Atraumatic Cardiac Arrest Research Articles

Abstract Su301: Longer Chest Compression Intervals Between Pulse Checks in Patients with Non-Shockable Rhythms are Associated with Increased Subsequent Return of Spontaneous Circulation Events

Background: Chest compressions are a cornerstone of cardiopulmonary resuscitation (CPR), and evidence shows that fewer interruptions and higher chest compression fractions improve outcomes in cardiac arrest. Interruptions in chest compression are important in patients with shockable rhythms to assess the need for defibrillation; however, in pulseless electrical activity (PEA) or asystole, a pause in chest compressions every 2 minutes may be detrimental, as it decreases chest compression fraction and reduces myocardial, cerebral, and systemic perfusion. Hypothesis: We hypothesize that patients with non-shockable rhythms on whom chest compression intervals were greater than 2 minutes have better odds of achieving return of spontaneous circulation (ROSC). Objective: Our primary objective is to determine if longer chest compression intervals are associated with improved subsequent ROSC in patients with initial PEA or asystole rhythms. Methods: We conducted a retrospective cohort study of video-recorded adult atraumatic cardiac arrest resuscitations in a quaternary care Emergency Department from 1/30/2018 to 2/20/2024. We only examined patients in PEA or asystole and determined the duration of all chest compression intervals for each patient. We grouped the chest compression interval durations into 3 groups (<1min 45sec, 1min 45sec to 2 min 14sec, ≥2min 15 sec) and determined the odds of subsequent ROSC for each chest compression interval duration. We assessed the association between chest compression interval duration and ROSC episodes using a logistic regression model. Results: Out of 326 video-reviewed patients, 235 patients had an initial rhythm of PEA or asystole of which 44 (18.7%) survived to admission and 9 (3.8%) to hospital discharge. The 235 patients yielded 1724 chest compression intervals and 151 ROSC episodes. The ROSC rate for the chest compression intervals <1:45sec was 7.3% (49 out of 673) versus 8.1% (51 out of 632) for intervals 1:45 to 2:14 versus 12.2% (51 out of 419) for intervals ≥2 min 15sec. In a logistic regression model, using the 1min 45 sec to 2min 14 sec interval as the reference group, the <1min 45sec group had 10% lower odds of ROSC (OR: 0.90; 95% CI: 0.60, 1.35) and the ≥2min 15 sec group had 58% higher odds of ROSC (OR: 1.58; 95% CI: 1.05, 2.38). Conclusion: In cardiac arrest patients presenting with non-shockable rhythms, chest compression intervals ≥2 min15sec are associated with higher odds of achieving ROSC.

Successful in-hospital clamshell thoracotomy in a young male patient with polytrauma (ISS57) : A case report

Life-threatened injured patients who suffer acardiovascular arrest after atrauma are still enormously challenging for both the paramedics and the trauma team in the clinic. This case illustrates the treatment of a16-year-old boy who suffered ablunt abdominal trauma with atraumatic cardiac arrest followed by an open resuscitation after clamshell thoracotomy. Subsequently, the treatment after damage control is discussed regarding the current literature and recommendations for treatment.

Mechanical versus manual chest compressions for cardiac arrest

This is the first update of the Cochrane review on mechanical chest compression devices published in 2011 (Brooks 2011). Mechanical chest compression devices have been proposed to improve the effectiveness of cardiopulmonary resuscitation (CPR). To assess the effectiveness of mechanical chest compressions versus standard manual chest compressions with respect to neurologically intact survival in patients who suffer cardiac arrest. We searched the Cochrane Central Register of Controlled Studies (CENTRAL; 2013, Issue 12), MEDLINE Ovid (1946 to 2013 January Week 1), EMBASE (1980 to 2013 January Week 2), Science Citation abstracts (1960 to 18 November 2009), Science Citation Index-Expanded (SCI-EXPANDED) (1970 to 11 January 2013) on Thomson Reuters Web of Science, biotechnology and bioengineering abstracts (1982 to 18 November 2009), conference proceedings Citation Index-Science (CPCI-S) (1990 to 11 January 2013) and clinicaltrials.gov (2 August 2013). We applied no language restrictions. Experts in the field of mechanical chest compression devices and manufacturers were contacted. We included randomised controlled trials (RCTs), cluster RCTs and quasi-randomised studies comparing mechanical chest compressions versus manual chest compressions during CPR for patients with atraumatic cardiac arrest. Two review authors abstracted data independently; disagreement between review authors was resolved by consensus and by a third review author if consensus could not be reached. The methodologies of selected studies were evaluated by a single author for risk of bias. The primary outcome was survival to hospital discharge with good neurological outcome. We planned to use RevMan 5 (Version 5.2. The Nordic Cochrane Centre) and the DerSimonian & Laird method (random-effects model) to provide a pooled estimate for risk ratio (RR) with 95% confidence intervals (95% CIs), if data allowed. Two new studies were included in this update. Six trials in total, including data from 1166 participants, were included in the review. The overall quality of included studies was poor, and significant clinical heterogeneity was observed. Only one study (N = 767) reported survival to hospital discharge with good neurological function (defined as a Cerebral Performance Category score of one or two), demonstrating reduced survival with mechanical chest compressions when compared with manual chest compressions (RR 0.41, 95% CI 0.21 to 0.79). Data from four studies demonstrated increased return of spontaneous circulation, and data from two studies demonstrated increased survival to hospital admission with mechanical chest compressions as compared with manual chest compressions, but none of the individual estimates reached statistical significance. Marked clinical heterogeneity between studies precluded any pooled estimates of effect. Evidence from RCTs in humans is insufficient to conclude that mechanical chest compressions during cardiopulmonary resuscitation for cardiac arrest are associated with benefit or harm. Widespread use of mechanical devices for chest compressions during cardiac events is not supported by this review. More RCTs that measure and account for the CPR process in both arms are needed to clarify the potential benefit to be derived from this intervention.

