The Pharmacologic Management of Cardiac Arrest

The effectiveness of pharmacologic management of cardiac arrest patients is widely debated; however, several studies published in the past 5 years have begun to clarify some of these issues. This article covers the current state of evidence for the effectiveness of the vasopressor epinephrine and the combination of vasopressin-steroids-epinephrine and antiarrhythmic medications amiodarone and lidocaine and reviews the role of other medications such as calcium, sodium bicarbonate, magnesium, and atropine in cardiac arrest care. We additionally review the role of β-blockers for refractory pulseless ventricular tachycardia/ventricular fibrillation and thrombolytics in undifferentiated cardiac arrest and suspected fatal pulmonary embolism.

Overview and future prospects of out-of-hospital cardiac arrest registries in Japan

Aim

Out-of-hospital cardiac arrest (OHCA) is a life-threatening emergency with high mortality. The "chain of survival" is critical to improving patient outcomes. To develop and enhance this chain of survival, measuring and monitoring the resuscitation processes and outcomes are essential for quality assurance. In Japan, several OHCA registries have successfully been implemented at both local and national levels. We aimed to review and summarise the conception, strengths, and challenges of OHCA registries in Japan.

Method and results

The following representing registries in Japan were reviewed: the All-Japan Utstein registry, the Utstein Osaka Project/the Osaka-CRITICAL study, the SOS-KANTO study, the JAAM-OHCA study, and the SAVE-J II study. The All-Japan Utstein registry, operated by the Fire and Disaster Management Agency of Japan and one of the largest nationwide population-based registries in the world, collects data concerning all patients with OHCA in Japan, excluding in-hospital data. Other research- and hospital-based registries collect detailed out-of-hospital and in-hospital data. The Osaka-CRITICAL study and the SOS-KANTO study are organized at regional levels, and hospitals in the Osaka prefecture and in the Kanto area participate in these registries. The JAAM-OHCA study is managed by the Japanese Association of Acute Medicine and includes 107 hospitals throughout Japan. The Save-J II study focuses on patients with OHCA treated with extracorporeal cardiopulmonary resuscitation.

Conclusion

Each OHCA registry has its own philosophy, strengths, perspectives, and challenges; however, all have been successful in contributing to the improvement of emergency medical service (EMS) systems through the quality improvement process. These registries are expected to be further utilized to enhance EMS systems and improve outcomes for patients with OHCA, while also contributing to the field of resuscitation science.

The Pharmacologic Management of Cardiac Arrest

The effectiveness of pharmacologic management of cardiac arrest patients is widely debated; however, several studies published in the past 5 years have begun to clarify some of these issues. This article covers the current state of evidence for the effectiveness of the vasopressor epinephrine and the combination of vasopressin-steroids-epinephrine and antiarrhythmic medications amiodarone and lidocaine and reviews the role of other medications such as calcium, sodium bicarbonate, magnesium, and atropine in cardiac arrest care. We additionally review the role of β-blockers for refractory pulseless ventricular tachycardia/ventricular fibrillation and thrombolytics in undifferentiated cardiac arrest and suspected fatal pulmonary embolism.

The Additive Effect of Atropine Sulfate during Cardiopulmonary Resuscitation in Out-of-hospital Non-traumatic Cardiac Arrest Patients with Non-shockable Rhythm

Objective The updated guidelines of 2015 for cardiopulmonary resuscitation (CPR) do not recommend the routine use of atropine for cardiopulmonary arrest. Methods The study population included out-of-hospital cardiac arrest (OHCA) patients with non-shockable rhythm who were encountered at a Japanese community hospital between October 1, 2012 and April 30, 2017. Results At the outcome, the epinephrine with atropine and epinephrine-only groups had a similar survival rate to that at hospital admission (28.7% vs. 26.7%: p=0.723). The odds ratio (OR) for the survival to hospital admission after the administration of atropine with epinephrine was 1.33 (95% CI 1.09-1.62; p<0.01), while that after the administration of epinephrine was 0.64 (95% CI: 0.55-0.74, p<0.01). The ORs for the survival to hospital admission for patients with pulseless electrical activity in the epinephrine-alone group and the atropine with epinephrine group were 0.62 (95% CI 0.49-0.78; p<0.01) and 1.35 (95% CI 0.99-1.83; p=0.06), respectively, and those for such patients with asystole in the epinephrine-alone group and the atropine with epinephrine group were 0.64 (95% CI 0.53-0.76; p<0.01) and 1.39 (95% CI 1.10-1.77; p<0.01), respectively. The OR for the survival to hospital admission after the administration of atropine sulfate (1 mg) was 2.91 (95% CI 1.49-5.67; p<0.01), while that for the survival to hospital admission after the administration of 0, 2 and ≥3 mg atropine sulfate was 0.38 (95% CI 0.29-0.50; p<0.01), 1.54 (95% CI 0.58-4.08; p=0.38) and 0.23 (95% CI 0.09-0.60; p<0.01), respectively. Conclusion The addition of atropine (within 2 mg) following epinephrine was a comprehensive independent predictor of the survival to hospital admission for non-shockable (especially asystole) OHCA adults.

