Cardiac Arrest Rhythm Research Articles

Abstract 12846: Resuscitation of Out-of-Hospital Cardiac Arrest Without CPR: The 13-Year Experience of Progetto Vita

Introduction: Cardiopulmonary resuscitation (CPR) currently represents standard of care in out-of-hospital cardiac arrest (OOHCA) despite the demonstration of its many side effects. To date, CPR has never been tested in a randomized, prospective clinical trial against an automated external defibrillator (AED) quick deployment, as such a trial is considered impossible for ethical reasons. Nevertheless, insights on the effective role of CPR when an AED is quickly available can be provided from the Progetto Vita of Piacenza, Italy: the first early defibrillation project established in Europe. Hypothesis: To compare differences in 13-year survival between OOHCA victims rescued by standard care and patients rescued by AED-only trained responders. Methods: Prospective, non-randomized parallel study comparing mortality when rescuers only used automated external defibrillators (AEDs) and did not perform CPR with mortality from the standard Emergency Medical Services (EMS) response, including CPR. Survival was followed over 13 years, from June 2001 to July 2014. Results: In 3366 OOHCAs, survival to hospital discharge occurred in 39 of the 95 patients treated with an AED only and in 193 of the 3271 patients treated by standard EMS (41.4% vs. 5.9%; p<0.001) The Kaplan Meier estimates of survival after 13-years follow-up are 31.8% when AEDs only were used versus 2.4% for standard EMS response. Estimates of survival also are significantly better for Progetto Vita when survival was stratified by gender and location of cardiac arrest. Presence of a shockable rhythm at rescuers arrival was associated with a 16.8-fold increased chance of survival to discharge. Progetto Vita intervention was independently associated with a 2.8-fold increased chance of survival to discharge, regardless of minutes from dispatch to arrival, cardiac arrest location, rhythm presentation, and age. Conclusions: Progetto Vita demonstrates excellent long-term survival from out-of-hospital cardiac arrest without CPR use compared with standard resuscitation. The findings from the present study could provide solid "real-world" evidence for the broadscale dissemination of AEDs quickly available to layperson rescuers.

Abstract 19427: Epidemiology and Outcomes of Out-of-hospital Cardiac Arrest in Qatar

Aim: There is a scarcity of population based studies on out-of-hospital cardiac arrest (OHCA) in the Middle East and the wider Asian region. This study describes the Epidemiology and outcomes of OHCA in Qatar, a Middle Eastern country. Methods: Data was extracted retrospectively from a national registry on all adult cardiac origin OHCA patients attended by Emergency Medical Services (EMS) in Qatar, from June 2012 - May 2013. Results: The annual crude incidence rate of cardiac origin OHCA attended by EMS was 23.5 per 100,000. The age-sex standardized incidence rate was 87.83 per 100,000 population. The annual sex-standardized incidence rate for males and females was 91.5 and 84.25 per 100,000 population respectively. Of 447 adult, cardiac origin OHCA patients included in the final analysis, most were male (n=360, 80.5%) with median age of 51 years (IQR = 39-66). Frequently observed nationalities of OHCA cases were Qatari (n=89, 19.9%), Indian (n=74, 16.6%) and Nepalese (n=52, 11.6%). Common initial cardiac arrest rhythms were asystole (n=301, 67.3%), ventricular fibrillation (n=82, 18.3%) and pulseless electrical activity (n=49, 11%). OHCA was unwitnessed (n=220, 49%) in nearly half of the cases while bystanders witnessed it in 170 (38%) patients. Bystander CPR was carried out in 92 (20.6%) of the cases. Of 187 (41.8%) patients who were given shocks, bystander defibrillation was delivered to 12 (2.7%) patients. Prehospital outcomes; 332 (74.3%) patients did not achieve return of spontaneous circulation (ROSC), 40 (8.9%) patients achieved unsustainable ROSC, 58 (13%) achieved ROSC till Emergency department (ED) handover and 5 patients achieved ROSC but rearrested again before reaching ED. Survival to hospital discharge occurred in 38 (8.5%) patients. Neurological outcomes were assessed utilizing Cerebral Performance Category [CPC] scores with a favorable CPC score of 1-2 at discharge in 27 (6%) patients, while 11 (2.5%) patients had a poor CPC score of 3-4. Of those with CPC score 1-2 at hospital discharge, 59% and 26% had CPC score 1-2, at 1 and 3 years follow-up respectively. Overall survival was 9.7%. Conclusion: Standardized rates are comparable to western countries, there are significant opportunities to improve outcomes, including better bystander CPR.

