Automated external defibrillator use in out-of-hospital cardiac arrest: Current limitations and solutions

Out-of-hospital sudden cardiac arrest (OHCA) is a major public health issue, with a survival rate at hospital discharge that remains below 10% in most cities, despite huge investments in this domain. Early basic life support (BLS) and early defibrillation using automated external defibrillators (AEDs) stand as key elements for improving OHCA survival rate. Nevertheless, the use of AEDs in OHCA remains low, for a variety of reasons, including the number, accessibility and ease of locating AEDs, as well as bystanders' awareness of BLS manœuvres and of the need to use AEDs. Several measures have been proposed to improve the rate of AED use, including optimization of AED deployment strategies as well as the use of drones to bring the AEDs to the OHCA scene and of mobile applications to locate the nearest AED. If they are to be effective, these measures should be combined with large communication campaigns on OHCA, and wide-scale education of the public in BLS and AEDs, to reduce the burden of OHCA.

Neurological consequences of cardiac arrest: where do we stand?

With increasing public education in basic life support and with the widespread use of automated defibrillators, post-cardiac arrest comatose patients represent a growing part of ICU admissions. However the prognosis remains very poor and only a very low proportion of these resuscitated patients will recover and will leave the hospital without major neurological impairments. Neurological dysfunction predominantly includes disorders of consciousness, and may also include other manifestations such as seizures, myoclonus status epilepticus and other forms of movement disorders including post-anoxic myoclonus. In the most severe cases, coma may be irreversible or evolve towards a minimally conscious state, a vegetative state or even brain death. These severe conditions represent by far the leading cause of mortality and disability in such patients. Currently, early use of mild therapeutic hypothermia is the only treatment that demonstrated its ability to decrease neurological consequences and to improve the prognosis. Prognostication outcome is still mainly based on a rigorous clinical evaluation coupled with neuro-physiological investigations, but brain functional imaging could become a valuable tool in the near future. Clinical research focusing on survivors should be strongly encouraged in order to assess the mid- and long-terms outcome of survivors and to evaluate the impact of new treatments or strategies.

Daily FOUR score assessment provides accurate prognosis of long-term outcome in out-of-hospital cardiac arrest

BACKGROUND

The accurate prediction of outcome after out-of-hospital cardiac arrest (OHCA) is of major importance. The recently described Full Outline of UnResponsiveness (FOUR) is well adapted to mechanically ventilated patients and does not depend on verbal response.

OBJECTIVE

To evaluate the ability of FOUR assessed by intensivists to accurately predict outcome in OHCA.

METHODS

We prospectively identified patients admitted for OHCA with a Glasgow Coma Scale below 8. Neurological assessment was performed daily. Outcome was evaluated at 6 months using Glasgow-Pittsburgh Cerebral Performance Categories (GP-CPC).

RESULTS

Eighty-five patients were included. At 6 months, 19 patients (22%) had a favorable outcome, GP-CPC 1-2, and 66 (78%) had an unfavorable outcome, GP-CPC 3-5. Compared to both brainstem responses at day 3 and evolution of Glasgow Coma Scale, evolution of FOUR score over the three first days was able to predict unfavorable outcome more precisely. Thus, absence of improvement or worsening from day 1 to day 3 of FOUR had 0.88 (0.79-0.97) specificity, 0.71 (0.66-0.76) sensitivity, 0.94 (0.84-1.00) PPV and 0.54 (0.49-0.59) NPV to predict unfavorable outcome. Similarly, the brainstem response of FOUR score at 0 evaluated at day 3 had 0.94 (0.89-0.99) specificity, 0.60 (0.50-0.70) sensitivity, 0.96 (0.92-1.00) PPV and 0.47 (0.37-0.57) NPV to predict unfavorable outcome.

CONCLUSION

The absence of improvement or worsening from day 1 to day 3 of FOUR evaluated by intensivists provides an accurate prognosis of poor neurological outcome in OHCA.

[Sudden cardiac death: A better understanting for a better prevention]

Sudden cardiac death is defined as a natural and unexpected death, in a previous apparently healthy individual. It represents a major public health issue, with up to 50% of the cardiovascular mortality. Using data from the Paris Sudden Death Expertise Centre registry, this article summarises the main cardiovascular abnormalities associated with sudden cardiac death, the different preventives approaches, and provides a systematic diagnostic approach.