Drugs in Out-of-Hospital Cardiac Arrest

Managing out-of-hospital cardiac arrest involves unique challenges, including delays in the initiation of advanced interventions and a limited number of trained personnel on scene. Recent out-of-hospital randomized controlled trials, systematic reviews, and metaanalyses provide key insights into what interventions are best proven to positively impact patient outcomes from out-of-hospital cardiac arrest. We review the literature on medications used in out-of-hospital cardiac arrest and summarize evidence-based guidelines from the American Heart Association that form the basis for most emergency medical services cardiac arrest protocols across the United States.

Does Antiarrhythmic Drug During Cardiopulmonary Resuscitation Improve the One-month Survival: The SOS-KANTO 2012 Study

BACKGROUND

Antiarrhythmic drugs (AAD) are often used for fatal ventricular arrhythmias during cardiopulmonary resuscitation (CPR). However, the efficacy of initial AAD administration during CPR in improving long-term prognosis remains unknown. This study retrospectively evaluated the effect of AAD administration during CPR on 1-month prognosis in the SOS-KANTO 2012 study population.

METHODS AND RESULTS

Of the 16,164 out-of-hospital cardiac arrest cases, 1350 shock-refractory patients were included: 747 patients not administered AAD and 603 patients administered AAD. Statistical adjustment for potential selection bias was performed using propensity score matching, yielding 1162 patients of whom 792 patients were matched (396 pairs). The primary outcome was 1-month survival. The secondary outcome was the proportion of patients with favorable neurological outcome at 1 month. Logistic regression with propensity scoring demonstrated an odds ratio (OR) for 1-month survival in the AAD group of 1.92 (P < 0.01), whereas the OR for favorable neurological outcome at 1 month was 1.44 (P = 0.26).

CONCLUSIONS

Significantly greater 1-month survival was observed in the AAD group compared with the non-AAD group. However, the effect of ADD on the likelihood of a favorable neurological outcome remains unclear. The findings of the present study may indicate a requirement for future randomized controlled trials evaluating the effect of ADD administration during CPR on long-term prognosis.

Improving Survival From Cardiac Arrest: A Review of Contemporary Practice and Challenges

Cardiac arrest is a common and lethal condition frequently encountered by emergency medicine providers. Resuscitation of persons after cardiac arrest remains challenging, and outcomes remain poor overall. Successful resuscitation hinges on timely, high-quality cardiopulmonary resuscitation. The optimal method of providing chest compressions and ventilator support during cardiac arrest remains uncertain. Prompt and effective defibrillation of ventricular arrhythmias is one of the few effective therapies available for treatment of cardiac arrest. Despite numerous studies during several decades, no specific drug delivered during cardiac arrest has been shown to improve neurologically intact survival after cardiac arrest. Extracorporeal circulation can rescue a minority of highly selected patients with refractory cardiac arrest. Current management of pulseless electrical activity is associated with poor outcomes, but it is hoped that a more targeted diagnostic approach based on electrocardiography and bedside cardiac ultrasonography may improve survival. The evolution of postresuscitation care appears to have improved cardiac arrest outcomes in patients who are successfully resuscitated. The initial approach to early stabilization includes standard measures, such as support of pulmonary function, hemodynamic stabilization, and rapid diagnostic assessment. Coronary angiography is often indicated because of the high frequency of unstable coronary artery disease in comatose survivors of cardiac arrest and should be performed early after resuscitation. Optimizing and standardizing our current approach to cardiac arrest resuscitation and postresuscitation care will be essential for developing strategies for improving survival after cardiac arrest.

Investigation and treatment of pulmonary embolism as a potential etiology may be important to improve post-resuscitation prognosis in non-shockable out-of-hospital cardiopulmonary arrest: report on an analysis of the SOS-KANTO 2012 study

Background

The prognosis of non-shockable out-of-hospital cardiac arrest is worse than that of shockable out-of-hospital cardiac arrest. We investigated the associations between the etiology and prognosis of non-shockable out-of-hospital cardiac arrest patients who experienced the return of spontaneous circulation after arriving at hospital.