Abstract 13691: Extracorporeal Cardiopulmonary Resuscitation for Nonshockable Rhythms

Introduction: In cardiac arrest patients, patients with shockable rhythms have more favorable outcomes than those with non-shockable rhythms. Recently, alternative cardiopulmonary resuscitation (CPR) using extracorporeal membrane oxygenation (ECMO) has shown the potential to improve the outcomes of patients who are unresponsive to conventional CPR. Hypothesis: We assessed the hypothesis that initial shockable rhythms are associated with improved outcomes in extracorporeal CPR (ECPR) using ECMO. Methods: Patients who were treated with ECPR were enrolled in this study. Patients were divided into 2 groups according to the whether the initial recorded rhythms were shockable (shockable group) or not (nonshockable group). Baseline characteristics and 90-day survival were assessed. We constructed 90-day survival curves using the Kaplan-Meier method. A P < 0.05 was defined as statistically significant. Results: The study patients in the shockable and nonshockable groups were similar in terms of age, witnessed to arrest, bystander initiated CPR, collapse to CPR, collapse to initiation of ECMO. Patients in the shockable group were more likely than those in the nonshockable group to undergo immediate coronary angiography (91% vs. 66%, P < 0.001), subsequent coronary revascularization (55% vs. 37%, P = 0.02), and targeted temperature management (56% vs. 49%, P = 0.37). The rates of return of spontaneous heart-beat (88% vs. 91%, P = 0.58) and weaning from ECMO (48% vs. 40%, P = 0.25) were similar between groups. The 90-day survival curves are shown in the figure. Cox proportional hazard regression suggested that the initial shockable rhythm was not an independent predictors of 90-day survival. Conclusions: Unlike in conventional CPR, the initial nonshockable rhythm is not necessarily associated with an adverse outcome. However, none of the patients with an initial asystole rhythm survived up to 90 days.

Towards a core outcome set for cardiac arrest clinical trials (COSCA): An international Delphi survey

fromthemedical records. Co-morbiditieswere assessedprior to the IHCA as ICD-10 codes in medical files according to Age-adjusted Charlson Comorbidity Score (ACCI). Differences in survival was assessed with adjusted Odds Ratio with 95% Confidence Intervals (OR 95% CI) between patients with an ACCI of 0–4 points versus thosewith 5–7 points as well as thosewith≥8 points. Adjustments were done for hospital site, first documented heart rhythm, ECG surveillance, witnessed and place of cardiac arrest. Results: In all, 175 patients suffered an IHCA, out of 41 (23%) survived at least 30 days. Patients with an ACCI of 5–7 points had a minor chance aswell as thosewith ACCI of≥8 points had aminimal chance to survive an IHCA compare to thosewithACCI of 0–4points (AdjustedOR0.10 95%, CI 0.04–0.26 andOR0.04, 95% C.I. 0.03–0.42, respectively). Conclusion: Patients with a moderate or severe burden of co-morbidities have a minor chance to survive an IHCA. This information could be used as a decision-tool during ongoing CPR aswell as it might aid clinicians when planning care and discussion DNAR orders.

Reanimación cardiopulmonar. Soporte vital básico y avanzado

The sequence of cardiopulmonary resuscitation is CAB, starting chest compressions before ventilation. Cardiopulmonary resuscitation should apply high quality compression with a frequency of 100 to 120 compressions per minute and a depth of at least 5cm, allowing full chest expansion, minimizing disruption of compressions and avoiding excessive ventilation. The automated external defibrillator should be used as soon as it becomes available. The foundation of successful advanced cardiovascular support is based on a high quality of cardiopulmonary resuscitation and ventricular fibrillation and pulseless ventricular tachycardia rapid defibrillation within minutes after the collapse. Understanding the importance of diagnosing and treating the possible underlying causes, considering therefore rule the “H” and “T” is fundamental to the management of all cardiac arrest rhythms, especially mentioning the cases of pulseless electrical activity. Once the patient reaches the spontaneous movement must “immediately” begin the post resuscitation care, optimizing the long-term survival with good neurological outcome.

Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care.

Therapeutic hypothermia (TH) improves neurologic outcome in patients resuscitated from ventricular fibrillation. The purpose of this study was to evaluate TH effects on neurologic outcome in patients resuscitated from a non-shockable out-of-hospital cardiac arrest rhythm. This is a retrospective cohort study of data reported to a registry in an emergency medical system in a large metropolitan region. Patients achieving field return of spontaneous circulation are transported to designated hospitals with TH protocols. Patients with an initial non-shockable rhythm were identified. Patients were excluded if awake in the Emergency Department or if TH was withheld due to preexisting coma or death prior to initiation. The decision to initiate TH was determined by the treating physician. The primary outcome was survival with good neurologic outcome defined by a cerebral performance category of 1 or 2. Of the 2772 patients treated for cardiac arrest during the study period, there were 1713 patients resuscitated from cardiac arrest with an initial non-shockable rhythm and 1432 patients met inclusion criteria. The median age was 69 years [IQR 59-82]; 802 (56%) male. TH was induced in 596 (42%) patients. Survival with good neurologic outcome was 14% in the group receiving TH, compared with 5% in those not treated with TH (risk difference = 8%, 95% CI 5-12%). The adjusted OR for a CPC 1 or 2 with TH was 2.9 (95% CI 1.9-4.4). Analyzing the data collected from the registry of the standard practice in a large metropolitan region, TH is associated with improved neurologic outcome in patients resuscitated from initial non-shockable rhythms in a regionalized system for post-resuscitation care.

One-year follow-up of neurological status of patients after cardiac arrest seen at the emergency room of a teaching hospital

ABSTRACTObjective:To describe neurological status and associated factors of survivors after cardiac arrest, upon discharge, and at 6 and 12 month follow-up.Methods:A cohort, prospective, descriptive study conducted in an emergency room. Patients who suffered cardiac arrest and survived were included. A one-year consecutive sample, comprising 285 patients and survivors (n=16) followed up for one year after discharge. Neurological status was assessed by the Cerebral Performance Category before the cardiac arrest, upon discharge, and at 6 and 12 months after discharge. The following factors were investigated: comorbidities, presence of consciousness upon admission, previous cardiac arrest, witnessed cardiac arrest, location, cause and initial rhythm of cardiac arrest, number of cardiac arrests, interval between collapse and start of cardiopulmonary resuscitation, and between collapse and end of cardiopulmonary resuscitation, and duration of cardiopulmonary resuscitation.Results:Of the patients treated, 4.5% (n=13) survived after 6 and 12 months follow-up. Upon discharge, 50% of patients remained with previous Cerebral Performance Category of the cardiac arrest and 50% had worsening of Cerebral Performance Category. After 6 months, 53.8% remained in the same Cerebral Performance Category and 46.2% improved as compared to discharge. After 12 months, all patients remained in the same Cerebral Performance Category of the previous 6 months. There was no statistically significant association between neurological outcome during follow-up and the variables assessed.Conclusion:There was neurological worsening at discharge but improvement or stabilization in the course of a year. There was no association between Cerebral Performance Category and the variables assessed.

Intraarrest rhythms and rhythm conversion in asphyxial cardiac arrest.

The objective was to analyze the cardiac arrest rhythms presenting during asphyxial cardiac arrest (ACA). Asphyxial cardiac arrest was induced in 30 Landrace large white piglets, aged 12 to 15weeks and with a mean (±SD) weight of 20 (±2) kg. After the onset of cardiac arrest, the animals were left untreated for 4minutes, after which cardiopulmonary resuscitation was commenced. Heart rhythms were monitored from the onset of asphyxia until return of spontaneous circulation or death. After endotracheal tube clamping and prior to cardiac arrest, normal sinus rhythm was noted in 14 animals, atrial fibrillation in two animals, Mobitz II atrioventricular block in 10 animals, and third-degree atrioventricular block in four animals. At the onset of cardiac arrest, seven animals had ventricular fibrillation (VF), two had asystole, and 21 had pulseless electrical activity (PEA). During the 4-minute period of untreated arrest, however, significant changes in the monitored rhythm were noted; at the end of the fourth minute, 19 animals had VF, two animals had asystole, and nine animals had PEA. The most common rhythm after 4minutes of untreated ACA was VF, while in 57% of animals, PEA was spontaneously converted to VF during the cardiac arrest interval.

