeutic hypothermia, which was previously validated. The primary outcome was the percentage of patients with a good neurologic outcome at 30 days, and the secondary outcome was the survival rate at 30 days. Multivariate analysis showed that targeted temperature management at 33-34°C was significantly associated with a good neurologic outcome and survival at 30 days in the moderate severity (odds ratio, 1.70 [95% CI, 1.03-2.83] and 1.90 [95% CI, 1.15-3.16], respectively), but not in the patients of low or high severity (pinteraction = 0.033). Propensity score analysis also showed that targeted temperature management at 33-34°C was associated with a good neurologic outcome in the moderate-severity group (p = 0.022).

CONCLUSIONS

Targeted temperature management at 33-34°C was associated with a significantly higher rate of a good neurologic outcome in the moderate-severity postcardiac arrest syndrome group, but not in the low- or high-severity group.

Effect of Adrenaline on Cerebral Blood Oxygenation Measured by NIRS in a Rat Asphyxia Cardiac Arrest Model

Adrenaline is an important pharmacologic treatment during cardiac arrest (CA) for resuscitation. Recent studies suggest that adrenaline increases the likelihood of return of spontaneous circulation (ROSC) but does not contribute to improving neurological outcomes of CA. The mechanisms have not been elucidated yet. A bimodal increase in mean arterial pressure (MAP) is observed after adrenaline injection in rodent CA models (Okuma et al. Intensive Care Med Exp 7(1), 2019). In this study, we focused on alteration of systemic arterial pressure in conjunction with the measurement of cerebral blood oxygenation (CBO) such as oxyhemoglobin (Oxy-Hb), deoxyhemoglobin (Deoxy-Hb), and tissue oxygenation index (TOI) by near-infrared spectroscopy (NIRS). Male Sprague-Dawley rats were used. We attached NIRS between the nasion and the upper cervical spine. Rats underwent 10 minute asphyxia to induce CA. Then, cardiopulmonary resuscitation (CPR) was started, followed by a 20 μg/kg of bolus adrenaline injection at 30 seconds of CPR. This injection accelerated the first increase in MAP, and ROSC was observed with an abrupt increase in CBO. Interestingly, the second increase in MAP, once it exceeded a certain value, was accompanied by paradoxical decreases of Oxy-Hb and TOI while Deoxy-Hb increased. Based on this finding, we compared Oxy-Hb, Deoxy-Hb, and TOI at the first MAP ≈ 100 mmHg and the second MAP ≈ 100 mmHg. The average of Oxy-Hb and TOI from the 13 animals significantly decreased at the second increase in MAP over 100 mmHg while Deoxy-Hb significantly increased. NIRS identified a decrease in Oxy-Hb after ROSC. These findings may be a clue in understanding the mechanism of how and why adrenaline alters the neurological outcomes of CA post resuscitation.

Effect of Adrenaline on Cerebral Blood Oxygenation Measured by NIRS in a Rat Asphyxia Cardiac Arrest Model

Adrenaline is an important pharmacologic treatment during cardiac arrest (CA) for resuscitation. Recent studies suggest that adrenaline increases the likelihood of return of spontaneous circulation (ROSC) but does not contribute to improving neurological outcomes of CA. The mechanisms have not been elucidated yet. A bimodal increase in mean arterial pressure (MAP) is observed after adrenaline injection in rodent CA models [17]. In this study, we focused on alteration of systemic arterial pressure in conjunction with the measurement of cerebral blood oxygenation (CBO) such as oxyhemoglobin (Oxy-Hb), deoxyhemoglobin (Deoxy-Hb), and tissue oxygenation index (TOI) by near-infrared spectroscopy (NIRS). Male Sprague-Dawley rats were used. We attached NIRS between the nasion and the upper cervical spine. Rats underwent 10-minute asphyxia to induce CA. Then, cardiopulmonary resuscitation (CPR) was started, followed by a 20 μg/kg of bolus adrenaline injection at 30 seconds of CPR. This injection accelerated the first increase in MAP, and ROSC was observed with an abrupt increase in CBO. Interestingly, the second increase in MAP, once it exceeded a certain value, was accompanied by paradoxical decreases of Oxy-Hb and TOI, while Deoxy-Hb increased. Based on this finding, we compared Oxy-Hb, Deoxy-Hb, and TOI at the first MAP ≈ 100 mmHg and the second MAP ≈ 100 mmHg. The average of Oxy-Hb and TOI from the 13 animals significantly decreased at the second increase in MAP over 100 mmHg, while Deoxy-Hb significantly increased. NIRS identified a decrease in Oxy-Hb after ROSC. These findings may be a clue to understanding the mechanism of how and why adrenaline alters the neurological outcomes of CA post-resuscitation.

Translation from animal studies of novel pharmacological therapies to clinical trials in cardiac arrest: A systematic review

BACKGROUND

There is a lack of new promising therapies to improve the dismal outcomes from cardiac arrest. The objectives of this study were: (1) To identify novel pharmacological therapies investigated in experimental animal studies and (2) to identify pharmacological therapies translated from experimental animal studies to clinical trials.

