Impact of Coronavirus Disease 2019 Pandemic on Cardiac Arrest and Emergency Care

The incidence of both out-of-hospital and in-hospital cardiac arrest increased during the coronavirus disease 2019 (COVID-19) pandemic. Patient survival and neurologic outcome after both out-of-hospital and in-hospital cardiac arrest were reduced. Direct effects of the COVID-19 illness combined with indirect effects of the pandemic on patient's behavior and health care systems contributed to these changes. Understanding the potential factors offers the opportunity to improve future response and save lives.

Etiology-Based Prognosis of Extracorporeal CPR Recipients After Out-of-Hospital Cardiac Arrest: A Retrospective Multicenter Cohort Study

BACKGROUND

A better understanding of the relative contributions of various factors to patient outcomes is essential for optimal patient selection for extracorporeal CPR (ECPR) therapy for patients with out-of-hospital cardiac arrest (OHCA). However, evidence on the prognostic comparison based on the etiologies of cardiac arrest is limited.

RESEARCH QUESTION

What is the etiology-based prognosis of patients undergoing ECPR for OHCA?

STUDY DESIGN AND METHODS

This retrospective multicenter registry study involved 36 institutions in Japan and included all adult patients with OHCA who underwent ECPR between January 2013 and December 2018. The primary etiology for OHCA was determined retrospectively from all hospital-based data at each institution. We performed a multivariable logistic regression model to determine the association between etiology of cardiac arrest and two outcomes: favorable neurologic outcome and survival at hospital discharge.

RESULTS

We identified 1,781 eligible patients, of whom 1,405 (78.9%) had cardiac arrest because of cardiac causes. Multivariable logistic regression analysis for favorable neurologic outcome showed that accidental hypothermia (adjusted OR, 5.12; 95% CI, 2.98-8.80; P < .001) was associated with a significantly higher rate of favorable neurologic outcome than cardiac causes. Multivariable logistic regression analysis for survival showed that accidental hypothermia (adjusted OR, 5.19; 95% CI, 3.15-8.56; P < .001) had significantly higher rates of survival than cardiac causes. Acute aortic dissection/aneurysm (adjusted OR, 0.07; 95% CI, 0.02-0.28; P < .001) and primary cerebral disorders (adjusted OR, 0.12; 95% CI, 0.03-0.50; P = .004) had significantly lower rates of survival than cardiac causes.

INTERPRETATION

In this retrospective multicenter cohort study, although most patients with OHCA underwent ECPR for cardiac causes, accidental hypothermia was associated with favorable neurologic outcome and survival; in contrast, acute aortic dissection/aneurysm and primary cerebral disorders were associated with nonsurvival compared with cardiac causes.

Canadian Cardiovascular Society/Canadian Cardiovascular Critical Care Society/Canadian Association of Interventional Cardiology Clinical Practice Update on Optimal Post Cardiac Arrest and Refractory Cardiac Arrest Patient Care

Survival to hospital discharge among patients with out-of-hospital cardiac arrest (OHCA) is low and important regional differences in treatment practices and survival have been described. Since the 2017 publication of the Canadian Cardiovascular Society's position statement on OHCA care, multiple randomized controlled trials have helped to better define optimal post cardiac arrest care. This working group provides updated guidance on the timing of cardiac catheterization in patients with ST-elevation and without ST-segment elevation, on a revised temperature control strategy targeting normothermia instead of hypothermia, blood pressure, oxygenation, and ventilation parameters, and on the treatment of rhythmic and periodic electroencephalography patterns in patients with a resuscitated OHCA. In addition, prehospital trials have helped craft new expert opinions on antiarrhythmic strategies (amiodarone or lidocaine) and outline the potential role for double sequential defibrillation in patients with refractory cardiac arrest when equipment and training is available. Finally, we advocate for regionalized OHCA care systems with admissions to a hospital capable of integrating their post OHCA care with comprehensive on-site cardiovascular services and provide guidance on the potential role of extracorporeal cardiopulmonary resuscitation in patients with refractory cardiac arrest. We believe that knowledge translation through national harmonization and adoption of contemporary best practices has the potential to improve survival and functional outcomes in the OHCA population.

Scrutinizing the Role of Venoarterial Extracorporeal Membrane Oxygenation: Has Clinical Practice Outpaced the Evidence?

The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for temporary mechanical circulatory support in various clinical scenarios has been increasing consistently, despite the lack of sufficient evidence regarding its benefit and safety from adequately powered randomized controlled trials. Although the ARREST trial (Advanced Reperfusion Strategies for Patients with Out-of-Hospital Cardiac Arrest and Refractory Ventricular Fibrillation) and a secondary analysis of the PRAGUE OHCA trial (Prague Out-of-Hospital Cardiac Arrest) provided some evidence in favor of VA-ECMO in the setting of out-of-hospital cardiac arrest, the INCEPTION trial (Early Initiation of Extracorporeal Life Support in Refractory Out-of-Hospital Cardiac Arrest) has not found a relevant improvement of short-term mortality with extracorporeal cardiopulmonary resuscitation. In addition, the results of the recently published ECLS-SHOCK trial (Extracorporeal Life Support in Cardiogenic Shock) and ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock) discourage the routine use of VA-ECMO in patients with infarct-related cardiogenic shock. Ongoing clinical trials (ANCHOR [Assessment of ECMO in Acute Myocardial Infarction Cardiogenic Shock, NCT04184635], REVERSE [Impella CP With VA ECMO for Cardiogenic Shock, NCT03431467], UNLOAD ECMO [Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO, NCT05577195], PIONEER [Hemodynamic Support With ECMO and IABP in Elective Complex High-risk PCI, NCT04045873]) may clarify the usefulness of VA-ECMO in specific patient subpopulations and the efficacy of combined mechanical circulatory support strategies. Pending further data to refine patient selection and management recommendations for VA-ECMO, it remains uncertain whether the present usage of this device improves outcomes.

Hypothermic Cardiac Arrest: A Case Report of an Unexpected Survivor Using Air Medical Transportation in Nepal

This is a case of a 34-year-old man surviving hypothermic cardiac arrest with excellent neurologic recovery in Nepal. After 3 days without communication at an altitude of approximately 6,000 m, the patient was located in a crevasse and retrieved by a helicopter-supported search and rescue team. At first contact, he was reported to be breathing and shivering with appropriate pupillary response. The patient was then flown to a local teaching hospital where he was assessed on arrival and found to be in cardiac arrest with absence of spontaneous breathing and a central pulse and bilaterally fixed and dilated pupils. An electrocardiogram demonstrated asystole, and his core temperature was unrecordably low on the available device. After resuscitation and return of spontaneous circulation, the patient received a secondary helicopter transfer to a major hospital in the capital, Kathmandu, where his recovery continued. The report discusses the physiological basis of the relatively favorable outcomes observed in hypothermic cardiac arrest and highlights the operations and capability of helicopter emergency medical services in a country on the United Nations list of least developed nations.

The association of clinical, treatment, and demographic characteristics with rearrest in a national dataset

INTRODUCTION

Following initial resuscitation from out-of-hospital cardiac arrest, rearrest frequently occurs and has been associated with adverse outcomes. We aimed to identify clinical, treatment, and demographic characteristics associated with prehospital rearrest at the encounter and agency levels.

METHODS

Adult non-traumatic cardiac arrest patients who achieved ROSC following EMS resuscitation in the 2018-2021 ESO annual datasets were included in this study. Patients were excluded if they had a documented DNR/POLST or achieved ROSC after bystander CPR only. Rearrest was defined as post-ROSC CPR initiation, administration of ≥ 1 milligram of adrenaline, defibrillation, or a documented non-perfusing rhythm on arrival at the receiving hospital. Multivariable logistic regression modeling was used to evaluate the association between rearrest and case characteristics. Linear regression modeling was used to evaluate the association between agency-level factors (ROSC rate, scene time, and scene termination rate), and rearrest rate.

RESULTS

Among the 53,027 cases included, 16,116 (30.4%) experienced rearrest. Factors including longer response intervals, longer 'low-flow' intervals, unwitnessed OHCA, and a lack of bystander CPR were associated with rearrest. Among agencies that treated ≥ 30 patients with outcome data, the agency-level rate of rearrest was inversely associated with agency-level rate of survival to discharge to home (R2 = -0.393, p < 0.001).

CONCLUSIONS

This multiagency retrospective study found that factors associated with increased ischaemic burden following OHCA were associated with rearrest. Agency-level rearrest frequency was inversely associated with agency-level survival to home. Interventions that decrease the burden of ischemia sustained by OHCA patients may decrease the rate of rearrest and increase survival.

Association of admission serum sodium and outcomes following out-of-hospital cardiac arrest

BACKGROUND

The prognostic association between dysnatremia and outcomes in out-of-hospital cardiac arrest (OHCA) is not well understood. Given hypernatremia is associated with poor outcomes in critical illness and hyponatremia may exacerbate cerebral edema, we hypothesized that dysnatremia on OHCA hospital admission would be associated with worse neurological outcomes.

METHODS

We studied adults (≥19 years) with non-traumatic OHCA between 2009 and 2016 who were enrolled in the British Columbia Cardiac Arrest Registry and survived to hospital admission at 2 quaternary urban hospitals. We stratified cases by admission serum sodium into hyponatremic (<135 mmol/L), normonatremic (135-145 mmol/L), and hypernatremic (>145 mmol/L) groups. We used logistic regression models, adjusted for age, sex, shockable rhythm, admission serum lactate, and witnessed arrest, to estimate the association between admission sodium and favorable neurological outcome (cerebral performance category 1-2 or modified Rankin scale 0-3).

