International Liaison Committee on Resuscitation: COVID-19 consensus on science, treatment recommendations and task force insights

Consensus on Science and Treatment recommendations aim to balance the benefits of early resuscitation with the potential for harm to care providers during the COVID-19 pandemic. Chest compressions and cardiopulmonary resuscitation have the potential to generate aerosols. During the current COVID-19 pandemic lay rescuers should consider compressions and public-access defibrillation. Lay rescuers who are willing, trained and able to do so, should consider providing rescue breaths to infants and children in addition to chest compressions. Healthcare professionals should use personal protective equipment for aerosol generating procedures during resuscitation and may consider defibrillation before donning personal protective equipment for aerosol generating procedures.

"All citizens of the world can save a life" - The World Restart a Heart (WRAH) initiative starts in 2018

"All citizens of the world can save a life". With these words, the International Liaison Committee on Resuscitation (ILCOR) is launching the first global initiative - World Restart a Heart (WRAH) - to increase public awareness and therefore the rates of bystander cardiopulmonary resuscitation (CPR) for victims of cardiac arrest. In most of the cases, it takes too long for the emergency services to arrive on scene after the victim's collapse. Thus, the most effective way to increase survival and favourable outcome in cardiac arrest by two- to fourfold is early CPR by lay bystanders and by "first responders". Lay bystander resuscitation rates, however, differ significantly across the world, ranging from 5 to 80%. If all countries could have high lay bystander resuscitation rates, this would help to save hundreds of thousands of lives every year. In order to achieve this goal, all seven ILCOR councils have agreed to participate in WRAH 2018. Besides schoolchildren education in CPR ("KIDS SAVE LIVES"), many other initiatives have already been developed in different parts of the world. ILCOR is keen for the WRAH initiative to be as inclusive as possible, and that it should happen every year on 16 October or as close to that day as possible. Besides recommending CPR training for children and adults, it is hoped that a unified global message will enable our policy makers to take action to address the inequalities in patient survival around the world.

Looking over the wall: Using a Haddon Matrix to guide public policy making on the problem of sudden cardiac arrest

Sudden cardiac arrest remains an important health care problem. If survival rates of all regions would equal those of the best performers, literally thousands of lives would be saved. Similar to injury, there is a need for an epidemiology-based approach for planning and execution of countermeasures. In this policy paper, we present the Haddon Matrix as an all-inclusive conceptual framework to assist in this. We advocate for a more community-centred 'public health' approach, with a crucial role for policy-level executives. There is a large potential gain in outcome by implementing 'passive' - not requiring individual action - measures. As happened for injury, 'Cardiac Arrest Academies' should be created to facilitate and coordinate this process.

Comparison of Helsinki and European Resuscitation Council "do not attempt to resuscitate" guidelines, and a termination of resuscitation clinical prediction rule for out-of-hospital cardiac arrest patients found in asystole or pulseless electrical activity

BACKGROUND

The outcome of out-of-hospital cardiac arrest (OHCA) with a non-shockable rhythm is poor. For patients found in asystole or pulseless electrical activity (PEA), recent guidelines or rules that may be used include "do not attempt to resuscitate" (DNAR) guidelines from Helsinki, discontinuing resuscitation in the guidelines of the European Resuscitation Council and a clinical prediction rule from Canada. We compared these guidelines and the rule using a large Scandinavian dataset.

MATERIALS AND METHODS

The Swedish Cardiac Arrest Registry includes prospectively collected data on 44121 OHCA patients. We identified patients with asystole or PEA as the initial rhythm and excluded cases caused by trauma or drowning. The specificities and positive predictive values (PPVs) were calculated for the guidelines, and the clinical prediction rule for comparison.

RESULTS

A total of 20484 patients with non-shockable rhythms were identified; 85% had asystole and 15% PEA. The overall survival to hospital admission was 9% (n=1.861) and 1% (n=231) were alive at 1 month from the arrest. The specificity of the Helsinki guidelines in identifying non-survivors was 71% (95% confidence interval (CI): 65-77%) and the PPV was 99.4% (95% CI: 99.3-99.5), while the corresponding values for the European Resuscitation Council (ERC) was 95% (95% CI: 91.3-97.5) and 99.9% (95% CI: 99.9-99.9) and, for the prediction rule, 99.1% (95% CI: 96.7-99.9) and 99.9% (95% CI: 99.9-100.00), respectively.

CONCLUSION

In this comparison study, the Helsinki DNAR guidelines did not perform well enough in a general OHCA material to be widely adopted. The main reason for this was the unpredicted survival of patients with unwitnessed asystole. The clinical prediction rule and the recommendations of the ERC Guidelines worked well.