Emergency department factors associated with survival after sudden cardiac arrest

BackgroundSudden cardiac arrest (SCA) is a leading cause of death in the US. Recent innovations in post-arrest care have been demonstrated to increase survival. However, little is known about the impact of emergency department (ED) and hospital characteristics on survival to hospital admission and ultimate outcome. ObjectiveWe sought to describe the incidence of SCA presenting to the ED and to identify ED and hospital characteristics associated with survival to hospital admission. MethodsWe identified patients with diagnoses of atraumatic cardiac arrest or ventricular fibrillation (ICD-9 427.5 or 427.41) in the 2007 Nationwide Emergency Department Sample (NEDS), a nationally representative estimate of all ED admissions in the United States. We defined SCA as cardiac arrest in the out-of-hospital or ED settings. We used the NEDS sample design to generate nationally representative estimates of the incidence of SCA that presents to EDs. We performed unadjusted and adjusted analyses to examine the relation between patient, ED, and hospital characteristics and outcome using logistic regression. Our primary outcome was survival to hospital admission. Survival to hospital discharge was a secondary outcome. Data are presented as odds ratios (OR) with 95% confidence intervals (CI). ResultsOf the 966 hospitals in the NEDS, 933 (96.6%) reported at least one SCA and were included in the analysis. We identified 38,593 cases of cardiac arrest representing an estimated 174,982 cases nationally. Overall ED SCA survival to hospital admission was 26.2% and survival to discharge was 15.7%. Greater survival to admission was seen in teaching hospitals (OR 1.3 95% CI 1.1–1.5, p=0.001), hospitals with ≥20,000 annual ED visits (OR 1.3 95% CI 1.1–1.6, p=0.003), and hospitals with percutaneous coronary intervention capability (OR 1.6 95% CI 1.4–1.8, p<0.001). Higher SCA volume (>40 annually) was associated with lower survival overall (OR 0.7 95% 0.6–0.9, p=0.010), but not when transferred patients were excluded from the analysis (OR 0.8 95% CI 0.6–1.1, p=0.116). ConclusionsAn estimated 175,000 cases of SCA present to or occur in US EDs each year. Percutaneous coronary intervention capability, ED volume, and teaching status were associated with higher survival to hospital admission. Emergency departments with higher annual SCA volume had lower survival rates, possibly because they transfer fewer patients. An improved understanding of the contribution of ED care to survival following SCA may be useful in advancing our understanding of how best to organize a system of care to ensure optimal outcomes for patients with SCA.

Outcomes of Trauma Victims With Cardiac Arrest Who Survive to Intensive Care Unit Admission

The prognosis for patients with return of spontaneous circulation after trauma-related cardiac arrest (TRCA) is unclear. Our purpose was to (1) determine outcomes for patients with TRCA resuscitated and admitted to the intensive care unit (ICU), (2) identify ICU-based predictors of in-hospital death in this population, and (3) compare outcomes of patients resuscitated from TRCA and atraumatic cardiac arrest (ATCA). We performed a cohort study using a registry of ICU admissions from 120 US hospitals from 2001 to 2005. Inclusion criteria were age >17 years, admission to ICU via the emergency department, and cardiopulmonary resuscitation preceding ICU arrival. The primary outcome measure was survival to hospital discharge. We compared TRCA and ATCA using binomial test and performed multivariable logistic regression to determine independent predictors of death among trauma subjects. A total of 4,048 subjects were included (309 TRCA and 3,739 nonTRCA). Forty percent of trauma subjects survived. Independent predictors of death among trauma subjects included persistent postresuscitation cardiovascular failure in the ICU and presentation to a nontrauma center. Despite being younger and having fewer comorbidities, subjects with TRCA had lower survival than subjects with ATCA (40% vs. 49%, p = 0.003). Despite lower survival than ATCAs, a significant percentage of TRCAs surviving to ICU admission were discharged alive. This suggests aggressive support of this population is not necessarily futile. Investigation into whether optimization of postresuscitation factors would improve outcome for these patients may be warranted.