RESULTS

Of 414 included patients, 63 were hyponatremic, 330 normonatremic, and 21 hypernatremic. In each respective group, 21 (33.3%), 159 (48.2%), and 3 (14.3%) experienced good neurological outcomes. In univariable models, hyponatremia (OR 0.53, 95% CI 0.30-0.93) and hypernatremia (OR 0.19, 95% CI 0.05-0.65) were associated with lower odds of good neurological outcomes compared to the normonatremia group. After adjustment, only hypernatremia was associated with lower odds of good neurological outcomes (OR 0.22, 95% CI 0.05-0.98).

CONCLUSIONS

Hypernatremia at admission was independently associated with decreased probability of good neurological outcomes at discharge post-OHCA. Future studies should focus on elucidating the pathophysiology of dysnatremia following OHCA.

Out-of-hospital cardiac arrest: Survival in children and young adults over 30 years, a nationwide registry-based cohort study

OBJECTIVES

We studied short-term (30-day) and long-term (up to ten-year) survival among children and young adults following out-of-hospital cardiac arrest (OHCA) in Sweden over the course of the past 30 years. We also studied the causes of OHCA in children and examined predictors of survival.

SETTING

This was a nationwide, registry-based cohort study, using the Swedish Registry of Cardiopulmonary Resuscitation. Our study comprised a cohort of 4,804 individuals aged 0 to 30 years who suffered OHCA between 1990 and 2020, in whom cardiopulmonary resuscitation (CPR) was initiated. We stratified the study cohort to distinct age groups and time periods.

RESULTS

We found an increase in 30-day survival from 7% to 20% over the span of 30 years. In those under 1 year of age, survival increased from 2% to 19%. Time to CPR decreased from 14 to 2 min. The 10-year survival was high among those who survived 30 days. The etiology of cardiac arrests exhibited significant variations across different age groups but remained relatively consistent over time. Causes linked to mental illness constituted a substantial percentage of these cases. Compared to the reference period (1990-1994), the odds of survival in 2015-2020 was 3.00 (95% CI: 1.43, 6.94; p = 0.006).

CONCLUSION

Survival rate after OHCA in children and young adults has increased three-fold over the past 30 years. Still overall mortality is high underscoring the need for continued efforts to mitigate risk factors and optimize survival.

Intra-aortic balloon pump in patients with extracorporeal cardiopulmonary resuscitation after cardiac arrest caused by acute coronary syndrome

BACKGROUND

This study evaluated the association between intra-aortic balloon pump (IABP) use in patients with out-of-hospital cardiac arrest (OHCA) caused by acute coronary syndrome (ACS) who received extracorporeal cardiopulmonary resuscitation (ECPR) and 30-day outcomes.

METHODS

This study was a secondary analysis of data from the SAVE-J II study, a retrospective, multicenter registry study involving 36 participating institutions in Japan. Patients with cardiac arrest caused by ACS who received ECPR were divided into two groups depending on whether or not they received IABP. The primary outcome was 30-day survival. Subgroup analysis was performed to detect what type of patients were mostly associated with improved outcomes.

RESULTS

Of 2,157 patients registered in the SAVE-J II study, 877 patients were enrolled in this study, 702 patients in the IABP group and 175 patients in the non-IABP group. Multivariable logistic regression analysis did not reveal a significant difference in 30-day survival (OR 1.37, 95% CI 0.91-2.07, p = 0.13). In the subgroup analysis, 30-day survival among patients without percutaneous coronary intervention (PCI) and stenosis of multiple coronary vessels were associated with IABP use.

CONCLUSIONS

IABP use in patients with OHCA with ACS who received ECPR is not associated with 30-day survival. The use of IABP in patients who did not have PCI and have multiple coronary vessel stenoses warrants further study.

Clinical and angiographic characteristics of out-of-hospital cardiac arrest among patients with ST-segment elevation myocardial infarction

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is the most severe complication of ST-segment elevation myocardial infarction (STEMI). Nevertheless, clinical and angiographic characteristics associated with OHCA among patients with STEMI have not been studied extensively.

AIM

To evaluate the clinical and angiographic characteristics of consecutive patients who presented with STEMI associated or not with OHCA.

METHODS

This was an observational study including consecutive patients treated for STEMI associated or not with OHCA. Baseline clinical and angiographic characteristics, biological characteristics and mortality were compared between patients with STEMI who experienced OHCA and patients with STEMI who did not.

RESULTS

Among the 686 included patients with STEMI, 148 (21.6%) presented with concomitant OHCA. Multivariable analysis revealed that culprit lesion localized on the left system (odds ratio [OR] 1.94, 95% confidence interval [CI] 1.24-3.13; P<0.01), culprit lesion at the level of a bifurcation lesion (OR 1.87, 95% CI 1.21-2.88; P<0.01) and the presence of chronic total occlusion on another artery (OR 3.39, 95% CI 1.93-5.99; P<0.001) were associated with the occurrence of OHCA, whereas dyslipidaemia, familial history of coronary artery disease and hypertension were found to be negatively associated with the occurrence of OHCA in patients with STEMI: OR 0.47, 95% CI 0.29-0.75 (P<0.01); OR 0.09, 95% CI 0.02-0.25 (P<0.001); and OR 0.60, 95% CI 0.38-0.93 (P=0.02), respectively.

CONCLUSION

In this study of consecutive patients with STEMI, culprit lesion localized on the left system, culprit lesion at the level of a bifurcation lesion and the presence of chronic total occlusion on a non-culprit artery were associated with OHCA.

Incidence and Long-Term Outcomes of Acute Myocardial Infarction Among Survivors of Out-of-Hospital Cardiac Arrest

BACKGROUND

Despite the increasing long-term survival after out-of-hospital cardiac arrest (OHCA), the risk of subsequent acute myocardial infarction (AMI) remains poorly understood. We aimed to determine the incidence, predictors, and long-term outcomes of AMI among survivors of OHCA.

METHODS AND RESULTS

We assembled a retrospective cohort of 882 patients with OHCA who survived to 30 days or discharge from the hospital between 2010 and 2019. Survivors of OHCA had an increased risk of subsequent AMI, defined as AMI occurring 30 days after index OHCA or following discharge from the hospital after OHCA, compared with the general population when matched for age and sex (standardized incidence ratio, 4.64 [95% CI, 3.52-6.01]). Age-specific risks of subsequent AMI for men (standardized incidence ratio, 3.29 [95% CI, 2.39-4.42]) and women (standardized incidence ratio, 6.15 [95% CI, 3.27-10.52]) were significantly increased. A total of 7.2%, 8.3%, and 14.3% of survivors of OHCA had a subsequent AMI at 3 years, 5 years, and end of follow-up, respectively. Age at OHCA (hazard ratio [HR], 1.04 [95% CI, 1.02-1.06]) and past medical history of prior AMI, defined as any AMI preceding or during the index OHCA event (HR, 1.84 [95% CI, 1.05-3.22]), were associated with subsequent AMI, while an initial shockable rhythm was not (HR, 1.00 [95% CI, 0.52-1.94]). Survivors of OHCA with subsequent AMI had a higher risk of death (HR, 1.58 [95% CI, 1.12-2.22]) than those without.

CONCLUSIONS

Survivors of OHCA are at an increased risk of subsequent AMI compared with the general population. Prior AMI, but not an initial shockable rhythm, increases this risk, while subsequent AMI predicts death. Preventive measures for AMI including cardiovascular risk factor control and revascularization may thus improve outcomes in selected patients with cardiac pathogenesis.

Acute coronary occlusion and percutaneous coronary intervention after out-of-hospital cardiac arrest

OBJECTIVES

Early coronary angiography (CAG) has been recommended in selected patients following out-of-hospital-cardiac-arrest (OHCA). We aimed to identify clinical features associated with acute coronary occlusion (ACO) and evaluate the associations between ACO, successful percutaneous coronary intervention (PCI) and outcomes in this population.

METHODS

We included comatose OHCA patients treated with targeted temperature management (TTM) between December 2005 and September 2016 who underwent early CAG within 24 hours. The co-primary outcomes were all-cause 30-day mortality and good neurological outcome (modified Rankin Score [mRS] ≤2) at hospital discharge.

RESULTS

Among 155 patients (93% shockable arrest rhythm, 55% with ST elevation), 133 (86%) had coronary artery stenosis ≥50% and 65 (42%) had ACO. ST elevation (sensitivity 74%, specificity 59%, OR 4.0, 95% CI 2.0-8.1) and elevated first troponin (sensitivity 88%, specificity 26%, OR 2.5, 95% CI 1.1-6.1) had limited sensitivity and specificity for ACO. Unadjusted 30-day mortality did not differ significantly by coronary disease severity or ACO. Successful PCI was associated with a lower risk of 30-day mortality (adjusted HR 0.5, 95% CI 0.2-0.9, P=.03), especially among patients with ACO (adjusted HR 0.4, 95% CI 0.1-0.9, P=0.03). After adjustment, ACO and PCI were not associated with the probability of good neurological outcome.