PROGNOSTIC VALUE OF APACHE SCORE AND LACTATE IN PATIENTS PRESENTING WITH OUT-OF-HOSPITAL CARDIAC ARREST AND SHOCKABLE RHYTHM IN THE ABSENCE OF ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION

The prognostic value of the APACHE score and lactate levels on mortality in patients with out-of-hospital cardiac arrest and shockable rhythm (OHCA-SR) without ST-segment elevation myocardial infarction (STEMI) are not well known. We assessed the impact of these variables on outcomes in patients

Is flat line truly asystole?

Sir, A 72-year-old man presented with gastric outlet obstruction. He was diagnosed to have adenocarcinoma of the pyloric region. He was posted for diagnostic laparoscopy followed by total gastrectomy/gastrojejunostomy. His general condition was poor; he was cachectic and had generalised oedema. His exercise tolerance was poor, and he was barely managing daily activities, equivalent to three metabolic equivalents. His vitals were stable. Pre-operative electrocardiogram (ECG) and echocardiogram (ECHO) were normal. The case was performed under general anaesthesia with controlled ventilation. An arterial line and a central venous pressure line were introduced. Diagnostic laparoscopy confirmed the inoperability of the case and feeding jejunostomy was planned. Patient was maintaining a normal ECG pattern on the monitor (GE B40® patient monitor, GE Healthcare United Kingdom); pulse rate was 75–80/min and invasive blood pressure (IBP) was 102/76 mm Hg. Midline incision was made; midway through the procedure, the patient developed fall in O2 saturation. Just before the desaturation 1 mg vecuronium (top up dose) was injected through the central line inserted in the internal jugular vein. In a matter of 2 min, SpO2 had fallen from 98 to 10. Arterial line tracing was absent. Immediate cardiopulmonary resuscitation (CPR) was started. The rhythm noted was pulseless ventricular tachycardia (VT). Patient was defibrillated with 200J biphasic defibrillator and adrenaline 1 mg was administered. Resuscitation was continued as per American Heart Association guidelines (CPR at the rate of 100/min with ventilation every 6–8 s) checking the rhythm every 2 min.[1] After 35 min of resuscitation, a stable rhythm was established. The surgeon was asked to hasten and close the abdominal defect. With the BP at 90 mm systolic, dopamine drip was started. Meanwhile, patient developed ventricular fibrillation (VF). Even after 20 min of resuscitation following advanced cardiac life support (ACLS) protocol, no evidence of cardiac activity was noticed. (Flat line seen in the ECG monitor). We were about to declare death when a timely intervention prevented a major error. We increased the gain of ECG on the monitor from 0.5 to 7, and there was perfect normal sinus rhythm. On checking carotid pulse was present. Surgery was completed, and the patient was shifted to the post-anaesthesia care unit. Patient's post-operative ECG and cardiac enzymes were normal, confirming that high-quality CPR was administered (and successful). As the hypoxic events unfolded after the injection through the central line, a possible air embolism was considered as the reason for the arrest. The post-operative ECG did not show S1Q3T3 pattern, nor any evidence of emboli; no right ventricular strain was noted in ECHO.[2] Post-operative X-ray was also normal. Patient recovered from effect of relaxant (vecuronium) after 4 h. The next morning, sedatives were stopped and sensorium assessed. He responded to oral commands. After 5 days of intensive care, he was extubated. Asystole is defined as a cardiac arrest rhythm in which there is no discernible electrical activity on the ECG monitor. Asystole is sometimes referred to as a “flat line”, which may be encountered during cardiac arrest with VF or VT, before returning to spontaneous circulation.[3] Confirmation that a “flat line” is truly asystole is an important step in the ACLS protocol. On seeing a flat line on the monitor, one has to ensure that asystole is not another rhythm that looks like a “flat line.” Fine-VF can appear to be asystole, and “flat line” on a monitor can be due to operator error or equipment failure. The common cause for the isoelectric line that is not asystole is loose or disconnected leads and a low signal on the ECG monitor.[4] We decided to post this case to highlight two main points. That adequate training helps a long way in providing high-quality CPR and that in case of asystole, simple measures such as checking the ECG leads for disconnection and increasing the gain can avoid major mistakes before deciding to stop resuscitation and declare death.

