Duration Of CPR Research Articles

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

Background/ObjectivePost-cardiac arrest patients are vulnerable to hypoxic-ischaemic brain injury (HIBI), but HIBI may not be identified until computed tomography (CT) scan of the brain is obtained post-resuscitation and stabilization. We aimed to evaluate the association of clinical arrest characteristics with early CT findings of HIBI to identify those at the highest risk for HIBI. MethodsThis is a retrospective analysis of out-of-hospital cardiac arrest (OHCA) patients who underwent whole-body imaging. Head CT reports were analyzed with an emphasis on findings suggestive of HIBI; HIBI was present if any of the following were noted on the neuroradiologist read: global cerebral oedema, sulcal effacement, blurred grey-white junction, and ventricular compression. The primary exposure was duration of cardiac arrest. Secondary exposures included age, cardiac vs noncardiac etiology, and witnessed vs unwitnessed arrest. The primary outcome was CT findings of HIBI. ResultsA total of 180 patients (average age 54 years, 32% female, 71% White, 53% witnessed arrest, 32% cardiac etiology of arrest, mean CPR duration of 15 ± 10 minutes) were included in this analysis. CT findings of HIBI were seen in 47 (48.3%) patients. Multivariate logistic regression demonstrated a significant association between CPR duration and HIBI (adjusted OR = 1.1, 95% CI 1.01–1.11, p < 0.01). ConclusionSigns of HIBI are commonly seen on CT head within 6 hours of OHCA, occurring in approximately half of patients, and are associated with CPR duration. Determining risk factors for abnormal CT findings can help clinically identify patients at higher risk for HIBI and target interventions appropriately.

Potential role for extracorporeal membrane oxygenation cardiopulmonary resuscitation (E-CPR) during in-hospital cardiac arrest in Australia: A nested cohort study

ObjectiveThis study aims to evaluate the characteristics and outcomes of patients who fulfilled extracorporeal membrane oxygenation cardiopulmonary resuscitation (E-CPR) selection criteria during in-hospital cardiac arrest (IHCA). DesignThis is a nested cohort study. SettingCode blue data were collected across seven hospitals in Australia between July 2017 and August 2018. ParticipantsParticipants who fulfilled E-CPR selection criteria during IHCA were included. Main outcome measuresReturn of spontaneous circulation and survival and functional outcome at hospital discharge. Functional outcome was measured using the modified Rankin scale, with scores dichotomised into good and poor functional outcome. ResultsTwenty-three (23/144; 16%) patients fulfilled E-CPR selection criteria during IHCA, and 11/23 (47.8%) had a poor outcome. Patients with a poor outcome were more likely to have a non-shockable rhythm (81.8% vs. 16.7%; p = 0.002), and a longer duration of CPR (median 12.5 [5.5, 39.5] vs. 1.5 [0.3, 2.5] minutes; p < 0.001) compared to those with a good outcome. The majority of patients (18/19 [94.7%]) achieved sustained return of spontaneous circulation within 15 minutes of CPR. All five patients who had CPR >15 minutes had a poor outcome. ConclusionApproximately one in six IHCA patients fulfilled E-CPR selection criteria during IHCA, half of whom had a poor outcome. Non-shockable rhythm and longer duration of CPR were associated with poor outcome. Patients who had CPR for >15 minutes and a poor outcome may have benefited from E-CPR. The feasibility, effectiveness and risks of commencing E-CPR earlier in IHCA and among those with non-shockable rhythms requires further investigation.

The impact of BMI on arrest characteristics and survival of patients with out-of-hospital cardiac arrest treated with extracorporeal cardiopulmonary resuscitation

AimTo assess the impact of body mass index (BMI) on survival to hospital discharge of patients presenting with refractory ventricular fibrillation treated with extracorporeal cardiopulmonary resuscitation. We hypothesize that due to limitations in pre-hospital care delivery, people with high BMI have worse survival after prolonged resuscitation and ECPR. MethodsThis study is a retrospective single-centre study that included patients suffering refractory VT/VF OHCA from December 2015 to October 2021 and had a BMI calculated at hospital admission. We compared the baseline characteristics and survival between patients with obesity (>30 kg/m2) and those without (≤30 kg/m2). ResultsTwo-hundred eighty-three patients were included in this study, and two-hundred twenty-four required mechanical support with veno-arterial extracorporeal cardiopulmonary membrane oxygenation (VA ECMO). Patients with BMI > 30 (n = 133) had significantly prolonged CPR duration compared to their peers with BMI ≤ 30 kg/m2 (n = 150) and were significantly more likely to require support with VA ECMO (85.7% vs 73.3%, p = 0.015). Survival to hospital discharge was significantly higher in patients with BMI ≤ 30 kg/m2 (48% vs. 29.3%, p < 0.001). BMI was an independent predictor of mortality in a multivariable logistic regression analysis. The four-year mortality rate was low and not significantly different between the two groups (p = 0.32). ConclusionECPR yields clinically meaningful long-term survival in patients with BMI > 30 kg/m2. However, the resuscitation time is significantly prolonged, and the overall survival significantly lower compared to patients with BMI ≤ 30 kg/m2. ECPR should, therefore, not be withheld for this population, but faster transport to an ECMO capable centre is mandated to improve survival to hospital discharge.