CONCLUSIONS

In this select cohort of resuscitated OHCA patients undergoing CAG, unstable coronary disease is highly prevalent and successful PCI was associated with a higher probability of 30-day survival, especially among those with ACO. Neither ACO nor successful PCI were independently associated with good neurological outcome.

The impact of COVID-19 pandemic on out-of-hospital cardiac arrest: An individual patient data meta-analysis

AIM

Prior studies have reported increased out-of-hospital cardiac arrests (OHCA) incidence and lower survival during the COVID-19 pandemic. We evaluated how the COVID-19 pandemic affected OHCA incidence, bystander CPR rate and patients' outcomes, accounting for regional COVID-19 incidence and OHCA characteristics.

METHODS

Individual patient data meta-analysis of studies which provided a comparison of OHCA incidence during the first pandemic wave (COVID-period) with a reference period of the previous year(s) (pre-COVID period). We computed COVID-19 incidence per 100,000 inhabitants in each of 97 regions per each week and divided it into its quartiles.

RESULTS

We considered a total of 49,882 patients in 10 studies. OHCA incidence increased significantly compared to previous years in regions where weekly COVID-19 incidence was in the fourth quartile (>136/100,000/week), and patients in these regions had a lower odds of bystander CPR (OR 0.49, 95%CI 0.29-0.81, p = 0.005). Overall, the COVID-period was associated with an increase in medical etiology (89.2% vs 87.5%, p < 0.001) and OHCAs at home (74.7% vs 67.4%, p < 0.001), and a decrease in shockable initial rhythm (16.5% vs 20.3%, p < 0.001). The COVID-period was independently associated with pre-hospital death (OR 1.73, 95%CI 1.55-1.93, p < 0.001) and negatively associated with survival to hospital admission (OR 0.68, 95%CI 0.64-0.72, p < 0.001) and survival to discharge (OR 0.50, 95%CI 0.46-0.54, p < 0.001).

CONCLUSIONS

During the first COVID-19 pandemic wave, there was higher OHCA incidence and lower bystander CPR rate in regions with a high-burden of COVID-19. COVID-19 was also associated with a change in patient characteristics and lower survival independently of COVID-19 incidence in the region where OHCA occurred.

Out-of-hospital cardiac arrest patients during the coronavirus disease 2019 pandemic

The coronavirus disease 2019 (COVID-19) pandemic had severe impact on the outcome of out-of-hospital cardiac arrest (OHCA) patients and the possibility of bystander cardiopulmonary resuscitation (CPR). Previous studies focused only on the short periods of the pandemic and reported a significant increase in the number of infections. In a retrospective cohort study we aimed to compare the outcomes of OHCA patients 1 year before and 1 year after the onset of COVID-19. Data of 519 OHCA patients during the pre-pandemic (January-December 2019; 262 patients) and intra-pandemic (April 2020-March 2021; 257 patients) periods in Yokohama Municipal Hospital, Japan were collected and analysed retrospectively. The study outcomes were the return of spontaneous circulation (ROSC), admission to hospital, survival to discharge, and cerebral performance category at discharge. The intra-pandemic period was associated with decreased bystander CPR (P = 0.004), prolonged transport time (P < 0.001), delayed first adrenaline administration (P < 0.001), and decrease in ROSC (P = 0.023). Logistic regression analysis revealed that the following factors were significantly associated with ROSC: "pandemic", "shockable initial waveform", and "witness presence".

Simultaneous Double-Vessel Coronary Thrombosis with Sudden Cardiac Arrest as the First Manifestation of COVID-19

The relationship between coronavirus disease 2019 (COVID-19) and myocardial injury was established at the onset of the COVID-19 pandemic. An increase in the incidence of out-of-hospital cardiac arrest was also observed. This case report aims to point to the prothrombotic and proinflammatory nature of coronavirus infection, leading to simultaneous coronary vessel thrombosis and subsequently to out-of-hospital cardiac arrest. During the COVID-19 pandemic, a 46-year-old male patient with no comorbidities suffered out-of-hospital cardiac arrest (OHCA) with ventricular fibrillation as the first recorded rhythm. The applied cardiopulmonary resuscitation (CPR) measures initiated by bystanders and continued by emergency medical service (EMS) resulted in the return of spontaneous circulation. The stabilized patient was transferred to the tertiary university center. Electrocardiogram (ECG) revealed "lambda-like" ST-segment elevation in DI and aVL leads, necessitating an immediate coronary angiography, which demonstrated simultaneous occlusion of the left anterior descending (LAD) and right coronary artery (RCA). Primary percutaneous coronary intervention (PCI) with the implantation of one drug-eluting stent (DES) in LAD and two DES in RCA was done. Due to the presence of cardiogenic shock (SCAI C), an intra-aortic balloon pump (IABP) was implanted during the procedure, and due to the comatose state and shockable cardiac arrest, targeted temperature management was initiated. The baseline chest X-ray revealed bilateral interstitial infiltrates, followed by increased proinflammatory markers and a positive polymerase chain reaction (PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) demasking underlying COVID-19-related pneumonia. Within the following 48 h, the patient was hemodynamically stable, which enabled weaning from IABP and vasopressor discontinuation. However, due to the worsening of COVID-19 pneumonia, prolonged mechanical ventilation, together with antibiotics and other supportive measures, was needed. The applied therapy resulted in clinical improvement, and the patient was extubated and finally discharged on Day 26, with no neurological sequelae and with mildly reduced left ventricle ejection fraction.

Favourable neurological outcome following paediatric out-of-hospital cardiac arrest: a retrospective observational study

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) in children is rare and can potentially result in severe neurological impairment. Our study aimed to identify characteristics of and factors associated with favourable neurological outcome following the resuscitation of children by the Swiss helicopter emergency medical service.

MATERIALS AND METHODS

This retrospective observational study screened the Swiss Air-Ambulance electronic database from 01-01-2011 to 31-12-2021. We included all primary missions for patients ≤ 16 years with OHCA. The primary outcome was favourable neurological outcome after 30 days (cerebral performance categories (CPC) 1 and 2). Multivariable linear regression identified potential factors associated with favourable outcome (odd ratio - OR).

RESULTS

Having screened 110,331 missions, we identified 296 children with OHCA, which we included in the analysis. Patients were 5.0 [1.0; 12.0] years old and 61.5% (n = 182) male. More than two-thirds had a non-traumatic OHCA (67.2%, n = 199), while 32.8% (n = 97) had a traumatic OHCA. Thirty days after the event, 24.0% (n = 71) of patients were alive, 18.9% (n = 56) with a favourable neurological outcome (CPC 1 n = 46, CPC 2 n = 10). Bystander cardiopulmonary resuscitation (OR 10.34; 95%CI 2.29-51.42; p = 0.002) and non-traumatic aetiology (OR 11.07 2.38-51.42; p = 0.002) were the factors most strongly associated with favourable outcome. Factors associated with an unfavourable neurological outcome were initial asystole (OR 0.12; 95%CI 0.04-0.39; p < 0.001), administration of adrenaline (OR 0.14; 95%CI 0.05-0.39; p < 0.001) and ongoing chest compression at HEMS arrival (OR 0.17; 95%CI 0.04-0.65; p = 0.010).

CONCLUSION

In this study, 18.9% of paediatric OHCA patients survived with a favourable neurologic outcome 30 days after treatment by the Swiss helicopter emergency medical service. Immediate bystander cardiopulmonary resuscitation and non-traumatic OHCA aetiology were the factors most strongly associated with a favourable neurological outcome. These results underline the importance of effective bystander and first-responder rescue as the foundation for subsequent professional treatment of children in cardiac arrest.

Air pollution and out-of-hospital cardiac arrest risk: a 7-year study from a highly polluted area

AIMS

Globally, nearly 20% of cardiovascular disease deaths were attributable to air pollution. Out-of-hospital cardiac arrest (OHCA) represents a major public health problem; therefore, the identification of novel OHCA triggers is of crucial relevance. The aim of the study was to evaluate the association between air pollution (short-, mid-, and long-term exposures) and OHCA risk, during a 7-year period in a highly polluted urban area in northern Italy, with a high density of automated external defibrillators (AEDs).

METHODS AND RESULTS

Out-of-hospital cardiac arrests were prospectively collected from the 'Progetto Vita Database' between 1 January 2010 and 31 December 2017; day-by-day air pollution levels were extracted from the Environmental Protection Agency stations. Electrocardiograms of OHCA interventions were collected from the AED data cards. Day-by-day particulate matter (PM) 2.5 and 10, ozone (O3), carbon monoxide (CO), and nitrogen dioxide (NO2) levels were measured. A total of 880 OHCAs occurred in 748 days. A significant increase in OHCA risk with a progressive increase in PM2.5, PM10, CO, and NO2 levels was found. After adjustment for temperature and seasons, a 9% and 12% increase in OHCA risk for each 10 μg/m3 increase in PM10 (P < 0.0001) and PM2.5 (P < 0.0001) levels was found. Air pollutant levels were associated with both asystole and shockable rhythm risk, while no correlation was found with pulseless electrical activity.

CONCLUSION

Short- and mid-term exposures to PM2.5 and PM10 are independently associated with the risk of OHCA due to asystole or shockable rhythm.