Paramedic and Emergency Medical Technicians Views on Opportunities and Challenges When Forgoing and Halting Resuscitation in the Field

The objective was to assess paramedic and emergency medical technicians (EMT) perspectives and decision-making after a policy change that allows forgoing or halting resuscitation in prehospital atraumatic cardiac arrest. Five semistructured focus groups were conducted with 34 paramedics and 2 EMTs from emergency medical services (EMS) agencies within Los Angeles County (LAC), 6 months after a policy change that allowed paramedics to forgo or halt resuscitation in the field under certain circumstances. Participants had an overwhelmingly positive view of the policy; felt it empowered their decision-making abilities; and thought the benefits to patients, family, EMS, and the public outweighed the risks. Except under certain circumstances, such as when the body was in public view or when family members did not appear emotionally prepared to have the body left on scene, they felt the policy improved care. Assuming that certain patient characteristics were present, decisions by paramedics about implementing the policy in the field involve many factors, including knowledge and comfort with the new policy, family characteristics (e.g., agreement), and logistics regarding the place of arrest (e.g., size of space). Paramedic and EMT experiences with and attitudes toward forgoing resuscitation, as well as group dynamics among EMS leadership, providers, police, and ED staff, also play a role. Participants view the ability to forgo or halt resuscitation in the field as empowering and do not believe it presents harm to patients or families under most circumstances. Factors other than patient clinical characteristics, such as knowledge and attitudes toward the policy, family emotional preparedness, and location of arrest, affect whether paramedics will implement it.

Developing Quality Indicators for the Appropriateness of Resuscitation in Prehospital Atraumatic Cardiac Arrest

Objective. The vast majority of out-of-hospital cardiac arrest victims do not survive or suffer severe neurological impairment. We sought to develop a set of straightforward clinical indicators that paramedics could use to better match resuscitation attempts to those most likely to benefit. Methods. In partnership with the Los Angeles County Emergency Medical Services, we used the RAND/UCLA appropriateness method of quantifying expert opinion regarding the risks andbenefits of medical procedures. We presented available scientific evidence related to potential indicators of the quality of resuscitative care to stakeholder-nominated experts. Forty-one candidate indicators incorporated key variables, including initial rhythm, patient preferences, presence of witnesses, andplace of arrest. Nine panelists, including palliative care andemergency medical specialists, rated the appropriateness of paramedic use of each indicator by using a 1–9 scale. An indicator was considered appropriate if the potential benefits outweighed the potential harm to the patient or their family. Indicators were retained if median score was ≥7. Results. The expert panel voted to retain 28 quality indicators. Three addressed signs of irreversible death (e.g., dependent lividity), 8 addressed patient preferences (e.g., inquiring about DNR status), andthe remainder addressed combinations of initial rhythm andother prognostic signs (e.g., “If initial rhythm is asystole andpatient is known by apparent surrogate decision maker to have a terminal illness, then forgo resuscitation.”). Our experts recommended a series of much more liberal criteria for forgoing resuscitation than is currently practiced. This includes ascertaining andhonoring patient preferences, either through written documents or family members, andcombinations of clinical criteria that predict poor neurological outcome, such as asystole, terminal illness, age greater than 70, andresponse time greater than 15 minutes. Conclusions. These quality indicators expand on the previously limited circumstances in which paramedics might forgo field resuscitation andimplementation could reduce future harm from such procedures among seriously ill patients. Our current efforts focus on using these indicators to aid implementation of a new resuscitation policy for seriously ill patients in our county.