METHODS

PubMed was searched to first identify relevant experimental cardiac arrest animal models published within the last 20 years. Based on this, a list of interventions was created and a second search was performed to identify clinical trials testing one of these interventions. Data extraction was performed using standardised data extraction forms.

RESULTS

We identified 415 animal studies testing 190 different pharmacological interventions. The most commonly tested interventions were classified as vasopressors, anaesthetics/gases, or interventions aimed at molecular targets. We found 43 clinical trials testing 26 different interventions identified in the animal studies. Of these, 13 trials reported positive findings and 30 trials reported neutral findings with regards to the primary endpoint. No study showed harm of the intervention. Some interventions tested in human clinical trials, had previously been tested in animal studies without a positive effect on outcomes. A large number of animal studies was performed after publication of a clinical trial.

CONCLUSION

Numerous different pharmacological interventions have been tested in experimental animal models. Despite this only a limited number of these interventions have advanced to clinical trials, however several of the clinical trials tested interventions that were first tested in experimental animal models.

Epinephrine's effects on cerebrovascular and systemic hemodynamics during cardiopulmonary resuscitation

BACKGROUND

Despite controversies, epinephrine remains a mainstay of cardiopulmonary resuscitation (CPR). Recent animal studies have suggested that epinephrine may decrease cerebral blood flow (CBF) and cerebral oxygenation, possibly potentiating neurological injury during CPR. We investigated the cerebrovascular effects of intravenous epinephrine in a swine model of pediatric in-hospital cardiac arrest. The primary objectives of this study were to determine if (1) epinephrine doses have a significant acute effect on CBF and cerebral tissue oxygenation during CPR and (2) if the effect of each subsequent dose of epinephrine differs significantly from that of the first.

METHODS

One-month-old piglets (n = 20) underwent asphyxia for 7 min, ventricular fibrillation, and CPR for 10-20 min. Epinephrine (20 mcg/kg) was administered at 2, 6, 10, 14, and 18 min of CPR. Invasive (laser Doppler, brain tissue oxygen tension [PbtO₂]) and noninvasive (diffuse correlation spectroscopy and diffuse optical spectroscopy) measurements of CBF and cerebral tissue oxygenation were simultaneously recorded. Effects of subsequent epinephrine doses were compared to the first.

RESULTS

With the first epinephrine dose during CPR, CBF and cerebral tissue oxygenation increased by > 10%, as measured by each of the invasive and noninvasive measures (p < 0.001). The effects of epinephrine on CBF and cerebral tissue oxygenation decreased with subsequent doses. By the fifth dose of epinephrine, there were no demonstrable increases in CBF of cerebral tissue oxygenation. Invasive and noninvasive CBF measurements were highly correlated during asphyxia (slope effect 1.3, p < 0.001) and CPR (slope effect 0.20, p < 0.001).

CONCLUSIONS

This model suggests that epinephrine increases CBF and cerebral tissue oxygenation, but that effects wane following the third dose. Noninvasive measurements of neurological health parameters hold promise for developing and directing resuscitation strategies.

Pre-Hospital Administration of Epinephrine in Pediatric Patients With Out-of-Hospital Cardiac Arrest

BACKGROUND

There is little evidence about pre-hospital advanced life support including epinephrine administration for pediatric out-of-hospital cardiac arrests (OHCAs).

OBJECTIVES

This study aimed to assess the effect of pre-hospital epinephrine administration by emergency-medical-service (EMS) personnel for pediatric OHCA.

METHODS

This nationwide population-based observational study in Japan enrolled pediatric patients age 8 to 17 years with OHCA between January 2007 and December 2016. Patients were sequentially matched with or without epinephrine during cardiac arrest using a risk-set matching based on time-dependent propensity score (probability of receiving epinephrine) calculated at each minute after initiation of cardiopulmonary resuscitation by EMS personnel. The primary endpoint was 1-month survival. Secondary endpoints were 1-month survival with favorable neurological outcome, defined as the cerebral performance category scale of 1 or 2, and pre-hospital return of spontaneous circulation (ROSC).

RESULTS

During the study period, a total of 1,214,658 OHCA patients were registered, and 3,961 pediatric OHCAs were eligible for analyses. Of these, 306 (7.7%) patients received epinephrine and 3,655 (92.3%) did not receive epinephrine. After time-dependent propensity score-sequential matching, 608 patients were included in the matched cohort. In the matched cohort, there were no significant differences between the epinephrine and no epinephrine groups in 1-month survival (epinephrine: 10.2% [31 of 304] vs. no epinephrine: 7.9% [24 of 304]; risk ratio [RR]: 1.13 [95% confidence interval (CI): 0.67 to 1.93]) and favorable neurological outcome (epinephrine: 3.6% [11 of 304] vs. no epinephrine: 2.6% [8 of 304]; RR: 1.56 [95% CI: 0.61 to 3.96]), whereas the epinephrine group had a higher likelihood of achieving pre-hospital ROSC (epinephrine: 11.2% [34 of 304] vs. no epinephrine: 3.3% [10 of 304]; RR: 3.17 [95% CI: 1.54 to 6.54]).