Effect of adjuvant thiamine and ascorbic acid administration on the neurologic outcomes of out-of-hospital cardiac arrest patients: A before-and-after study

AIM

This study aimed to evaluate the impact of early thiamine and ascorbic acid administration on the neurologic outcome in out-of-hospital cardiac arrest (OHCA) patients treated with targeted temperature management (TTM).

METHODS

This before-and-after cohort study used data extracted from two hospitals of the Korean Hypothermia Network prospective registry. The treatment group incorporated patients enrolled from December 2019 to May 2021, that received intravenous thiamine (200 mg) and ascorbic acid (3 g) at 12-hour intervals for a total of six doses. The control group incorporated those enrolled from May 2018 to November 2019. The one-month good neurologic outcome, defined as a Cerebral Performance Category score ≤ 2, between the groups was evaluated using inverse probability of treatment weighting (IPTW).

RESULTS

Among the 234 OHCA survivors with TTM, 102 were included in the treatment group and 132 were included in the control group. The one-month (31.4 % vs. 29.5 %, respectively; P = 0.76) good neurologic outcome rates did not differ between the treatment and control groups. After adjusting using the IPTW, vitamin supplementation was not associated with good neurologic outcome (odds ratio [OR], 1.134; 95 % confidence interval [CI], 0.644-1.999; P = 0.66). In subgroup analysis, vitamin administration was significantly associated with a good neurologic outcome in older (≥65 years) patients (adjusted OR, 5.53; 95 % CI, 1.21-25.23; P = 0.03).

CONCLUSION

Adjuvant thiamine and ascorbic acid administration in OHCA survivors with TTM did not improve their neurologic outcome after one month. Further clinical trials are warranted.

Coronary features across the spectrum of out-of-hospital cardiac arrest with ST-elevation myocardial infarction (CAD-OHCA study)

AIM

We hypothesized that adult patients with out-of-hospital cardiac arrest (OHCA) and ST-elevation myocardial infarction (STEMI) requiring prolonged resuscitation have more severe coronary artery disease (CAD) than those responding rapidly, and more severe CAD than patients with STEMI without OHCA.

METHODS

Consecutive conscious and comatose OHCA patients with STEMI after reestablishment of spontaneous circulation (ROSC), and patients with refractory OHCA undergoing veno-arterial extracorporeal membrane oxygenation (E-CPR OHCA) were compared to STEMI without OHCA (STEMI no OHCA). CAD severity was assessed by a single physician blinded to the resuscitation method, time to ROSC and level of consciousness.

RESULTS

Between 2016 and 2022, 71 conscious OHCA, 157 comatose OHCA, 50 E-CPR OHCA and 101 STEMI no OHCA underwent immediate coronary angiography. Acute culprit lesion was documented less often in OHCA (88.1% vs 97%; p = 0.009) but complete occlusion was more frequent (68.8% vs 58.4%; p = 0.038) than in STEMI no OHCA. SYNTAX score was 5.6 in STEMI no OHCA, 10.2 in conscious OHCA, 13.4 in comatose OHCA and 26.8 in E-CPR OHCA (p < 0.001). There was a linear correlation between SYNTAX score and delay to ROSC/ECMO initiation (r2 = 0.61; p < 0.001). Post PCI culprit TIMI 3 flow was comparable between the groups (≥86%). SYNTAX score was among independent predictors of 5-year survival which was significantly decreased in comatose OHCA (56.1%) and E-CPR OHCA (36.0%) compared to conscious OHCA (83.1%) and STEMI no OHCA (88.1%).

CONCLUSION

Compared to STEMI no OHCA, OHCA was associated with increased incidence of acute coronary occlusion and more complex non culprit CAD which progressively increased from conscious OHCA to E-CPR OHCA. Severity of CAD was associated with increased delays to ROSC/ECMO initiation and decreased long term survival.

Diagnostic Value of High-Sensitivity Cardiac Troponin-I in Patients After Out-of-Hospital Cardiac Arrest

Knowing the etiology of cardiac arrest (CA) is important for treatment decisions. Results of previous studies on the diagnostic role of cardiac troponin in patients resuscitated from CA are controversial, few studies were done during the era of high-sensitivity cardiac troponin-I (hs-cTnI), and kinetics of hs-cTnI was not thoroughly investigated. We aimed to explore the diagnostic value of hs-cTnI in patients resuscitated from out-of-hospital CA (OHCA). This retrospective study included 201 consecutive patients after OHCA admitted to the intensive cardiac care unit at Rambam Health Care Campus from 2016 to 2021. Patients were divided into 2 groups according to etiology of CA: group 1-patients with definite acute myocardial infarction (AMI), group 2-patients in whom AMI was excluded. Values of hs-cTnI on admission, peak hs-cTnI, and hs-cTnI upslope were compared between patients with AMI and non-AMI. Peak hs-cTnI and hs-cTnI upslope differed significantly between patients with non-AMI versus AMI CA (median 1,424 vs 32,558 ng/L, p <0.0001 and median 109 vs 2,322 ng/L/h, p <0.0001, respectively). Moreover, peak hs-cTnI and hs-cTnI upslope were found to have good discrimination performance between patients with non-AMI and AMI, with area under the curve receiver operating characteristics (ROC) curves of 0.83 and 0.80, respectively. In conclusion, in patients resuscitated from OHCA values of peak hs-cTnI and hs-cTnI upslope could be helpful in the diagnosis of etiology of CA as adjunct to other diagnostic methods.

Association Between Body Weight Changes and Subsequent Development of Out-of-Hospital Cardiac Arrest: A Population-Based Nested Case-Control Study

BACKGROUND

Body weight is a modifiable demographic factor. Although the association of body mass index (BMI) categories with sudden cardiac death was reported, dynamic changes of BMI and the risk of cardiac arrest remain unknown. This study aimed to evaluate the association between the out-of-hospital cardiac arrest (OHCA) occurrence within a year and the percent changes of BMI preceding the OHCA.

METHODS

This population-based nested case-control study used the National Health Insurance Service Data of Korea. In all, 24,465 patients with non-traumatic OHCA between 2010 and 2018, who underwent national health check-up twice (one within a year and the other within 2-4 years before OHCA) and 32,434 controls without OHCA, were matched for age and sex. The association between the risk of OHCA and BMI percent change stratified by sex was investigated.

RESULTS

All the BMI percent changes of ≥ 5% significantly increased the OHCA occurrence with a reverse J-shaped association. Compared to individuals with a stable weight, those with severe (> 15%) BMI decrease had the highest odds ratio (OR) of 4.29 (95% confidence intervals [CIs], 3.72-4.95) for OHCA occurrence followed by those with moderate (10-15%) weight loss (OR, 2.80; 95% CI, 2.55-3.08) and those with severe (> 15%) weigh gain (OR, 2.24; 95% CI, 1.96-2.57), respectively. The impact of weight loss on the cardiac arrest occurrence was more prominent in men, while the impact of weight gain was more prominent in women.

CONCLUSION

Significant weight changes increase the risk of OHCA within a year with a reverse J-shaped association. Significant weight loss might be a warning sign for OHCA especially for men.

Epidemiology of pediatric out-of-hospital cardiac arrest compared with adults

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is associated with ∼90% mortality rate. In the pediatric population, this would equate to a large number of years of life lost, posing a heavy medical and economic burden to society.

OBJECTIVE

The purpose of this study was to outline the characteristics and causes of pediatric OHCA (pOHCA) and associations with survival until discharge in patients enrolled in the End Unexplained Cardiac Death Registry.

METHODS

A prospective statewide multisource registry identified all pOHCAs cases in patients aged 1-18 years in Victoria, Australia (population 6.5 million), from April 2019 to April 2021. Cases were adjudicated using ambulance, hospital, and forensic records; clinic assessments; and interviews of survivors and family members.

RESULTS

The analysis included 106 cases after adjudication (62, 58.5% male), 45 (42.5%) of which were due to cardiac causes of OHCA, with unascertained (n = 33 [31.1%]) being the most common cardiac cause reported. Respiratory events (n = 28 [26.4%]) were the most common noncardiac cause of pOHCA. Noncardiac causes were more likely to present with asystole or pulseless electrical activity (P = .007). The overall survival to hospital discharge rate was 11.3% and associated with increasing age, witnessed cardiac arrest, and initial ventricular arrhythmias (P < .05).

CONCLUSION

The incidence of pOHCA in the study population was 3.69 per 100,000 child-years. In contrast to young adults with OHCA, the most common etiology was noncardiac in pediatric patients. Prognostic factors associated with survival to discharge included increasing age, witnessed arrest, and initial ventricular arrhythmias. Rates of cardiopulmonary resuscitation and defibrillation were suboptimal.

Indications for Cardiac Catheterization and Percutaneous Coronary Intervention in Patients with Resuscitated Out-of-Hospital Cardiac Arrest

PURPOSE OF REVIEW

The role of emergent cardiac catheterization after resuscitated out-of-hospital cardiac arrest (OHCA) has evolved based on recent randomized evidence. This review aims to discuss the latest evidence and current indications for emergent coronary angiography (CAG) and mechanical circulatory support (MCS) use following OHCA.