Favorable Outcome and Survival Using a Hypothermia Protocol After Successful Cardiopulmonary Resuscitation.

Use of mild therapeutic hypothermia to goal 32 34 °C, after return of spontaneous circulation (ROSC) in cardiac arrest patients, has been shown to increase the rates of survival and favorable neurological outcomes [1, 2]. The American Heart Association (AHA) recommends mild therapeutic hypothermia after ROSC for out-of-hospital cardiac arrest with an initial documented rhythm of ventricular fibrillation (class I, level of evidence B) [3]. International resuscitation guidelines also support mild therapeutic hypothermia as the best medical practice for shockable rhythms in patients resuscitated from cardiac arrest due to ventricular fibrillation and pulseless ventricular tachycardia after ROSC [4]. Herein, we wish to notify the readers on a case of therapeutic hypothermia after ROSC in a young man associated with favorable neurologic outcome and survival. A 34-yearold electrical worker is brought to the emergency department (ED) by co-workers having been injured by electrical strike at work. On arrival in the ED, he had a Glasgow coma score (GCS) of 3/15 and dilated sluggish pupils. Additionally, there were no heartbeats or respiration. Cardiac monitoring revealed ventricular fibrillation and the patient received treatment with 150-J biphasic waveform shock. Cardiopulmonary resuscitation (CPR) was immediately instituted after the shock. After 2 min of CPR, ROSC was achieved and his rhythm has restored to sinus rhythm. Neither epinephrine nor antidysrhythmic agents were administered. He was resuscitated succesufully but yet remained comatose after CPR at the ED, following vital signs: GCS 8, heart rate 110/min, and blood pressure 80/50 mm Hg. Advanced cardiac life support measures were initiated (i.e., controlled intravenous fluid support, administration of dopamine, adequate oxygenation, and support of respiration with bag ventilation) following ROSC in the ED. Furthermore, therapeutic hypothermia protocol was started immediately with ice packs in the ED to decrease the patient’s temperature below 34 °C. Two hours after admission to the ED, he was transferred to the intensive care unit (ICU) for optimal care. Therapeutic cooling was maintained for 24 h by gel-circulation cooling pads (temperature management system; Artric Sun® 5000) in the ICU, and the patient was discharged home with mild neurologic deficit on ICU day 20. Therapeutic hypothermia is associated with favorable neurologic outcome and survival in patients who have experienced cardiac arrest and resuscitated succesufully, as it was in the present case. This therapy should be started as quickly as possible in post-cardiac arrest care patients, particularly with shockable cardiac arrest rhythms.

Abstract 75: Ventricular Fibrillation in Cardiac Arrest with Nonshockable Initial Rhythm

The initial shockable rhythm in cardiac arrest is a well known factor of good prognosis. Little is known about the influence of the onset of ventricular fibrillation during resuscitation at cardiac arrest whose initial rhythm was non-shockable. Methods: Retrospective analysis of a continuous registry of out-of-hospital cardiac arrest (OHCA) Inclusion criteria, all consecutive patients suffering OHCA attended by emergency teams in Andalusia, Spain. Period January 2008 - December 2012. Results: 5067 patients were included. According to the initial cardiac arrest rhythm 1038 (20.5%) cases presented initial shockable rhythm (SR) and 4029 (79.5%) with non-shockable initial rhythm (NSR). Of these patients 150 (3%) reported one or more episodes of ventricular fibrillation during resuscitation (NSRVF). The main clinical characteristics of these three groups are shown in Table 1. Variables associated with good neurological status at hospital discharge are shown in Table 2. Conclusions: NSRVF patients present higher survival with good neurological status than NSR patients. These patients may represent a third prognostic group in cardiac arrest with a survival rate between shockable and non-shockable initial rhythms. Table 1. Clinical data of patients regarding rhythm of cardiac arrest Table 2. Variables associated with good neurological status at discharge (CPC 1-2 ) SD: Standard deviation. IQR: Interquartile range. OR: Odds Ratio. CI: Confidence Interval. ET: Emergency Team. VF: Ventricular Fibrillation. CPR: Cardiopulmonary resuscitation. CPC: Cerebral Perfomance Category. ROSC: Return of spontaneous circulation

Abstract 74: The Survival Benefit of Coronary Angiography After Cardiac Arrest Is Observed Only in Patients with Shockable Rhythms