Do patient characteristics or factors at resuscitation influence long-term outcome in patients surviving to be discharged following in-hospital cardiac arrest?

INTRODUCTION

Few studies have focused on factors influencing long-term outcome following in-hospital cardiac arrest. The present study assesses whether long-term outcome is influenced by difference in patient factors or factors at resuscitation.

METHODS

An analysis of cardiac arrest data collected from one Swedish tertiary hospital and from five Finnish secondary hospitals supplemented with data on 1 year survival. Multiple logistic regression analysis was used to identify factors associated with survival at 12 months.

RESULTS

A total of 441 patients survived to hospital discharge following in-hospital cardiac arrest and 359 (80%) were alive at 12 months. Factors independently associated with survival [odds ratio (OR) >1 indicates increased survival and <1 decreased survival] at 12 months were; age [OR 0.95, 95% confidence interval (CI) 0.93-0.98], renal disease (OR 0.3, CI 0.1-0.9), good functional status at discharge (OR 4.9, CI 1.3-18.9), arrest occurring at (compared with arrests on general wards) emergency wards (OR 4.7, CI 1.4-15.3), cardiac care unit (OR 2.8, CI 1.2-6.4), intensive care unit (OR 2.4, CI 1.1-5.7), ward for thoracic surgery (OR 10.2, CI 2.6-40.1) and unit for interventional radiology (OR 13.3, CI 3.4-52.0). There was no difference in initial rhythm, delay to defibrillation or delay to return of spontaneous circulation between survivors and nonsurvivors.

CONCLUSION

Several patient factors, mainly age, functional status and co-morbid disease, influence long-term survival following cardiac arrest in hospital. The location where the arrest occurred also influences survival, but initial rhythm, delay to defibrillation and to return of spontaneous circulation do not.

Post resuscitation care: what are the therapeutic alternatives and what do we know?

A large proportion of deaths in the Western World are caused by ischaemic heart disease. Among these patients a majority die outside hospital due to sudden cardiac death. The prognosis among these patients is in general, poor. However, a significant proportion are admitted to a hospital ward alive. The proportion of patients who survive the hospital phase of an out of hospital cardiac arrest varies considerably. Several treatment strategies are applicable during the post resuscitation care phase, but the level of evidence is weak for most of them. Four treatments are recommended for selected patients based on relatively good clinical evidence: therapeutic hypothermia, beta-blockers, coronary artery bypass grafting, and an implantable cardioverter defibrillator. The patient's cerebral function might influence implementation of the latter two alternatives. There is some evidence for revascularisation treatment in patients with suspected myocardial infarction. On pathophysiological grounds, an early coronary angiogram is a reasonable alternative. Further randomised clinical trials of other post resuscitation therapies are essential.

Training trauma teams in the Nordic countries: an overview and present status

BACKGROUND

During the last decade there has been an increased interest in the organisation and quality of trauma care in the Nordic countries. Still, most patients are initially cared for at hospitals with low caseloads of severe trauma. More than 200 hospitals offer initial care to trauma patients. Training of trauma teams using simulators or simulated patients has evolved in the same period, as one important factor to overcome lack of practical training. This overview describes the present state of trauma team training in the Nordic countries.

METHODS

Members of a Nordic working group on the use of simulation in medicine reviewed present literature on training with simulation and described the present use of team training in their own countries during winter 2004.

RESULTS

There is an increasing amount of evidence indicating that training of teams with simulation reduces treatment errors and improves performance. The training activities do not need to be complex, but skilled debriefing seems necessary. Few Nordic hospitals train their trauma teams. The training activities vary considerably between and within countries.

CONCLUSION

There is considerable evidence supporting an increased use of experience gained in other high-risk domains where training in communication, leadership and decision-making is the focus for safety and improvement efforts. There is a need for more widespread training of trauma teams. The different training activities actually undertaken should be scientifically evaluated.

The use of undiluted amiodarone in the management of out-of-hospital cardiac arrest

INTRODUCTION

The Resuscitation 2000 Guidelines recommends amiodarone as the antiarrhythmic drug of choice in treatment of resistant ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). Amiodarone has been associated with side-effects and difficulty of administration, due to recommended dilution, rendering it suboptimal for out-of-hospital cardiac arrest (CA) management. In the present study we report experiences and side-effects of the use of undiluted amiodarone in CA management in Helsinki Emergency Medical Service (EMS) during a 2-year period.