RECENT FINDINGS

In contrast to previous observational data, recent RCTs evaluating early CAG in resuscitated OHCA patients without ST elevation have uniformly demonstrated a lack of benefit in terms of survival or neurological outcome. There is currently no randomized evidence supporting MCS use specifically in patients with resuscitated OHCA and cardiogenic shock. Urgent CAG should be considered in all patients with ST elevation, recurrent electrical or hemodynamic instability, those who are awake following resuscitated OHCA, and those receiving extracorporeal cardiopulmonary resuscitation (ECPR). Recent evidence suggests that CAG may be safely delayed in hemodynamically stable patients without ST-segment elevation following resuscitated OHCA.

Development and validation of a novel score to predict brain death after out-of-hospital cardiac arrest

BACKGROUND AND OBJECTIVES

Brain death (BD) occurs in 9-24% of successfully resuscitated out-of-hospital cardiac arrests (OHCA). To predict BD after OHCA, we developed a novel brain death risk (BDR) score.

METHODS

We identified independent predictors of BD after OHCA in a retrospective, single academic center cohort between 2011 and 2021. The BDR score ranges from 0 to 7 points and includes: non-shockable rhythm (1 point), drug overdose as etiology of arrest (1 point), evidence of grey-white differentiation loss or sulcal effacement on head computed tomography (CT) radiology report within 24 hours of arrest (2 points), Full-Outline-Of-UnResponsiveness (FOUR) score of 0 (2 points), FOUR score 1-5 (1 point), and age <45 years (1 point). We internally validated the BDR score using k-fold cross validation (k = 8) and externally validated the score at an independent academic center. The main outcome was BD.

RESULTS

The development cohort included 362OHCA patients, of whom 18% (N = 58) experienced BD. Internal validation provided an area under the receiving operator characteristic curve (AUC) (95% CI) of 0.931 (0.905-0.957). In the validation cohort, 19.8% (N = 17) experienced BD. The AUC (95% CI) was 0.849 (0.765-0.933). In both cohorts, a BDR score >4 was the optimal cut off (sensitivity 0.903 and 0.882, specificity 0.830 and 0.652, in the development and validation cohorts respectively).

DISCUSSION

The BDR score identifies those at highest risk for BD after OHCA. Our data suggest that a BDR score >4 is the optimal cut off.

Survival in a young child with out-of-hospital cardiac arrest: diagnostic dilemma and when to deviate from standard resuscitation guidelines

A boy in early childhood presented in cardiac arrest. Care was provided out of hospital and in the emergency department as per standard paediatric resuscitation guidelines. Despite initial return of spontaneous circulation following cardiopulmonary resuscitation, two defibrillation shocks and epinephrine via intraosseous access, he had recurrent episodes of pulseless ventricular tachycardia and ventricular fibrillation. In total, 40 defibrillation shocks were administered, and he subsequently stabilised on combined treatment with intravenous esmolol, amiodarone and milrinone. He was transferred to the paediatric intensive care unit and had an automated implantable cardioverter-defibrillator inserted prior to discharge. Genetic testing has confirmed a diagnosis of catecholaminergic polymorphic ventricular tachycardia and it is hypothesised that the childhood excitement at a popular time of year, combined with caffeinated drinks, instigated his initial cardiac arrest which was propagated with iatrogenic epinephrine. He has remained stable since, with no neurological sequelae thus far from a significantly prolonged downtime.

Neurological outcomes and reperfusion strategies in out-of-hospital cardiac arrest patients due to pulmonary embolism who underwent venoarterial extracorporeal membrane oxygenation: A post-hoc analysis of a multicenter retrospective cohort study

INTRODUCTION

This study aimed to evaluate the effect of different reperfusion strategies on neurological outcomes in patients with pulmonary embolism who received venoarterial extracorporeal membrane oxygenation (VA-ECMO) for out-of-hospital cardiac arrest (OHCA).

METHODS

This was a post-hoc analysis of a multicenter retrospective cohort study conducted in 36 institutions in Japan over six years. We included patients who underwent VA-ECMO and were diagnosed with pulmonary embolism caused by OHCA. Neurological outcomes were evaluated on the basis of the cerebral performance category at hospital discharge. We also assessed the association between reperfusion strategies and successful separation from ECMO.

RESULTS

Among the 78 included patients, approximately half were successfully weaned from ECMO. Hospital mortality and favorable neurological outcomes at hospital discharge were 60.3% and 17.9%, respectively. Thirty-one patients (39.7%) underwent reperfusion strategies after ECMO, including 13 who received systemic thrombolytic therapy and 18 who underwent mechanical reperfusion strategy. After adjusting for prespecified covariates using the competing risk model, reperfusion strategies increased ECMO separation rate (systemic thrombolytic therapy: subdistribution hazard ratio [sHR] 2.24, 95% confidence interval [CI] 1.21-4.17, P = 0.011; mechanical reperfusion strategy: sHR 1.70, 95% CI 0.86-3.41, P = 0.129) compared with anticoagulation therapy alone, whereas higher cardiac Sequential Organ Failure Assessment score decreased ECMO separation rate (sHR 0.81, 95% CI 0.67-0.97, P = 0.020).

CONCLUSIONS

Favorable neurological outcomes were observed in less than 20% of patients with OHCA due to pulmonary embolism undergoing ECMO. Reperfusion strategies may be associated with shorter ECMO durations in these patients.

CLINICAL TRIAL REGISTRATION

https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000041577 (unique identifier: UMIN000036490).

Comparison of Out-of-Hospital Cardiac Arrest Outcomes Between Asian and White Individuals in the United States

Background Disparities in bystander cardiopulmonary resuscitation (CPR) and survival have been reported for Black and Hispanic individuals with out-of-hospital cardiac arrest (OHCA). Whether Asian individuals have lower rates of bystander CPR and survival for OHCA, as compared with White individuals, remains unknown. Methods and Results Within the US-based CARES (Cardiac Arrest Registry to Enhance Survival), we identified 278 989 OHCAs in Asian and White individuals during 2013 to 2021. Using hierarchical Poisson logistic regression with emergency medical service agency modeled as a random effect and patient and OHCA characteristics as fixed effects, we compared rates of bystander CPR, survival to discharge, and favorable neurological survival between Asian and White individuals with OHCA. Overall, 14 835 (5.3%) OHCAs occurred in Asian individuals. Compared with White individuals with OHCA, Asian individuals were older (67.0±17.6 versus 62.8±16.9 years) and were less likely to have drug overdose as the cause of OHCA (1.3% versus 6.6%) and a shockable arrest rhythm (19.2% versus 22.4%). Layperson bystander CPR rates were similar between Asian and White individuals (42.6% versus 42.1%; adjusted relative risk for Asian individuals, 0.99 [95% CI, 0.97-1.02]; P=0.69). However, rates of survival to discharge were lower in Asian individuals with OHCA (8.2% versus 10.3%; adjusted relative risk 0.92 [0.86-0.98] P=0.006). Similarly, the rate of favorable neurological survival was lower for Asian individuals (6.5% versus 8.7%; adjusted relative risk, 0.85 [0.79-0.91]; P<0.001). Conclusions Despite similar rates of bystander CPR, Asian individuals with OHCA have lower survival rates than White individuals with OHCA. The reasons for the lower survival rate deserve further study to determine whether there are disparities in resuscitation care between Asian and White individuals with OHCA.

Outcomes of out-of-hospital cardiac arrest in adult congenital heart disease: a Danish nationwide study

AIMS

The risk, characteristics, and outcome of out-of-hospital cardiac arrest (OHCA) in patients with congenital heart disease (CHD) remain scarcely investigated.

METHODS AND RESULTS

An epidemiological registry-based study was conducted. Using time-dependent Cox regression models fitted with a nested case-control design, hazard ratios (HRs) with 95% confidence intervals of OHCA of presumed cardiac cause (2001-19) associated with simple, moderate, and severe CHD were calculated. Moreover, using multiple logistic regression, we investigated the association between pre-hospital OHCA characteristics and 30-day survival and compared 30-day survival in OHCA patients with and without CHD. Overall, 43 967 cases (105 with simple, 144 with moderate, and 53 with severe CHD) and 219 772 controls (median age 72 years, 68.2% male) were identified. Any type of CHD was found to be associated with higher rates of OHCA compared with the background population [simple CHD: HR 1.37 (1.08-1.70); moderate CHD: HR 1.64 (1.36-1.99); and severe CHD: HR 4.36 (3.01-6.30)]. Pre-hospital cardiopulmonary resuscitation and defibrillation were both associated with improved 30-day survival in patients with CHD, regardless of CHD severity. Among patients with OHCA, simple, moderate, and severe CHD had a similar likelihood of 30-day survival compared with no CHD [odds ratio 0.95 (0.53-1.69), 0.70 (0.43-1.14), and 0.68 (0.33-1.57), respectively].

CONCLUSION

A higher risk of OHCA was found throughout the spectrum of CHD. Patients with and without CHD showed the same 30-day survival, which relies on the pre-hospital chain of survival, namely cardiopulmonary resuscitation and defibrillation.

Associations between clinical characteristics of cardiac arrest and early CT head findings of hypoxic ischaemic brain injury following out-of-hospital cardiac arrest

BACKGROUND/OBJECTIVE

Post-cardiac arrest patients are vulnerable to hypoxic-ischaemic brain injury (HIBI), but HIBI may not be identified until computed tomography (CT) scan of the brain is obtained post-resuscitation and stabilization. We aimed to evaluate the association of clinical arrest characteristics with early CT findings of HIBI to identify those at the highest risk for HIBI.