Epidemiology of sudden cardiac death in Cameroon: rationale and design of the Douala-SUD survey

BACKGROUND

The burden of sudden unexplained death in sub-Saharan Africa is unknown.

AIM

The aim of this study is to establish the epidemiology of sudden cardiac death in Cameroon.

METHODS

The Douala sudden unexplained death (Douala-SUD) study is a prospective, multiple-source, community-based surveillance of all cases of unexpected death (< 24 hours from onset of symptoms) occurring in victims aged>15 years. After approval from institutional boards, all deaths occurring in residents of four areas of Douala city will be checked for circumstances of death and past medical history. Subjects who die naturally will be further investigated. Unexpected death victims will be checked for detailed demographic, clinical, electrocardiographic, echocardiographic and biological records. Autopsy background and genetic analysis (postmortem or in first relatives if the young victim is aged<40 years) will be performed as far as possible. Finally, the use of cardiopulmonary resuscitation efforts during the timeframe of sudden cardiac arrest will also be evaluated.

CONCLUSION

The Douala-SUD study will provide comprehensive, contemporary data on the epidemiology of sudden unexplained and cardiac death in sub-Saharan Africa and will help in the development of strategies to prevent and manage cardiac arrest in Cameroon as well as in other sub-Saharan countries.

Balancing thrombosis and bleeding after out-of-hospital cardiac arrest related to acute coronary syndrome: A literature review

Balance between thrombosis and bleeding is now well recognized in patients treated for acute coronary syndrome, with impact on short- and long-term prognosis, including survival. Recent data suggest that patients who are resuscitated after out-of-hospital cardiac arrest related to myocardial infarction are at an even higher risk of bleeding and thrombosis than those with uncomplicated acute coronary syndrome. Delayed enteral absorption of medication due to induced hypothermia and systemic inflammation increases thrombosis risk, whereas transfemoral access site, cardiopulmonary resuscitation manoeuvres and mechanical circulatory support devices increase bleeding risk. In addition, post-resuscitation syndrome and renal or hepatic impairment are potential risk factors for both bleeding and thrombotic complications. There are currently no randomized controlled trials comparing various P₂Y₁₂ inhibitor and/or anticoagulation strategies in the setting of out-of-hospital cardiac arrest, and current practice is largely derived from management of patients with uncomplicated acute coronary syndrome. The aim of this review is therefore to describe the bleeding and thrombosis risk factors in this specific population, and to review recent data on antithrombotic drugs in this patient subset.

Immediate coronary angiography in survivors of out-of-hospital cardiac arrest without obvious extracardiac cause: Who benefits?

BACKGROUND

Immediate coronary angiography (iCA) and primary percutaneous coronary angioplasty (pPCI) in patients successfully resuscitated after out-of-hospital cardiac arrest (OHCA) of suspected cardiac cause is controversial. Our aims were to assess the results of iCA, the prognostic impact of pPCI after OHCA, and to identify subgroups most likely to benefit from this strategy.

METHODS

In this single-centre retrospective study, patients aged ≥18 years with sustained return of spontaneous circulation after OHCA and no evidence of a non-cardiac cause underwent routine iCA at admission, with pPCI if indicated. Results of iCA, and factors associated with in-hospital survival were analysed.

RESULTS

Between 2006 and 2013, 160 survivors from OHCA presumed of cardiac origin were included (median age, 60 years; 85% males). iCA showed significant coronary-artery lesions in 75% of patients, and acute occlusion or unstable lesion in only 41%. pPCI was performed in 34% of patients and was not associated with survival by univariate or multivariate analysis (P=0.67). ST-segment elevation predicted acute coronary occlusion in 40%. An initial shockable rhythm was associated with higher in-hospital survival (52% vs. 19%; P<0.001). After initial defibrillation, the first rhythm recorded by 12-lead electrocardiography was highly associated with prognosis: secondary asystole had a very low survival rate (5%, 1/21) despite PCI in 43% of patients, compared to sustained ventricular tachycardia/fibrillation (42%, 15/36) and supraventricular rhythm (71%, 50/70) (P<0.001).