METHODS

On October 1, the Resuscitation 2000 Guidelines were put into practice in Helsinki EMS. Thus, in the cardiac arrest treatment protocol, after three ineffective shocks and 1 mg of adrenaline (epinephrine), a bolus of 300 mg of undiluted amiodarone (Cordarone 50 mg ml(-1), Sanofi-Synthelabo, Helsinki, Finland) was administered into a vein located as centrally as possible. The Helsinki EMS performs systematic data collection according to the Utstein Guidelines. The blood pressure levels, heart rates and the need for vasopressors, of the patients with sustained return of spontaneous circulation (ROSC), were collected from the ambulance charts.

RESULTS

During October 1, 2000 and September 30, 2002, 712 patients were considered for resuscitation and 566 were resuscitated. The initial rhythms were as follows: 32% had VF/VT, 36% had asystole and 32% had pulseless electrical activity (PEA). Of the 180 patients with VF/VT, 75 (42%) received undiluted amiodarone in addition to other resuscitative measures. Of the patients with asystole or PEA, 12 (6%) and 18 (10%), respectively, received amiodarone. The blood pressure levels and the need vasopressors after ROSC and during transportation to the hospital were similar among the patients who received and those who did not receive amiodarone.

CONCLUSIONS

The present study suggests that amiodarone can be administered undiluted without unmanageable haemodynamical side-effects in the treatment of out-of-hospital cardiac arrest. This is likely to save time and simplifies the treatment protocol in the prehospital setting.

Inhibition of lipopolysaccharide-induced monocyte interleukin-1 receptor antagonist synthesis by cortisol: involvement of the mineralocorticoid receptor

Glucocorticoids, as a part of their physiological role in the control of inflammatory and immune processes, suppress the expression of interleukin-1 (IL-1) and other cytokines. Human monocyte IL-1 receptor antagonist (IL-1ra) messenger ribonucleic acid (mRNA) expression and protein secretion are inhibited by dexamethasone. We have now further studied the regulation of IL-1ra by the major physiological human glucocorticoid, cortisol. We found that cortisol incubation induced a decrease in IL-1ra mRNA expression and a significant inhibition of IL-1ra protein secretion in cell cultures of human peripheral monocytes stimulated with the bacterial endotoxin lipopolysaccharide (LPS). Oral administration of 276 mumol cortisol to normal subjects also decreased LPS-induced IL-1ra synthesis in cultured monocytes. By coincubating the monocytes with either the mineralocorticoid antagonist spironolactone or the glucocorticoid receptor antagonist RU 38486, the in vitro cortisol-induced inhibition of LPS-stimulated IL-1ra secretion was partially reversed. The mineralocorticoid aldosterone exerted a significant decrease in LPS-induced monocyte IL-1ra secretion in vitro, which was blocked by coincubation with spironolactone. In addition, the expression of mineralocorticoid receptor mRNA in human monocytes was observed by PCR of reversed transcribed RNA. Our results further indicate that corticosteroids physiologically control the IL-1/IL-1ra system during inflammatory or immune processes. Moreover, we provide evidence that, in addition to a glucocorticoid receptor-mediated effect, the mineralocorticoid receptor is involved in the inhibition of monocyte IL-1ra secretion by cortisol.

Hepatosplenic yeast infection in patients with acute leukemia: a diagnostic problem

The occurrence of hepatosplenic candidiasis following prolonged neutropenic periods has emerged as a major problem for patients with leukemia. In order to evaluate the diagnostic value of various available procedures, we analyzed our findings regarding 26 leukemic patients with hepatosplenic candidiasis. A significantly increased level (> 50 mg/L) of serum C-reactive protein (S-CRP) was significantly more common than a daily fever (for which the mean temperature peak was > 37.5 degrees C) or raised levels of liver enzymes (serum alanine transferase, aspartate transferase, or alkaline phosphatase). Focal changes in the liver, spleen, or kidneys were detected in > 90% of the patients examined by computed tomography (CT) but in < 50% of those examined by ultrasonography. Seventeen diagnoses were based on the findings from microscopy of samples obtained invasively, whereas a positive fungal culture was the basis of the diagnosis for only five patients. In conclusion, monitoring the S-CRP level after a patient's recovery from neutropenia is useful in that its elevation is cause for early suspicion of hepatosplenic candidiasis. In detection of the hepatosplenic foci, CT is superior to ultrasonography. For establishing the specific diagnosis, aggressive collection of samples for microscopy is essential.

Comparison of surgical lasers and conventional methods in skin incisions

Steel scalpel, electrocautery, CO2 laser used in a continuous wave mode (CW) and rapid superpulse mode (RSP), and contact Nd: YAG laser were tested on pig skin incisions. Speed of incision and histological changes near the wounds were examined. Light microscopical observations were made on postoperative day 0 using standard Van Gieson stain. Width of the scar on postoperative day 14 was also measured. Steel scalpel produced the least pathological changes in the skin, followed by RSP. Electrocautery did not differ significantly from the CO2 lasers in this respect on postoperative day 0. The damage was larger after contact Nd:YAG laser. The situation was essentially similar on postoperative day 14. The width of the scar was narrowest after steel scalpel and widest after contact Nd:YAG laser (p less than 0.01; Nd:YAG vs. other methods). Electrocautery and the two CO2 lasers produced equal scarring. However, electrocautery was significantly faster than any of the lasers (p less than 0.001).