BACKGROUND: The identification and treatment of a reversible cause of arrest is considered an important step in post arrest care. Observational data suggests a survival benefit is derived from the performance of coronary angiography in post cardiac arrest patients who survive to hospital admission. We hypothesized that the benefit of this therapy would be diminished in victims who presented with non-shockable rhythms. METHODS: We analyzed a prospectively-collected registry of all cardiac arrests in the state of Utah between July 1, 2012 through December 31, 2013. We compared outcomes of patients surviving to hospital admission, stratified by presenting rhythm and performance of angiography. Logistic regression was used to control for confounders. RESULTS: During the study period, 464/1,534 (30.2%) out-of-hospital cardiac arrest victims survived to hospital admission. Coronary angiography was performed in 133 (28.7%). Neurologically-intact survival was higher in patients with shockable rhythms who underwent angiography compared with those who didn’t (73% vs 32%, p<0.0001, TABLE). However, this survival benefit was not apparent in patients with a presenting rhythm of asystole or pulseless electrical activity (17% vs 20%, p=0.7). When stratified by presenting rhythm and controlling for age, witnessed arrest, bystander CPR, and gender, only victims with an initial shockable rhythm demonstrated increased odds of neurologically-intact survival (OR 5.9, 95% CI 2.9-11.7, p<0.0001) CONCLUSIONS: Our analysis suggests that post arrest angiography, on average, provides a survival advantage only among victims with an initial shockable rhythm. However, this data is observational and prone to selection bias and residual confounding.

General practitioner contribution to out-of-hospital cardiac arrest outcome: A national registry study

Background: There is a wide variation in reported survival from out-of-hospital cardiac arrest (OHCA). One factor in this variation may be the contribution of general practitioners to pre-hospital resuscitation. Studies using self-reported data describe increased survival proportions when general practitioners are involved.Objectives: This study aims to investigate the contribution of general practitioner involvement in out-of-hospital cardiac arrest events.Design and Setting: A retrospective observational study using data collected from ambulance records in the Republic of Ireland to describe general practitioner (GP) contribution to pre-hospital resuscitation attempts (n = 2369). Analysis is limited to patients with presumed cardiac cause and first arrest rhythm recorded as shockable (n = 510).Results: When a GP is present at scene (n = 199) patients are less likely to achieve return of spontaneous circulation (ROSC) (P < 0.001) or be transported to hospital (P < 0.001). When GPs participate in resuscitation (n = 92), patients are more likely to have collapsed in a public place (P < 0.01), receive bystander CPR (P < 0.001) and survive to hospital discharge (P < 0.001). Multiple logistic analysis of survival suggests that GP participation in resuscitation increases the odds of survival (4.6; 95% CI 1.6–13.3) and having collapsed in a public place increases chances of survival (5.8; 95% CI 2.1–15.7).Conclusion: Our analysis suggests that in this subgroup, GP participation in OHCA resuscitation attempts is associated with improved patient survival. Furthermore, resuscitation is more likely to be ceased at scene when a GP is present, highlighting the role that GPs play in the compassionate management of death in unviable circumstances.

An optimal transition time to extracorporeal cardiopulmonary resuscitation for predicting good neurological outcome in patients with out-of-hospital cardiac arrest: a propensity-matched study.

IntroductionProlonged conventional cardiopulmonary resuscitation (CCPR) is associated with a poor prognosis in out-of-hospital cardiac arrest (OHCA) patients. Alternative methods can be needed to improve the outcome in patients with prolonged CCPR and extracorporeal cardiopulmonary resuscitation (ECPR) can be considered as an alternative method. The objectives of this study were to estimate the optimal duration of CPR to consider ECPR as an alternative resuscitation method in patients with CCPR, and to find the indications for predicting good neurologic outcome in OHCA patients who received ECPR.MethodsThis study is a retrospective analysis based on a prospective cohort. We included patients ≥ 18 years of age without suspected or confirmed trauma and who experienced an OHCA from May 2006 to December 2013. First, we determined the appropriate cut-off duration for CPR based on the discrimination of good and poor neurological outcomes in the patients who received only CCPR, and then we compared the outcome between the CCPR group and ECPR group by using propensity score matching. Second, we compared CPR related data according to the neurologic outcome in matched ECPR group.ResultsOf 499 patients suitable for inclusion, 444 and 55 patients were enrolled in the CCPR and ECPR group, respectively. The predicted duration for a favorable neurologic outcome (CPC1, 2) is < 21 minutes of CPR in only CCPR patients. The matched ECPR group with ≥ 21 minutes of CPR duration had a more favorable neurological outcome than the matched CCPR group at 3 months post-arrest. In matched ECPR group, younger age, witnessed arrest without initial asystole rhythm, early achievement of mean arterial pressure ≥ 60 mmHg, low rate of ECPR-related complications, and therapeutic hypothermia were significant factors for expecting good neurologic outcome.ConclusionsECPR should be considered as an alternative method for attaining good neurological outcomes in OHCA patients who required prolonged CPR, especially of ≥ 21 minutes. Younger or witnessed arrest patients without initial asystole were good candidates for ECPR. After implantation of ECPR, early hemodynamic stabilization, prevention of ECPR-related complications, and application of therapeutic hypothermia may improve the neurological outcome.