CONCLUSIONS

In our experience, the prevalence of acute coronary occlusion or unstable lesion immediately after OHCA of likely cardiac cause is only 41%. Immediate CA in OHCA survivors, with pPCI if indicated, should be restricted to highly selected patients.

[Sudden cardiac death: Are women different?]

Sudden cardiac death is a major public health problem with around 40,000 cases per year in France. Epidemiological, clinical and prognostic differences according to gender have been described in most cardiovascular diseases, including sudden cardiac death. In this article, we will review gender differences in sudden cardiac death incidence, circumstance of occurrence, management, and prognosis.

[Cardiac impairment after hanging attempt: a preliminary descriptive study]

PURPOSE OF THE STUDY

Cardiomyopathy has sometimes been reported after suicide attempts by hanging. The objective of this retrospective observational study was to describe cardiac dysfunction occurring after hanging and its consequences on prognosis.

PATIENTS AND METHODS

Fifteen patients admitted to the intensive care unit for hanging from 1997 to 2011 were included and divided into two groups according to presence or absence of cardiac arrest at initial presentation. Cardiac dysfunction was defined by the presence of clinical, biological, electrocardiographic or echocardiographic abnormalities.

RESULTS

Cardiac impairment was diagnosed in nine patients over 15 (60%). Of the six patients with initial cardiac arrest, only one survived without severe neurological sequellae. Among the nine patients without cardiac arrest, eight survived and five patients (56%) had cardiac impairment, including two cases of echocardiographic aspect of Takotsubo complicated by pulmonary edema. Mortality in intensive care was significantly related to the severity of the initial neurological state assessed by the Glasgow Coma Score (OR=1.7; P=0.02), and the occurrence of cardiac arrest (OR=40; P=0.016). The presence of cardiac involvement, reversible after the acute phase in all surviving patients was not associated with increased mortality.

CONCLUSION

In the aftermath of hanging, predictors of mortality are the presence of impaired consciousness or initial cardiac arrest, but not the occurrence of cardiac disease.

Easily applicable SEP-monitoring of the N20 wave in the intensive care unit

In this technical note, a conveniently sized, single-channel somatosensory evoked potentials (SEP)-stimulation-recording unit for bedside use in the intensive care unit is presented. The validation of the SEP N20 wave in intensive care guidelines as initial parameter for the prognostic evaluation of cardiac arrest has increased the demand for a more widespread availability of SEP, outside the electrophysiological domain. A device with a simplified interface that safely guides the user through a complete examination and that includes artifact removal is a prerequisite for such more widespread use, in which expert interpretation can be reduced to a necessary minimum.

Survivors of out-of-hospital cardiac arrest treated with percutaneous coronary intervention: Thrombotic and bleeding events among different oral P2Y12 inhibitor regimens

BACKGROUND

Survivors of out-of-hospital cardiac arrest undergoing percutaneous coronary intervention are at high thrombotic and bleeding risk. The type of antiplatelet that should be used in these patients remains controversial.

AIM

To compare the impact of the use of more potent P2Y₁₂ receptor inhibitors on thrombotic and bleeding events with that of clopidogrel in survivors of out-of-hospital cardiac arrest undergoing percutaneous coronary intervention.

METHODS

This was an observational study including consecutive patients treated for out-of-hospital cardiac arrest associated with acute coronary syndrome by percutaneous coronary intervention with stent implantation and dual antiplatelet therapy between January 2007 and December 2017. Baseline characteristics, mortality and in-hospital haemorrhagic and thrombotic events were compared between patients who received clopidogrel and those who received more potent P2Y₁₂ receptor inhibitors.

RESULTS

Among the 359 included patients, 197 received clopidogrel and 162 received ticagrelor or prasugrel. The primary composite endpoint of death, definite stent thrombosis or major bleeding was similar in the two groups (57.4% in the clopidogrel group vs. 53.7% in the new P2Y₁₂ receptor inhibitors group; P=0.49). Fewer haemorrhagic events occurred in the clopidogrel group (21.8% vs. 31.5%; P=0.04), whereas similar rates of definite stent thrombosis were observed (5.1% vs. 6.2%; P=0.65). The use of more potent P2Y₁₂ receptor inhibitors was an independent predictor of major bleeding (odds ratio 2.69, 95% confidence interval 1.37-5.25; P=0.004).