Sequential changes of noradrenaline content of vein grafts in rats: quantitative estimation by high-performance liquid chromatography using electrochemical detection

Supradiaphragmatic inferior vena cava was transplanted end-to-end into the abdominal aorta of 11-week-old rats of the same inbred strain and same litter using microvascular technique. The grafts were removed 3 days, 4, 8, 16, and 35 weeks postoperatively, and their noradrenaline (NA) content was estimated by high-performance liquid chromatography using electrochemical detection. The amount of NA was significantly lower (P less than .001) in all vein grafts as compared to nontransplanted vena cava. The substantial decrease of NA in the vein grafts throughout the observation period indicates a persistent denervation of the transplant.

Lactate dehydrogenase in laser incisions: a comparative analysis of skin wounds made with steel scalpel, electrocautery, superpulse--continuous wave mode carbon-dioxide lasers, and contact Nd:YAG laser

A histochemical method for demonstrating lactate dehydrogenase activity was used in addition to standard Van Gieson stain to study early alterations near wounds made in pig skin by steel scalpel, electrocautery, two modes of CO2 laser (the rapid super-pulse mode and the continuous wave mode), and contact Nd:YAG laser. The enzyme-free zone near the wounds made using the thermal knives appeared to be twice as wide as the necrotic zone observed with Van Gieson stain. In polarized light, the enzyme-free area showed two zones of equal width with respect to birefringence of collagen fibers. The zone lacking birefringence correlated well with that observed with Van Gieson stain. The birefringent zone represented functionally damaged tissue with more or less normal structures by light microscopy. The damage to adjacent tissue caused with the thermal knives seems to be considerably larger than has usually been reported.

Effects of different contact laser scalpels on skin and subcutaneous fat

The tissue effects of different Nd:YAG contact laser scalpels on pig skin and subcutaneous fat were studied using various power settings. Three different laser scalpels were tested: 0.2 mm nonfrosted (LR2), 0.6 mm nonfrosted (LR6), and 1.0 mm frosted (LRP10), using 3 different power settings (8 W, 14 W, 18 W). The tissue effects of a steel scalpel were used as reference. Incisions on pig loin (40/pig) were made at randomized sites. Specimens were taken at postoperative days 0 and 14. The depth of tissue damage was measured using a light microscope. The amount of time required for making each incision was recorded. Significant differences between the LR2 and the LR6 were observed in the skin at 2 weeks (P less than .05) at all power settings used, indicating superiority of the smaller scalpel for use in skin incisions. The LRP10 did not cause more tissue damage than did the LR6 in any of the power settings used. In subcutaneous fat the smallest scalpel (LR2) caused significantly less tissue damage evident at 2 weeks postoperatively (P less than .05) than did the other two laser scalpels, whereas the effects of the different power settings were minor. The incision time in skin decreased by more than 50% when the power was increased from 8 W to 18 W for all laser scalpels studied.

Cloning of the human thyrotropin beta-subunit gene and transient expression of biologically active human thyrotropin after gene transfection

A 17 kilobase pair fragment of DNA containing the human TSH (hTSH) beta-subunit gene was isolated from a human leukocyte genomic library. Using a 621 base pair human CG alpha-subunit cDNA and a 2.0 kilobase pair genomic fragment of hTSH beta containing both coding exons, we constructed hCG alpha and hTSH beta expression vectors containing either the early promoter of simian virus 40 or the promoters of adeno-associated virus. Cotransfection of two adeno-associated virus vectors, each containing one subunit of hTSH, together with a plasmid containing the adenovirus VA RNA genes produced hTSH as well as free human alpha- and TSH beta-subunits in an adenovirus transformed human embryonal kidney cell line (293). The levels of protein expression in this system were 10- to 100-fold greater than that found in a simian virus transformed monkey kidney cell line (COS) using vectors containing the early promoter of simian virus 40. The hTSH synthesized in 293 cells was glycosylated as indicated by complete binding to concanavalin A-Sepharose but was larger in apparent molecular weight than a standard hTSH preparation on gel chromatography suggesting an altered glycosylation pattern. However, it was immunologically and biologically indistinguishable from two pituitary hTSH standards in an immunoradiometric and in vitro iodide trapping assay, respectively.