METHODS

This is a retrospective analysis of out-of-hospital cardiac arrest (OHCA) patients who underwent whole-body imaging. Head CT reports were analyzed with an emphasis on findings suggestive of HIBI; HIBI was present if any of the following were noted on the neuroradiologist read: global cerebral oedema, sulcal effacement, blurred grey-white junction, and ventricular compression. The primary exposure was duration of cardiac arrest. Secondary exposures included age, cardiac vs noncardiac etiology, and witnessed vs unwitnessed arrest. The primary outcome was CT findings of HIBI.

RESULTS

A total of 180 patients (average age 54 years, 32% female, 71% White, 53% witnessed arrest, 32% cardiac etiology of arrest, mean CPR duration of 15 ± 10 minutes) were included in this analysis. CT findings of HIBI were seen in 47 (48.3%) patients. Multivariate logistic regression demonstrated a significant association between CPR duration and HIBI (adjusted OR = 1.1, 95% CI 1.01-1.11, p < 0.01).

CONCLUSION

Signs of HIBI are commonly seen on CT head within 6 hours of OHCA, occurring in approximately half of patients, and are associated with CPR duration. Determining risk factors for abnormal CT findings can help clinically identify patients at higher risk for HIBI and target interventions appropriately.

Research on the Rescue Time of the Taiwan Marathon Emergency Medical Service System Between 2013 and 2021

BACKGROUND

While there are several studies on marathon injuries worldwide, there are no related studies on the Taipei Marathon regarding the rescue time of onsite injury cases, the incidence of out-of-hospital cardiac arrest (OHCA) cases, and the success rate of recovery of spontaneous circulation (ROSC). This study aims to fill that gap.

HYPOTHESIS

The rescue time onsite of contact injury cases was in the prime time for lifesaving.

STUDY DESIGN

Descriptive epidemiological study.

LEVEL OF EVIDENCE

Level 2c.

METHODS

This is a retrospective study of numerical and timeflow data using descriptive statistics. Our data were obtained from records of the Taipei Marathon from 2013 to 2021. These included (1) notification data, (2) the time record of the emergency care personnel in contact with patients, (3) incidence of OHCA, (4) the success rate of ROSC, (5) the location of occurrence of OHCA, and (6) emergency medical service capacity and configuration.

RESULTS

The average time taken for first contact was 1.56 minutes in OHCA cases, and the total incidence rate of OHCA in 9 years was 4 people per 100,000 people, with a 100% ROSC success rate. Further, the location of OHCA cases was mostly in Q4 of the race (66.67%), followed by Q3 (22.22%) and Q2 (1.11%). The average number of emergency care personnel per marathon was 78, spread across 6 rescue and 6 medical stations and equipped with 8 ambulances and 35 automated external defibrillators.

CONCLUSION

Shortening the arrival time of medical personnel to the scene and implementing a complete chain of survival can improve survival rates. Other ways to provide faster and more timely emergency rescue services require further study.

CLINICAL RELEVANCE

Contact with patients as soon as possible, timely implementation of cardiopulmonary resuscitation, and use of an automated external defibrillator are the basic requirements of the chain of survival theory.

Out-of-Hospital Cardiac Arrests during Mass-Participation Endurance Events: A Case Series

INTRODUCTION

Mass-participation endurance events take place throughout the United Kingdom. Although out-of-hospital cardiac arrests (OHCAs) occur during these events, little is known about them. This case series aims to describe the number, type, etiology, and outcome of OHCAs treated by a UK-based specialist sports medicine provider over a period of 8 y.

METHODS

The medical records of a UK-based sports medicine provider were reviewed from 2014 to 2022. Anonymized information from OHCAs during this time was recorded. This included type of event, patient demographics, details of OHCA, and patient outcomes.

RESULTS

Ten OHCAs were identified during the course of 110 sporting events. These included the cases of 9 participants and 1 spectator. Return of spontaneous circulation (ROSC) was achieved on-site in all patients. Eight survived beyond 24 h and achieved a full neurological recovery. Seventy percent of these patients achieved ROSC within 4 min of cardiopulmonary resuscitation being initiated. The 2 patients who died both presented with a nonshockable rhythm.

CONCLUSIONS

OHCAs during mass-participation endurance events are rare. However, medical providers must be prepared to respond promptly. Quick interventions can result in a full neurological recovery.

Rewarming Young Children After Drowning-Associated Hypothermia and Out-of-Hospital Cardiac Arrest: Analysis Using the CAse REport Guideline

OBJECTIVES

Extracorporeal membrane oxygenation (ECMO) is recommended in adults with drowning-associated hypothermia and out-of-hospital cardiac arrest (OHCA). Our experience of managing a drowned 2-year-old girl with hypothermia (23°C) and cardiac arrest (58 min) prompted this summary using the CAse REport (CARE) guideline to address the question of optimal rewarming procedure in such patients.

DESIGN/PATIENTS

Following the CARE guideline, we identified 24 reports in the "PubMed database" describing children less than or equal to 6 years old with a temperature less than or equal to 28°C who had been rewarmed using conventional intensive care ± ECMO. Adding our patient, we were able to analyze a total of 57 cases.

MAIN RESULTS

The two groups (ECMO vs non-ECMO) differed with respect to submersion time, pH and potassium but not age, temperature or duration of cardiac arrest. However, 44 of 44 in the ECMO group were pulseless on arrival versus eight of 13 in the non-ECMO group. Regarding survival, 12 of 13 children (92%) undergoing conventional rewarming survived compared with 18 of 44 children (41%) undergoing ECMO. Among survivors, 11 of 12 children (91%) in the conventional group and 14 of 18 (77%) in the ECMO group had favorable outcome. We failed to identify any correlation between "rewarming rate" and "outcome."

CONCLUSIONS

In this summary analysis, we conclude that conventional therapy should be initiated for drowned children with OHCA. However, if this therapy does not result in return of spontaneous circulation, a discussion of withdrawal of intensive care might be prudent when core temperature has reached 34°C. We suggest further work is needed using an international registry.

The New South Wales Sudden Cardiac Arrest Registry: A Data Linkage Cohort Study

BACKGROUND

Sudden cardiac arrest (SCA) in young people aged 1 to 50 years often occurs with no presenting symptoms or risk factors prompting screening for cardiovascular disease prior to their cardiac arrest. Approximately 3,000 young Australians suffer from sudden cardiac death (SCD) each year, making this a major public health issue. However, there is significant variation in the way incidence is estimated resulting in discrepancy across reporting which impacts our ability to understand and prevent these devastating events. We describe the New South Wales (NSW) Sudden Cardiac Arrest Registry: a retrospective, data linkage study which will identify all SCAs in the young in NSW from 2009 through to June 2022.

OBJECTIVE

To determine the incidence, demographic characteristics and causes of SCA in young people. We will develop an NSW-based registry that will contribute to a greater understanding of SCA including risk factors and outcomes.

METHODS

The cohort will include all people who experience a SCA in the NSW community aged between 1 to 50 years. Cases will be identified using the following three datasets: the Out of Hospital Cardiac Arrest Register housed at NSW Ambulance, the NSW Emergency Department Data Collection, and the National Coronial Information System. Data from eight datasets will be collected, anonymised and linked for the entire cohort. Analysis will be undertaken and reported using descriptive statistics.

CONCLUSIONS

The NSW SCA registry will be an important resource for the improved understanding of SCA and inform the widespread impacts it has on individuals, their families and society.

Pulmonary embolism-related refractory out-of-hospital cardiac arrest and extracorporeal cardiopulmonary resuscitation: Prague OHCA study post hoc analysis

AIMS

Refractory out-of-hospital cardiac arrest (r-OHCA) in patients with pulmonary embolism (PE) is associated with poor outcomes. The role of extracorporeal cardiopulmonary resuscitation (ECPR) in this patient group is uncertain. This study aims to analyse clinical course, outcomes, and the effect of an invasive procedure, including ECPR, in a randomized population.

METHODS AND RESULTS

A post hoc analysis of a randomized controlled trial (Prague OHCA study) was conducted to evaluate the effect of ECPR vs. a standard approach in r-OHCA. A subgroup of patients with PE-related r-OHCA was identified, and procedural and outcome characteristics, including favourable neurological survival, organ donation, and complications, were compared to patients without PE. Pulmonary embolism was identified as a cause of r-OHCA in 24 of 256 (9.4%) enrolled patients. Patients with PE were more likely to be women [12/24 (50%) vs. 32/232 (13.8%); P < 0.001] and presented more frequently with an initial non-shockable rhythm [23/24 (95.8%) vs. 77/232 (33.2%); P < 0.001], as well as more severe acidosis at admission [median pH (interquartile range); 6.83 (6.75-6.88) vs. 6.98 (6.82-7.14); P < 0.001]. Their favourable 180-day neurological survival was significantly lower [2/24 (8.3%) vs. 66/232 (28.4%); P = 0.049], but the proportion of accepted organ donors was higher (16.7 vs. 4.7%, P = 0.04).

CONCLUSION

Refractory out-of-hospital cardiac arrest due to PE has a different presentation and inferior outcomes compared to other causes but may represent an important source of organ donations. The ECPR method did not improve patient outcomes.

Outcomes after Clinical and Traumatic Out-of-Hospital Cardiac Arrest

BACKGROUND

Data on out-of-hospital cardiac arrest are still scarce, very varied, and indicate a poor prognosis for traumatic events.