CONCLUSIONS

In this specific population, the use of more potent P2Y₁₂ receptor inhibitors was not associated with a reduced thrombosis rate compared with clopidogrel, but with a higher haemorrhagic risk. Prospective studies should be performed on the optimal antithrombotic therapy in this subset of patients.

[Improving vital organs perfusion by the respiratory pump: physiology and clinical use]

OBJECTIVE

In this article, we review the effects of the respiratory pump to improve vital organ perfusion by the use of an inspiratory threshold device.

DATA SOURCES

Medline and MeSH database.

STUDY SELECTION

All papers with a level of proof of I to III have been used.

DATA EXTRACTION

The analysis of the papers has focused on the physiological modifications induced by intrathoracic pressure regulation.

DATA SYNTHESIS

Primary function of breathing is to provide gas exchange. Studies of the mechanisms involved in animals and humans provide the physiological underpinnings for "the other side of breathing": to increase circulation to the heart and brain. We describe studies that focus on the fundamental relationship between the generation of negative intrathoracic pressure during inspiration through a low-level of resistance created by an impedance threshold device and the physiologic effects of a respiratory pump. A decrease in intrathoracic pressure during inspiration through a fixed resistance resulting in an intrathoracic pressure of -7 cmH2O has multiple physiological benefits including: enhanced venous return, cardiac stroke volume and aortic blood pressure; lower intracranial pressure; resetting of the cardiac baroreflex; elevated cerebral blood flow oscillations and increased tissue blood flow/pressure gradient.

CONCLUSION

The clinical and animal studies support the use of the intrathoracic pump to treat different clinical conditions: hemorrhagic shock, orthostatic hypotension, septic shock, and cardiac arrest.

[Coronary artery spasm revealed by an out-of-hospital cardiac arrest associated with a moyamoya disease. A case report of multimodality imaging]

Moyamoya disease is a rare angiopathy characterized by a progressive distal occlusion of the internal carotid arteries and their branches. Extracerebral involvement, including coronary arteries, has been described. We report the case of a patient with moyamoya disease who suffered an out-of-hospital cardiac arrest associated with coronary spasm. We discussed the possible links between coronary spasm and moyamoya, as well as the contribution of multimodal cardiac imaging, combining conventional and intracoronary imaging, cardiac MRI, provocative tests for spasm, in the exploration of out-of-hospital cardiac arrest without obvious electrocardiographic and angiographic cause.

[Deceased donation in renal transplantation]

OBJECTIVES

To review epidemiologic data's and medical results of deceased donation in renal transplantation.

MATERIAL AND METHODS

Relevant publications were identified through Medline (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) database using the following keywords, alone or in association, "brain death; cardiac arrest; deceased donation; organ procurement; transplantation". Articles were selected according to methods, language of publication and relevance. The reference lists were used to identify additional historical studies of interest. Both prospective and retrospective series, in French and English, as well as review articles and recommendations were selected. In addition, French national transplant and health agencies (http://www.agence-biomedecine.fr and http://www.has-sante.fr) databases were screened using identical keywords. A total of 2498 articles, 8 official reports and 17 newspaper articles were identified; after careful selection 157 publications were eligible for our review.

RESULTS

Deceased donation may involve either brain death or non-heartbeating donors (NHBD). Organ shortage led to the procurement of organs from expanded-criteria donors, with an increased age at donation and extended vascular disease, leading to inferior results after transplantation and underlining the need for careful donor management during brain death or cardiac arrest. Evolution of French legislation covering bioethics allowed procurement from Maastricht categories II and recently III non-heartbeating donors.

CONCLUSION

The increase of organ shortage emphasizes the need for a rigorous surgical technique during procurement to avoid loss of transplants. A history or current neoplasm in deceased-donors, requires attention to increase the pool of organs without putting the recipients at risk for cancer transmission. French NHBD program, especially from Maastricht category III, may stand for a potential source of valuable organs.