Electrocardiogram characteristics prior to in-hospital cardiac arrest.

Survival after in-hospital cardiac arrest (I-HCA) remains < 30 %. There is very limited literature exploring the electrocardiogram changes prior to I-HCA. The purpose of the study was to determine demographics and electrocardiographic predictors prior to I-HCA. A retrospective study was conducted among 39 cardiovascular subjects who had cardiopulmonary resuscitation from I-HCA with initial rhythms of pulseless electrical activity (PEA) and asystole. Demographics including medical history, ejection fraction, laboratory values, and medications were examined. Electrocardiogram (ECG) parameters from telemetry were studied to identify changes in heart rate, QRS duration and morphology, and time of occurrence and location of ST segment changes prior to I-HCA. Increased age was significantly associated with failure to survive to discharge (p < 0.05). Significant change was observed in heart rate including a downtrend of heart rate within 15 min prior to I-HCA (p < 0.05). There was a significant difference in heart rate and QRS duration during the last hour prior to I-HCA compared to the previous hours (p < 0.05). Inferior ECG leads showed the most significant changes in QRS morphology and ST segments prior to I-HCA (p < 0.05). Subjects with an initial rhythm of asystole demonstrated significantly greater ECG changes including QRS morphology and ST segment changes compared to the subjects with initial rhythms of PEA (p < 0.05). Diagnostic ECG trends can be identified prior to I-HCA due to PEA and asystole and can be further utilized for training a predictive machine learning model for I-HCA.

Evaluating Simulation-Based ACLS Education on Patient Outcomes: A Randomized, Controlled Pilot Study.

Simulation training is widely accepted as an effective teaching tool, especially for dealing with high-risk situations. We assessed whether standardized, simulation-based advanced cardiac life support (ACLS) training improved performance in managing simulated and actual cardiac arrests. A total of 103 second- and third-year internal medicine residents were randomized to 2 groups. The first group underwent conventional ACLS training. The second group underwent two 2 1/2-hour sessions of standardized simulation ACLS teaching. The groups were assessed by evaluators blinded to their assignment during in-hospital monthly mock codes and actual inpatient code sheets at 3 large academic hospitals. Primary outcomes were time to initiation of cardiopulmonary resuscitation, time to administration of first epinephrine/vasopressin, time to delivery of first defibrillation, and adherence to American Heart Association guidelines. There were no differences in primary outcomes among the study arms and hospital sites. During 21 mock codes, the most common error was misidentification of the initial rhythm (67% [6 of 9] and 58% [7 of 12] control and simulation arms, respectively, P = .70). There were no differences in primary outcome among groups in 147 actual inpatient codes. This blinded, randomized study found no effect on primary outcomes. A notable finding was the percentage of internal medicine residents who misidentified cardiac arrest rhythms.