OBJECTIVES

To describe the out-of-hospital/in-hospital survival, survival time, and neurological conditions of those treated by advanced life support units and submitted to cardiopulmonary resuscitation and compare the results of clinical and traumatic cardiac arrests.

METHODS

This is a cohort study carried out in three stages; in the first two, data were collected from the Mobile Emergency Care Service forms and medical records; then, the Brain Performance Category Scale was applied in the third stage. The sample consisted of resuscitated victims aged ≥18 years. Fisher's and log-rank tests were used to compare the causes, considering a significance level of 5%.

RESULTS

852 patients were analyzed; 20.66% were hospitalized, 4.23% survived until transfer or discharge, and 58.33% had a favorable outcome one year after arrest. There was an association between pre/in-hospital survival and the nature of the occurrence (p=0.026), but there was no difference between the survival curves (p=0.6).

CONCLUSIONS

Survival of hospitalization after out-of-hospital cardiac arrest was low; however, most who survived to be discharged achieved a favorable outcome after one year. The survival time of those hospitalized after clinical and traumatic events were similar, but pre-hospital survival was higher among trauma patients.

Associations between prehospital defibrillation and outcomes of out-of-hospital cardiac arrests presumed to be caused by hypothermia: A nationwide observational study with epidemiological analysis

This study aimed to clarify the epidemiology of out of-hospital cardiac arrest (OHCA) cases caused by hypothermia. The associations between the presence/absence of shockable initial electrocardiography rhythm, prehospital defibrillation and the outcomes of OHCA were also investigated. This study involved the retrospective analysis of prospectively collected, nationwide, population-based data for OHCA cases caused by hypothermia. One thousand five hundred seventy-five emergency medical service (EMS)-confirmed OHCA cases with hypothermia, recorded between 2013 and 2019, were extracted from the Japanese nationwide database. The primary outcome was neurologically favorable 1-month survival, defined as cerebral performance category 1 or 2. The secondary outcome was 1-month survival. OHCA cases with hypothermia occurred more frequently in the winter. In approximately half (837) of the hypothermic OHCA cases, EMS was activated in the morning (6:00 am to 11:59 am). Shockable initial electrocardiogram rhythms were recorded in 30.8% (483/1570) of cases. prehospital defibrillation was attempted in 96.1% (464/483) of cases with shockable rhythms and 25.8% (280/1087) of cases with non-shockable initial rhythms. EMS-witnessed cases, prolonged transportation time intervals and prehospital epinephrine administration were associated with rhythm conversion in cases with non-shockable initial rhythms. Binominal logit test followed by multivariable logistic regression revealed that shockable initial rhythms were associated with better outcomes. prehospital defibrillation was not significantly associated with better outcomes, regardless of the type of initial rhythm (shockable or non-shockable). Transportation to high-level emergency hospitals was associated with better outcomes (adjusted odds ratio: 2.94, 95% confidence interval: 1.66-5.21). In hypothermic OHCA, shockable initial rhythm but not prehospital defibrillation is likely to be associated with better neurologically favorable outcomes. In addition, transport to a high-level acute care hospital may be appropriately considered despite prolonged transport. Further investigation, including core temperature data in analyses, is necessary to determine the benefit of prehospital defibrillation in hypothermic OHCA.

TIMECARD score: An easily operated prediction model of unfavorable neurological outcomes in out-of-hospital cardiac arrest patients with targeted temperature management

BACKGROUND

Targeted temperature management (TTM) is recommended for comatose out-of-hospital cardiac arrest (OHCA) survivors. Several prediction models have been proposed; however, most of these tools require data conversion and complex calculations. Early and easy predictive model of neurological prognosis in OHCA survivors with TTM warrant investigation.

MATERIALS AND METHODS

This multicenter retrospective cohort study enrolled 408 non-traumatic adult OHCA survivors with TTM from the TaIwan network of targeted temperature ManagEment for CARDiac arrest (TIMECARD) registry during January 2014 to June 2019. The primary outcome was unfavorable neurological outcome at discharge. The clinical variables associated with unfavorable neurological outcomes were identified and a risk prediction score-TIMECARD score was developed. The model was validated with data from National Taiwan University Hospital.

RESULTS

There were 319 (78.2%) patients presented unfavorable neurological outcomes at hospital discharge. Eight independent variables, including malignancy, no bystander cardiopulmonary resuscitation (CPR), non-shockable rhythm, call-to-start CPR duration >5 min, CPR duration >20 min, sodium bicarbonate use during resuscitation, Glasgow Coma Scale motor score of 1 at return of spontaneous circulation, and no emergent coronary angiography, revealed a significant correlation with unfavorable neurological prognosis in TTM-treated OHCA survivors. The TIMECARD score was established and demonstrated good discriminatory performance in the development cohort (area under the receiver operating characteristic curve [AUC] = 0.855) and validation cohorts (AUC = 0.918 and 0.877, respectively).

CONCLUSION

In emergency settings, the TIMECARD score is a practical and simple-to-calculate tool for predicting neurological prognosis in OHCA survivors, and may help determine whether to initiate TTM in indicated patients.

Relationship of Public Interest in Cardiopulmonary Resuscitation with Cardiac Arrest Epidemiology and National Socioeconomic Indicators: Exploratory Infodemiology Study

STUDY OBJECTIVE

Web-based big data analytics provides a great opportunity to measure public interest in cardiac arrest (CA) and cardiopulmonary resuscitation (CPR). This study aimed to examine associations of online interest in CPR and CA with epidemiological characteristics of out-of-hospital CA (OHCA) and national socioeconomic indicators in a set of European countries.

METHODS

Country-level online search popularity data for CPR and CA topics measured in relative search volume (RSV) with Google Trends (GT), published OHCA epidemiological indicators, and World Bank's socioeconomic statistics of 28 European countries for the year 2017 were analyzed for correlation using Spearman's rank correlation coefficient (r _S ).

RESULTS

Whereas OHCA incidence, bystander CPR rate, and hospital survival did not correlate with RSV for CPR or CA, the rate of return of spontaneous circulation (ROSC) demonstrated a positive correlation with RSV for CPR (r _S = 0.388; P = .042). Further, RSV for CPR positively correlated with countries' gross domestic product and health expenditure (r _S = 0.939 and 0.566; P ≤.002) and negatively correlated with mortality caused by road traffic injury (r _S = -0.412; P = .029).

CONCLUSION

For the sample of European countries, public interest in CPR or CA showed no relationship with real bystander CPR rates and therefore could not be recommended as a proxy of community readiness to attempt resuscitation. The association of RSV for CPR with the rate of ROSC and countries' socioeconomic characteristics suggests it could be used for identifying geographies with poor performance of prehospital systems in terms of managing CA, in particular where effective epidemiological surveillance for CA may be unavailable.

Supraglottic Airway Devices are Associated with Asphyxial Physiology After Prolonged CPR in Patients with Refractory Out-of-Hospital Cardiac Arrest Presenting for Extracorporeal Cardiopulmonary Resuscitation

BACKGROUND

Multiple randomized clinical trials have compared specific airway management strategies during ACLS with conflicting results. However, patients with refractory cardiac arrest died in almost all cases without the availability of extracorporeal cardiopulmonary resuscitation (ECPR). Our aim was to determine if endotracheal intubation (ETI) was associated with improved outcomes compared to supraglottic airways (SGA) in patients with refractory cardiac arrest presenting for ECPR.

METHODS

We retrospectively studied 420 consecutive adult patients with refractory out-of-hospital cardiac arrest due to shockable presenting rhythms presenting to the University of Minnesota ECPR program. We compared outcomes between patients receiving ETI (n=179) and SGA (n=204). The primary outcome was the pre-cannulation arterial PaO₂ upon arrival to the ECMO cannulation center. Secondary outcomes included neurologically favorable survival to hospital discharge and eligibility for VA-ECMO based upon resuscitation continuation criteria applied upon arrival to the ECMO cannulation center.

RESULTS

Patients receiving ETI had significantly higher median PaO₂ (71 vs. 58 mmHg, p=0.001), lower median PaCO₂ (55 vs. 75 mmHg, p<0.001), and higher median pH (7.03 vs. 6.93, p<0.001) compared to those receiving SGA. Patients receiving ETI were also significantly more likely to meet VA-ECMO eligibility criteria (85% vs. 74%, p=0.008). Of patients eligible for VA-ECMO, patients receiving ETI had significantly higher neurologically favorable survival compared to SGA (42% vs. 29%, p=0.02).

CONCLUSIONS

ETI was associated with improved oxygenation and ventilation after prolonged CPR. This resulted in increased rate of candidacy for ECPR and increased neurologically favorable survival to discharge with ETI compared to SGA. Short Title: Airway Effects in Refractory Cardiac Arrest.

Abnormal ambient temperature change increases the risk of out-of-hospital cardiac arrest: A systematic review and meta-analysis of exposure types, risk, and vulnerable populations

BACKGROUND

There is growing evidence in support of a short-term association between ambient temperature and cardiac arrest attacks that is a serious manifestation of cardiovascular disease and has a high incidence and low survival rate. However, it remains unrecognized about the hazardous temperature exposure types, exposure risk magnitude, and vulnerable populations.

OBJECTIVES

We comprehensively summarize prior epidemiological studies looking at the short-term associations of out-of-hospital cardiac arrest (OHCA) with various temperature exposures among different populations.