[Fighting against unexplained sudden death]

Sudden cardiac death, mostly related to ventricular arrhythmia, is a major public health issue, with still very poor survival at hospital discharge. Although coronary artery disease remains the leading cause, other etiologies should be systematically investigated. Exhaustive and standardized exploration is required to eventually offer specific therapeutics and management to the patient as well as his/her family members in case of inherited cardiac disease. Identification and establishing direct causality of the detected cardiac anomaly may remain challenging, underlying the need for a multidisciplinary and experimented team.

[Maternal deaths and management by emergency departments in France 2016-2018]

In France, 272 maternal deaths occurred during the period 2016-2018, of which 131 were initially treated by healthcare professionals not specialized in obstetric. Fifty-six files were excluded because they did not concern emergency services or because there was insufficient data to allow analysis. Seventy-five cases of maternal deaths initially treated by emergency services (in-hospital emergency department [ED] or emergency medical ambulance [SAMU]) were analyzed. Fifty-six cases were treated by the SAMU and 22 by an ED (both in 3 cases). The causes of death were 20 cardiovascular events, 18 pulmonary embolisms, 9 neurological failures and 8 hemorrhagic shocks. The event occurred during pregnancy in 48 cases (64%) and during per or postpartum period in 27 cases (36%). The motivations for consultation at the ED were mainly pain (n=9), respiratory distress (n=6) or faintness (n=3). The reasons for calling emergency dispatching service (SAMU) were cardiorespiratory arrest in 32 cases (57%) and neurological failure (coma or status epilepticus) in 6 cases (11%). Among the 56 patients treated outside the hospital, 17 died on scene and 39 were transported to a resuscitation room (n=13), a specialized department (n=13), an obstetrics department (n=8) and less often in the ED (n=2). This was considered appropriate in 35 out of 39 cases (90%). Concerning the 75 files analyzed (ED and SAMU), death was considered unavoidable in 37 cases (49%) and potentially avoidable in 29 cases (38%) (maybe=23, probably=6). Avoidability could not be established in 9 cases. Among the 29 potentially avoidable deaths (38%), one of the criteria of avoidability concerned emergency services in 14 cases (ED=9, SAMU/SMUR=5, 18% of the files studied). ED's cares were considered optimal in 11 cases (50%) and non-optimal in 11 cases (50%). SAMU's cares were considered optimal in 45 cases (80%).

[Maternal mortality due to Amniotic Fluid Embolism in France 2016-2018]

Amniotic embolism remains the 3rd leading cause of maternal death in France, with 21 maternal deaths over the 2016-2018 triennium. The women who died were more likely to be obese (25%), to benefit from induction of labor (71%) and be cared in a maternity hospital <1500 deliveries/year (45%), compared with the reference population (ENP 2016). The symptom occurred mainly during labor (95%) and the course was rapid, with a symptom-to-fatality interval of 4hours 45minutes (min: 25minutes - max: 8 days). Preventability was proposed for 35% of the deaths assessed, with areas for improvement identified in terms of technical skills (haemostasis procedures, management of polytransfusion), non-technical skills (communication) and health care organization (human resources, vital emergency plan, wide access to PSL). An autopsy was performed in 38% of deaths.

[Sudden cardiac death and coronary thrombus]

Out-of-hospital cardiac arrest is most often due to an acute coronary artery occlusion. The cause of coronary thrombosis in cardiac arrest is debated. Plaque erosion could be a trigger leading to immediate thrombus formation followed by ventricular fibrillation or rapid ventricular tachycardia. Coronary artery spasm is frequent: spasm provocation tests should be performed in survivors with normal coronary arteries. Use of drugs such as cocaine can lead to sudden death and blood sampling at arrival is recommended in survivors of out-of-hospital cardiac arrest. Delivery of immediate and effective basic life support remains the most important predictive factor for survival in out-of-hospital cardiac arrest.

The impact of clinical result acquisition and interpretation on task performance during a simulated pediatric cardiac arrest: a multicentre observational study

PURPOSE

The acquisition and interpretation of clinical results during resuscitations is common; however, this can delay critical clinical tasks, resulting in increased morbidity and mortality. This study aims to determine the impact of clinical result acquisition and interpretation by the team leader on critical task completion during simulated pediatric cardiac arrest before and after team training.