Outcomes following out-of-hospital cardiac arrest with an initial cardiac rhythm of asystole or pulseless electrical activity in Victoria, Australia

BackgroundWhile internationally reported survival from out-of-hospital cardiac arrest (OHCA) is improving, much of the increase is being observed in patients presenting to emergency medical services (EMS) in shockable rhythms. The purpose of this study was to assess survival and 12-month functional recovery in patients presenting to EMS in asystole or pulseless electrical activity (PEA). MethodsThe Victorian Ambulance Cardiac Arrest Registry was searched for adult OHCA patients presenting in non-shockable rhythms in Victoria, Australia between 1st July 2003 and 30th June 2013. We excluded patients defibrillated prior to EMS arrival and arrests witnessed by EMS. Twelve-month quality-of-life interviews were conducted on survivors who arrested between 1st January 2010 and 31st December 2012. The main outcome measures were survival to hospital discharge and 12-month functional recovery measured by the Extended Glasgow Outcome Scale (GOSE). ResultsA total of 38,378 non-shockable OHCA attended by EMS were included, of which 88.0% were asystole and 11.6% were PEA. Of the patients receiving resuscitation, survival to hospital discharge was 1.1% for asystole and 5.9% for PEA (p<0.001), with no significant improvement observed over the 10 year study period. In survivors with 12-month follow-up data, the combined rate of death, vegetative state or lower severe disability was 66.7% (95% CI 41.0–80.0%) for asystole and 44.7% (95% CI 30.2–59.9%) for PEA. ConclusionSurvival outcomes following OHCA with initial rhythms of asystole or PEA did not improve over the 10-year study period. Our findings indicate high rates of death within 12 months, and unfavourable functional recovery for survivors.

Out-of-hospital cardiac arrest: determinant factors for immediate survival after cardiopulmonary resuscitation.

OBJECTIVE: to analyze determinant factors for the immediate survival of persons who receive cardiopulmonary resuscitation from the advanced support units of the Mobile Emergency Medical Services (SAMU) of Belo Horizonte. METHOD: this is a retrospective, epidemiological study which analyzed 1,165 assistance forms, from the period 2008 - 2010. The collected data followed the Utstein style, being submitted to descriptive and analytical statistics with tests with levels of significance of 5%. RESULTS: the majority were male, the median age was 64 years, and the ambulance response time, nine minutes. Immediate survival was observed in 239 persons. An association was ascertained of this outcome with "cardiac arrest witnessed by persons trained in basic life support" (OR=3.49; p<0.05; CI 95%), "cardiac arrest witnessed by Mobile Emergency Medical Services teams" (OR=2.99; p<0.05; CI95%), "only the carry out of basic life support" (OR=0.142; p<0.05; CI95%), and "initial cardiac rhythm of asystole" (OR=0.33; p<0.05; CI 95%). CONCLUSION: early access to cardiopulmonary resuscitation was related to a favorable outcome, and the non-undertaking of advanced support, and asystole, were associated with worse outcomes. Basic and advanced life support techniques can alter survival in the event of cardiac arrest.

Treatment and Outcomes of ST Segment Elevation Myocardial Infarction and Out-of-Hospital Cardiac Arrest in a Regionalized System of Care Based on Presence or Absence of Initial Shockable Cardiac Arrest Rhythm

The aim of this study was to evaluate the treatment and outcomes of patients with ST-segment elevation myocardial infarctions complicated by out-of-hospital cardiac arrest in a regional system of care. In this retrospective study, the effect of the absence of an initial shockable arrest rhythm was analyzed. The primary end point of survival with good neurologic outcome in patients with and without an initial shockable arrest rhythm was adjusted for age, witnessed arrest, bystander cardiopulmonary resuscitation, and treatment with therapeutic hypothermia and percutaneous coronary intervention. One-hundred sixty-eight of 348 patients (49%) survived to hospital discharge. Patients with a shockable initial rhythm were more likely to receive therapeutic hypothermia (48% vs 37%, risk ratio 1.2, 95% confidence interval [CI] 1.0 to 1.5) and to be treated in the cardiac catheterization laboratory (80% vs 43%, risk ratio 2.8, 95% CI 2.0 to 3.8). The likelihood of survival with good neurologic outcome in patients with a shockable initial rhythm compared with those presenting without a shockable rhythm was 4.8 (95% CI 2.7 to 8.7). In patients who underwent percutaneous coronary intervention, the likelihood of survival with good neurologic outcome was higher (risk ratio 2.7, 95% CI 1.1 to 6.8) in those with a shockable rhythm. In conclusion, the absence of an initial shockable rhythm in patients with ST-segment elevation myocardial infarctions plus out-of-hospital cardiac arrest is associated with significantly worse survival and neurologic outcome. These differences persist despite application of therapies including therapeutic hypothermia and percutaneous coronary intervention within a regionalized system of care.