METHODS

We searched PubMed and Web of Science databases from inception to October 2021 for eligible English language. Temperature exposure was categorized into three types: heat (included high temperature, extreme heat, and heatwave), cold (included low temperature and extreme cold), and temperature variation (included diurnal temperature range and temperature change between two adjacent days). Meta-analysis weighted by inverse variance was used to pool effect estimates.

RESULTS

This study included 15 studies from 8 countries, totaling around 1 million OHCA events. Extreme heat and extreme cold were significantly associated with an increased risk of OHCA, and the pooled relative risks (RRs) were 1.071 [95 % confidence interval (CI): 1.019-1.126] and 1.662 (95%CI: 1.138-2.427), respectively. The risk of OHCA was also elevated by heatwaves (RR = 1.248, 95%CI: 1.091-1.427) and more intensive heatwaves had a greater effect. Notably, the elderly and males seemed to be more vulnerable to the effects of heat and cold. However, we did not observe a significant association between temperature variation and the risk of OHCA (1.005, 95%CI: 0.999-1.012).

CONCLUSION

Short-term exposure to heat and cold may be novel risk factors for OHCA. Considering available studies in limited regions, the temperature effect on OHCA should be urgently confirmed in different regions.

Pulmonary fat embolism after cardiopulmonary resuscitation

Pulmonary fat embolism (PFE) is usually observed in patients with long bone fractures, patients with extensive subcutaneous fat contusions or skin burns. Chest compressions during cardiopulmonary resuscitation (CPR) present powerful repetitive violence against victim's chest. Skeletal chest fractures are the most frequent complication of CPR, and probably the most important cause of PFE autopsy finding in persons, which have been resuscitated before death. The aim of the present paper was to investigate the prevalence and seriousness of PFE in non-survivors after out-of-hospital cardiac arrest. During autopsy, PFE can be diagnosed in 30 - 42 % of persons after unsuccessful CPR; skeletal chest fractures are associated with significantly higher prevalence of PFE. After successful CPR, fat embolism may contribute significantly to acute respiratory distress syndrome, or multiorgan failure. The issue of CPR associated injuries has two medical aspects - clinical and forensic. From clinical point of view, the presence of CPR associated injuries must be acknowledged when offering healthcare to patients after successful CPR. During autopsy, CPR associated injuries should be diagnosed and evaluated as these injuries may contribute to death or may be potentially lethal.

Impact of COVID-19 Pandemic on Patients with ST-Segment-Elevation Myocardial Infarction Complicated by Out-of-Hospital Cardiac Arrest

Patients with ST-segment-elevation myocardial infarction (STEMI) treated during the COVID-19 pandemic might experience prolonged time to reperfusion. The delayed reperfusion may potentially aggravate the risk of out-of-hospital cardiac arrest (OHCA) in those patients. Limited access to healthcare, more reluctant health-seeking behaviors, and bystander readiness to render life-saving interventions might additionally contribute to the suggested change in the risk of OHCA in STEMI. Thus, we sought to explore the effects of the COVID-19 outbreak on treatment delay and clinical outcomes of patients with STEMI with OHCA. Overall, 5,501 consecutive patients with STEMI complicated by OHCA and treated with primary percutaneous coronary intervention with stent implantation were enrolled. A propensity score matching was used to obviate the possible impact of non-randomized design. A total of 740 matched pairs of patients with STEMI and OHCA treated before and during the COVID-19 pandemic were compared. A similar mortality and prevalence of periprocedural complications were observed in both groups. However, patients treated during the COVID-19 outbreak experienced longer delays from first medical contact to angiography (88.8 (±61.5) vs. 101.4 (±109.8) [minutes]; p = 0.006). There was also a trend toward prolonged time from pain onset to angiography in patients admitted to the hospital in the pandemic era (207.3 (±192.8) vs. 227.9 (±231.4) [minutes]; p = 0.06). In conclusion, the periprocedural outcomes in STEMI complicated by OHCA were comparable before and during the COVID-19 era. However, treatment in the COVID-19 outbreak was associated with a longer time from first medical contact to reperfusion.

Machine Learning Analysis to Identify Data Entry Errors in Prehospital Patient Care Reports: A Case Study of a National Out-of-Hospital Cardiac Arrest Registry

Background: The objective of this study was to develop and validate machine learning models for data entry error detection in a national out-of-hospital cardiac arrest (OHCA) prehospital patient care report database.Methods: Adult OHCAs of presumed cardiac etiology were included. Data entry errors were defined as discrepancies between the coded data and the free-text note documenting the intervention or event; for example, information that was recorded as "absent" in the coded data but "present" in the free-text note. Machine learning models using the extreme gradient boosting, logistic regression, extreme gradient boosting outlier detection, and K-nearest neighbor outlier detection algorithms for error detection within nine core variables were developed and then validated for each variable.Results: Among 12,100 OHCAs, the proportion of cases with at least one error type was 16.2%. The area under the receiver operating characteristic curve (AUC) of the best-performing model (model with the highest AUC for each outcome variable) was 0.71-0.95. Machine learning models detected errors most efficiently for outcome place and initial rhythm errors; 82.6% of place errors and 93.8% of initial rhythm errors could be detected while checking 11 and 35% of data, respectively, compared to the strategy of checking all data.Conclusion: Machine learning models can detect data entry errors in care reports of emergency medical services (EMS) clinicians with acceptable performance and likely can improve the efficiency of the process of data quality control. EMS organizations that provide more prehospital interventions for OHCA patients could have higher error rates and may benefit from the adoption of error-detection models.

Impact of COVID-19 on out-of-hospital cardiac arrest: A registry-based cohort-study from the German Resuscitation Registry

Introduction

The global COVID-19 pandemic effects people and the health system. Some international studies reported an increasing number of out-of-hospital cardiac arrest (OHCA). Comparable studies regarding the impact of COVID-19 on incidence and outcome of OHCA are not yet available for Germany.

Materials and methods

This epidemiological study from the German Resuscitation Registry (GRR) compared a non-pandemic period (01.03.2018–28.02.2019) and a pandemic period (01.03.2020–28.02.2021) regarding the pandemic-related impact on OHCA care.

Results

A total of 18,799 cases were included. The incidence of OHCA (non-pandemic 117.9 vs. pandemic period 128.0/100,000 inhabitants) and of OHCA with resuscitation attempted increased (66.0 vs. 69.1/100,000). OHCA occurred predominantly and more often at home (62.8% vs. 66.5%, p<0.001). The first ECG rhythm was less often shockable (22.2% vs. 20.3%, p = 0.03). Fewer cases of OHCA were observed (58.6% vs. 55.6% p = 0.02). Both the bystander resuscitation rate and the proportion of telephone guided CPR remained stable (38.6% vs. 39.8%, p = 0.23; and 22.3% vs. 22.5%, p = 0.77). EMS arrival times increased (08:39 min vs. 09:08 min, p<0.001). Fewer patients reached a return of spontaneous circulation (ROSC) (45.4% vs. 40.9%, p<0.001), were admitted to hospital (50.2% vs. 45.0%, p<0.001), and discharged alive (13.9% vs. 10.2%, p<0.001).

Discussion

Survival after OHCA significantly decreased while the bystander resuscitation rate remained stable. However, longer EMS arrival times and fewer cases of witnessed OHCA may have contributed to poorer survival. Any change to EMS systems in the care of OHCA should be critically evaluated as it may mean a real loss of life—regardless of the pandemic situation.

Women Are Less Likely to Survive AMI Presenting With Out-of-Hospital Cardiac Arrest: A Nationwide Study

OBJECTIVE

To assess the impact of patient's sex on outcomes and management of acute myocardial infarction (AMI) patients presenting with out-of-hospital cardiac arrest (OHCA).

PATIENTS AND METHODS

We conducted a population-based retrospective cohort study in AMI patients admitted with OHCA between 2010 and 2017 from the Myocardial Ischaemia National Audit Project (MINAP) registry. We used multivariable logistic regression models to evaluate the role of sex as a predictor of clinical outcomes and treatment strategy.

RESULTS

Of 16,278 patients, women constituted almost one-quarter of the population (n=3710 [22.7%]). Women were older (median age 69 [IQR, 57-79] years vs 63 [IQR, 54-72] years, P<.001), experienced longer call-to-hospital-arrival time (median, 1.2 hours vs 1.1 hours; P=.008), were less likely to present with shockable rhythm (86.8% vs 91.5%, P<.001), and less likely to receive dual antiplatelet therapy (73.8% vs 78.6%, P<.001), beta blockers (64.7% vs 72.3%, P<.001), angiotensin-converting enzyme inhibitors (49.0% vs 55.3%, P<.001), coronary angiography (73.7% vs 83.3%, P<.001), and percutaneous coronary intervention (37.5% vs. 40.7%, p 0.004). After adjusting for patient characteristics and management, women had significantly higher odds of in-hospital death compared with men (odds ratio [OR], 1.3; 95% CI, 1.1 to 1.5) and lower odds of receiving coronary angiography (OR, 0.67; 95% CI, 0.59 to 0.75) and coronary artery bypass graft (OR, 0.28; 95% CI, 0.19 to 0.40).

CONCLUSION

Women were less likely to survive following OHCA secondary to AMI. Hospital protocols that minimize physician bias and improve women-physician communication are needed to close this gap.