Evolution of a community-wide early defibrillation programme: Experience over 13 years using police/fire personnel and paramedics as responders

Background: In November 1990, a 2-year trial period was initiated in which police officers in the city of Rochester, Minnesota, were trained in the operation of automated external defibrillators (AEDs). Following the trial, the program was expanded as the city grew in population and area. In 1998 firefighters also were equipped with AEDs, bringing to a total 18 AEDs with police and fire personnel, in addition to paramedic capability. Methods: From November 1990 to December 2003, all adult patients with atraumatic cardiac arrest with ventricular fibrillation (VF) as the presenting rhythm were included for analysis. Call-to-shock time intervals, restoration of spontaneous circulation after defibrillation shocks only (without need for vasoactive or inotropic drug administration), and neurologically intact survival (overall performance category (OPC) 1 or 2) were study end-points. Results: One hundred and ninety-three patients presented in VF. Of these, 80 (41%) were discharged neurologically intact. Of the 159 VF patients whose arrest was bystander-witnessed 73 (46%) were discharged. Survival from non-VF arrest was very low (5%). Assessment of VF survivors demonstrated a quality of life, adjusted for age, gender, and disease, similar to that of the general population. Conclusions: These data demonstrate that a relatively high survival can be obtained in a city of this size and area employing a non-tiered community-wide approach within the emergency medical services (EMS) system.

High Discharge Survival Rate After Out-of-Hospital Ventricular Fibrillation With Rapid Defibrillation by Police and Paramedics

Study objective: To assess outcome in patients with ventricular fibrillation (VF) treated by defibrillator-equipped police and emergency medical technician-paramedics in an advanced life support (ALS) emergency medical services (EMS) system. Methods: We carried out a retrospective observational outcome study of all consecutive adult patients with atraumatic cardiac arrest treated from November 1990 through July 1995. The study was carried out in a city with a population of 76,865 in an area of 32.6 square miles. Central 911 dispatched police and an ALS ambulance simultaneously. Accurate intervals were obtained with the synchronization of all defibrillator clocks with the 911 dispatch clock. The personnel who arrived first delivered the initial shock. After shocks delivered by police, paramedics provided additional treatment if needed. Main outcome measures were time elapsed before delivery of the first shock, restoration of spontaneous circulation (ROSC), and survival to discharge home. Results: Of 84 patients, 31 (37%) were first shocked by police. Thirteen of the 31 demonstrated ROSC, without need for ALS treatment. All 13 survived to discharge. The other 18 patients required ALS; 5 (27.7%) survived. Among the 53 patients first shocked by paramedics, 15 had ROSC after shocks only, and 14 survived. The other 38 needed ALS treatment; 9 survived. Call-to-shock time for all patients was less in the police group than in the paramedic group (5.6 versus 6.3 minutes, P=.038). For all patients, call-to-shock time was less in those with ROSC after shocks only than in those who needed ALS (5.4 versus 6.3 minutes, P=.011). Survival to discharge was 49% (41 of 84), with 18 of 31 (58%) in the police group and 23 of 53 (43%) in the paramedic group. Call-to-shock time for survivors was 5.8 minutes; it was 6.4 minutes for the nonsurvivors ( P=.020). Neither ROSC nor discharge survival was significantly different between police- and paramedic-shocked patients. ROSC after initial shock and call-to-shock time were major determinants of survival, whether the first shocks were administered by police or by paramedics. With ROSC after shocks only, 27 of 28 (96%) survived, whereas 14 of 56 (25%) needing ALS survived ( P<.001). Conclusion: A high discharge-to-home survival rate was obtained with early defibrillation by both police and paramedics. When shocks resulted in ROSC, the overwhelming majority of patients survived (96%). Even brief time decreases (eg, 1 minute) in call-to-shock time increase the likelihood of ROSC from shocks only, with a consequent decrease in the need for ALS intervention. Short call-to-shock time and ROSC response to shocks only are major determinants of a high rate of survival after VF. [White RD, Asplin BR, Bugliosi TF, Hankins DG: High discharge survival rate after out-of-hospital ventricular fibrillation with rapid defibrillation by police and paramedics. Ann Emerg Med November 1996;28:480-485.]

Analysing calls by lay persons reporting cardiac arrest

Prior to establishing a protocol for pre-arrival instructions for cardio-pulmonary resuscitation in the Vienna emergency medical system dispatch centre, a study was performed to determine whether any problems exist which may compromise guidance for basic life-support on the telephone. To evaluate the feasibility of prearrival instructions, a retrospective analysis of cardiac arrest calls was performed. We reviewed the Vienna emergency medical services dispatch centre tape recordings, ambulance run sheets and the hospital charts of 114 patients suffering from atraumatic cardiac arrest. Analysis showed that in 59 cases the arrest occurred in the victim's home. The telephone and the patient were either in the same or in adjoining rooms in 55% of the calls. We did not experience any technical or language difficulties. The caller and victim were related in 51 cases. The callers were completely calm in 77% and fairly calm in an additional 15%. Not one caller was distraught. Our data show that most objections to the feasibility of pre-arrival instructions can be refuted. We conclude that in Vienna the setting and location of arrest will impose few problems on the performance of bystander-cardio-pulmonary resuscitation using pre-arrival instructions given by dispatchers.