Methods and Results

All subjects were extracted from the SOS-KANTO 2012 study population. The subjects were 3,031 adults: (i) who had suffered out-of-hospital cardiac arrest, (ii) for whom there were no pre-hospital data on ventricular fibrillation/pulseless ventricular tachycardia until arrival at hospital, (iii) who experienced the return of spontaneous circulation after arriving at hospital. We compared the patients' prognosis after 1 and 3 months between various etiological and presumed cardiac factors. The proportion of the favorable brain function patients that developed pulmonary embolism or incidental hypothermia was significantly higher than that of the patients with presumed cardiac factors (1 month, P < 0.0001 and P < 0.0001, respectively; 3 months, P = 0.0018 and P < 0.0001, respectively). In multiple logistic regression analysis, pulmonary embolism and incidental hypothermia were found to be significant independent prognostic factors for 1- and 3-month survival and the favorable brain function rate.

Conclusions

In patients who suffer non-shockable out-of-hospital cardiac arrest, but who experience the return of spontaneous circulation after arriving at hospital, the investigation and treatment of pulmonary embolism as a potential etiology may be important for improving post-resuscitation prognosis.

Changes in pre- and in-hospital management and outcomes for out-of-hospital cardiac arrest between 2002 and 2012 in Kanto, Japan: the SOS-KANTO 2012 Study

Aim

The current study compares pre- and in-hospital management and outcomes of out-of-hospital cardiac arrest cases between 2002 and 2012 in the Kanto region of Japan.

Methods

We compared the data collected for the SOS-KANTO study project in 2002 and 2012. We included adult patients (aged >18 years) who experienced bystander-witnessed out-of-hospital cardiac arrest of cardiac etiology. The outcomes were as follows: proportion of favorable neurological outcomes at 1 month, bystander cardiopulmonary resuscitation provision, and pre- and postresuscitation treatment administration.

Results

Of 4,171 patients (1,982 in SOS-KANTO in 2002 and 2,189 in 2012), the proportion of those with favorable neurological outcomes at 1 month (4.8% versus 9.0%, P < 0.001), and bystander cardiopulmonary resuscitation rates increased significantly between 2002 and 2012 (24.5% versus 38.9%, P < 0.001). Although none were documented in 2002, 118 cases (5.4%) of layperson use of an automated external defibrillator were recorded in 2012. Relative to 2002, use of an i.v. line to provide fluid was more frequently attempted and carried out successfully by emergency medical service providers in 2012. Among cases in which return of spontaneous circulation was achieved, more postresuscitation treatment was provided in 2012 (13.3% versus 43.8%, P < 0.001) relative to that provided in 2002.

Conclusions

Proportions of bystander cardiopulmonary resuscitation, layperson use of automated external defibrillator, provision of prehospital adrenaline and postresuscitation treatment, and favorable neurological outcomes at 1 month increased significantly over 10 years in the Kanto region of Japan.

Updates in the American Heart Association guidelines for cardiopulmonary resuscitation and potential applications to veterinary patients

OBJECTIVE

To review the updates in the American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and identify potential applications to veterinary patients.

ETIOLOGY

Cardiopulmonary arrest is common in veterinary emergency and critical care, and consensus guidelines are lacking. Human resuscitation guidelines are continually evolving as new clinical and experimental studies support updated recommendations. Synthesis of human, experimental animal model, and veterinary literature support the potential for updates and advancement in veterinary CPR practices.

THERAPY

This review serves to highlight updates in the AHA guidelines for CPR and evaluate their application to small animal veterinary patients. Interventions identified will be evaluated for trans-species potential, raise questions regarding best resuscitation recommendations, and offer opportunities for further research to continue to advance veterinary CPR.

PROGNOSIS

The prognosis for any patient undergoing cardiopulmonary arrest remains guarded.

Changes of cerebral oxygen metabolism and hemodynamics during ECPR with hypothermia measured by near-infrared spectroscopy: a pilot study

BACKGROUND

The 2010 CPR Guidelines recommend that extracorporeal cardiopulmonary resuscitation (ECPR) using an emergency cardiopulmonary bypass (CPB) should be considered for patients with cardiac arrest. However, it is not yet clear whether this therapy can improve cerebral circulation and oxygenation in these patients. To clarify this issue, we evaluated changes of cerebral blood oxygenation (CBO) during ECPR using near-infrared spectroscopy (NIRS).

METHODS

We employed NIRS to measure CBO in the bilateral frontal lobe in patients transported to the emergency room (ER) after out-of-hospital cardiac arrest between November 2009 and June 2011.

RESULTS

Fifteen patients met the above criteria. The tissue oxygenation index (TOI) on arrival at the ER was 36.5 %. This increased to 67.8 % during ECPR (P < 0.001). The one patient whose TOI subsequently decreased had a favorable neurological outcome.

CONCLUSION

Increase of TOI during ECPR might reflect an improvement in cerebral blood flow, while decrease of TOI after ECPR might reflect oxygen utilization by the brain tissue as a result of neuronal cell survival. NIRS may be useful for monitoring cerebral hemodynamics and oxygen metabolism during CPR.