METHODS

This is a secondary data analysis of video-recorded simulated resuscitation scenarios conducted during Teams4Kids (T4K) study (June 2011-January 2015); scenarios included cardiac arrest before and after team training. The scenario included either a scripted paper or a phone call delivery of results concurrently with a clinical transition to pulseless ventricular tachycardia. Descriptive statistics and non-parametric tests were used to compare team performance before and after training.

RESULTS

Performance from 40 teams was analyzed. Although the time taken to initiate CPR and defibrillation varied depending on the type of interruption and whether the scenario was before or after team training, these findings were not significantly associated with the leader's behaviour [Kruskal-Wallis test (p > 0.05)]. An exact McNemar's test determined no statistically significant difference in the proportion of leaders involved or not in interpreting results between and after the training (exact p value = 0.096).

CONCLUSIONS

Team training was successful in reducing time to perform key clinical tasks. Although team training modified the way leaders behaved toward the results, this behaviour change did not impact the time taken to start CPR or defibrillate. Further understanding the elements that influence time to critical clinical tasks provides guidance in designing future simulated educational activities, subsequently improving clinical team performance and patient outcomes.

[Sudden cardiac death in women, data from the northern Tunisian sudden cardiac-death registry]

BACKGROUND

Sudden cardiac death is a major public health problem. Epidemiological and clinical differences according to gender have been described in sudden cardiac death. The aim of this study was to examine the gender differences between autopsy findings and circumstance of occurrence associated with sudden cardiac death.

METHODS

We prospectively collected epidemiological and autopsy data of victims of sudden cardiac death occurring in the northern governorates of Tunisia between January 2013 and December 2019. Symptoms preceding death, circadian, weekly and seasonal variations of sudden death were also analyzed.

RESULTS

The study population included 1834 men and 468 women with a mean age of 56.5±14.2 years. All cardiovascular risk factors except smoking were significantly more frequent among women but ischemic heart disease was the most common cause of death in men (51.3 %, versus 28 %, P<0.001). Women were more likely to have a negative macroscopic autopsy than men (34 % versus 23.6 %, P<0.001). Chest pain preceding sudden death was more frequent in male (24 % versus 13.2 %, P<0.001). In contrast, women were more likely to have dyspnea (8.1 % versus 15.6 %, P<0.001). Sudden death in women occurred indoors more often than in men (63.9 % versus 54.5 %, P<0.001) and also more often during night (midnight to 6 am). We also recorded an excess cardiac mortality in winter in both sexes.

CONCLUSIONS

Women had considerably more cardiovascular risk factors and more commonly negative macroscopic autopsy. Death occurred indoors and during night more often than in men.

[Patients hospitalized in the ICU for acute coronary syndrome from 2012 to 2021: A single-center retrospective study]

INTRODUCTION

Acute Coronary Syndrome (ACS) are one of the main causes of mortality in France. Patients presenting with ACS are typically hospitalized in a specialized cardiology ward. The main objective of this study was to describe, characterize and evaluate the outcome of patients hospitalized for ACS in a generalist intensive care unit (rather than a cardiac care unit).

METHODS

This was a retrospective study. Our population consisted of ACS patients admitted to an intensive care unit in a hospital center (Centre Hospitalier de Troyes) between 2012 and 2021. All patients admitted for ACS to the intensive care unit and who underwent coronary angiography were included.

RESULTS

In 10 years, 104 patients, or 3.8% of ACS patients who underwent coronary angiography were admitted to intensive care. The majority were admitted after recovered cardiac arrest (72%) and were in cardiogenic shock (68%), accounting for a high in-hospital mortality (45.2%). In-hospital mortality was 45.2%. In multivariate analysis, the GRACE score was associated with in-hospital mortality (OR for each additional point = 1.024, 95% confidence interval 1.006-1.045, p = 0.01). Among the survivors, 88% had good neurological function when leaving the hospital.

DISCUSSION

Mortality of ACS patients in intensive care was close to 50%. However, the neurological prognosis of the surviving patients was good. This population is rarely mentioned in the literature, and deserves to be evaluated by multicenter, prospective registries, with a view to improving management and prognosis.