CONCLUSIONS

In this study, pre-hospital epinephrine administration was associated with ROSC, whereas there were no significant differences in 1-month survival and favorable neurological outcome between those with and without epinephrine.

Epidemiology of pediatric cardiopulmonary resuscitation

OBJECTIVE

To analyze the main epidemiological aspects of prehospital and hospital pediatric cardiopulmonary resuscitation and the impact of scientific evidence on survival.

SOURCE OF DATA

This was a narrative review of the literature published at PubMed/MEDLINE until January 2019 including original and review articles, systematic reviews, meta-analyses, annals of congresses, and manual search of selected articles.

SYNTHESIS OF DATA

The prehospital and hospital settings have different characteristics and prognoses. Pediatric prehospital cardiopulmonary arrest has a three-fold lower survival rate than cardiopulmonary arrest in the hospital setting, occurring mostly at home and in children under 1year. Higher survival appears to be associated with age progression, shockable rhythm, emergency medical care, use of automatic external defibrillator, high-quality early life support, telephone dispatcher-assisted cardiopulmonary resuscitation, and is strongly associated with witnessed cardiopulmonary arrest. In the hospital setting, a higher incidence was observed in children under 1year of age, and mortality increased with age. Higher survival was observed with shorter cardiopulmonary resuscitation duration, occurrence on weekdays and during daytime, initial shockable rhythm, and previous monitoring. Despite the poor prognosis of pediatric cardiopulmonary resuscitation, an increase in survival has been observed in recent years, with good neurological prognosis in the hospital setting.

CONCLUSIONS

A great progress in the science of pediatric cardiopulmonary resuscitation has been observed, especially in developed countries. The recognition of the epidemiological aspects that influence cardiopulmonary resuscitation survival may direct efforts towards more effective actions; thus, studies in emerging and less favored countries remains a priority regarding the knowledge of local factors.

The use of prefilled adrenaline syringes improves cardiopulmonary resuscitation quality-high-fidelity simulator-based study

BACKGROUND

In some countries, adrenaline is available only in glass ampoules. However, simplification of cardiopulmonary resuscitation (CPR) by introducing prefilled syringes may ensure more efficient CPR. The aim of this study was to investigate the impact of different forms of adrenaline on the CPR quality.

METHODS

In a randomized cross-examination simulation study, 100 two-person paramedical teams took part in two 10-minute scenarios of sudden cardiac arrest (SCA) in a pulseless electrical activity mechanism (PEA). In the first scenario the set of medicines contained glass ampoules (group ST) with adrenaline, in the second prefilled syringes (group AMPS). The parameters of the CPR quality [correct number and depth of chest compressions (CC), no flow time, chest recoil, time to apply supraglottic airways device (SAD)] were compared.

RESULTS

In group AMPS the first dose of adrenaline was administered after 114.2±28.3 seconds after the initiation of CPR whereas after 178.1±62.6 seconds in group ST (P<0.001). Chest compression fraction (CCF) was higher (81.8%±6.1%) in group AMPS than in group ST (71.2%±7.5%). Paramedics performed CC at better frequency, to a preferred depth and in an appropriate place in group AMPS. Faster decision to apply SAD (131.7±34.0 s in group AMPS and 220.3±81.5 s in group ST) ensured faster achievement of airway patency in this group (181.5±48.7 vs. 271.2±101.5 s).

CONCLUSIONS

Prefilled syringes with crucial drugs during CPR may significantly improve the quality of CPR performed by two-person teams.

Handling of Ventricular Fibrillation in the Emergency Setting

Ventricular fibrillation (VF) and sudden cardiac death (SCD) are predominantly caused by channelopathies and cardiomyopathies in youngsters and coronary heart disease in the elderly. Temporary factors, e.g., electrolyte imbalance, drug interactions, and substance abuses may play an additive role in arrhythmogenesis. Ectopic automaticity, triggered activity, and reentry mechanisms are known as important electrophysiological substrates for VF determining the antiarrhythmic therapies at the same time. Emergency need for electrical cardioversion is supported by the fact that every minute without defibrillation decreases survival rates by approximately 7%–10%. Thus, early defibrillation is an essential part of antiarrhythmic emergency management. Drug therapy has its relevance rather in the prevention of sudden cardiac death, where early recognition and treatment of the underlying disease has significant importance. Cardioprotective and antiarrhythmic effects of beta blockers in patients predisposed to sudden cardiac death were highlighted in numerous studies, hence nowadays these drugs are considered to be the cornerstones of the prevention and treatment of life-threatening ventricular arrhythmias. Nevertheless, other medical therapies have not been proven to be useful in the prevention of VF. Although amiodarone has shown positive results occasionally, this was not demonstrated to be consistent. Furthermore, the potential proarrhythmic effects of drugs may also limit their applicability. Based on these unfavorable observations we highlight the importance of arrhythmia prevention, where echocardiography, electrocardiography and laboratory testing play a significant role even in the emergency setting. In the following we provide a summary on the latest developments on cardiopulmonary resuscitation, and the evaluation and preventive treatment possibilities of patients with increased susceptibility to VF and SCD.