The impact of levosimendan on survival and weaning from ECMO after extracorporeal cardiopulmonary resuscitation.

Extracorporeal cardiopulmonary resuscitation (eCPR) is increasingly used due to its beneficial outcomes and results compared to conventional CPR. After cardiac arrest, the overall ejection fraction is severely impaired; thus, weaning from ECMO is often prolonged or impossible. We hypothesized that early application of levosimendan in these patients facilitates ECMO weaning and survival. From 2016 until 2020, patients who underwent eCPR after cardiac arrest at our institution were analyzed retrospectively and divided into two groups: patients who received levosimendan during ICU stay (n = 24) and those who did not receive levosimendan (n = 84) and analyzed for outcome parameters. Furthermore, we used propensity-score matching and multinomial regression analysis to show the effect of levosimendan on outcome parameters. Overall, in-hospital mortality was significantly lower in the group which received levosimendan (28% vs. 88%, p ≤ 0.01), and ECMO weaning was more feasible in patients who received levosimendan (88% vs. 20%, p ≤ 0.01). CPR duration until ECMO cannulation was significantly shorter in the levosimendan group (44 + 26 vs. 65 + 28, p = 0.002); interestingly, the rate of mechanical chest compressions before ECMO cannulation was lower in the levosimendan group (50% vs. 69%, p = 0.005). In patients after cardiac arrest treated with eCPR, levosimendan seems to contribute to higher success rates of ECMO weaning, potentially due to a short to mid-term increase in inotropy. Also, the survival after levosimendan application was higher than patients who did not receive levosimendan.

Long-term function, quality of life and healthcare utilization among survivors of pediatric out-of-hospital cardiac arrest

BackgroundSurvival following pediatric out-of-hospital cardiac arrest (OHCA) has improved over the past 2 decades but data on survivors’ long-term outcomes are limited. We aimed to evaluate long-term outcomes in pediatric OHCA survivors more than one year after cardiac arrest. MethodsOHCA survivors <18 years old who received post-cardiac arrest care in the PICU at a single center between 2008–2018 were included. Parents of patients <18 years and patients ≥18 years at least one year after cardiac arrest completed a telephone interview. We assessed neurologic outcome (Pediatric Cerebral Performance Category [PCPC]), activities of daily living (Pediatric Glasgow Outcomes Scale-Extended, Functional Status Scale (FSS)), HRQL (Pediatric Quality of Life Core and Family Impact Modules), and healthcare utilization. Unfavorable neurologic outcome was defined as PCPC > 1 or worsening from pre-arrest baseline to discharge. FindingsForty four patients were evaluable. Follow-up occurred at a median of 5.6 years [IQR 4.4, 8.9] post-arrest. Median age at arrest was 5.3 [1.3,12.6] years; median CPR duration was 5 [1.5, 7] minutes. Survivors with unfavorable outcome at discharge had worse FSS Sensory and Motor Function scores and higher rates of rehabilitation service utilization. Parents of survivors with unfavorable outcome reported greater disruption to family functioning. Healthcare utilization and educational support requirements were common among all survivors. ConclusionsSurvivors of pediatric OHCA with unfavorable outcome at discharge have more impaired function multiple years post-arrest. Survivors with favorable outcome may experience impairments and significant healthcare needs not fully captured by the PCPC at hospital discharge.

Evaluation of Serum Biomarkers and Electroencephalogram to Determine Survival Outcomes in Pediatric Post-Cardiac-Arrest Patients

Cardiac arrest causes primary and secondary brain injuries. We evaluated the association between neuron-specific enolase (NSE), serum S-100B (S100B), electroencephalogram (EEG) patterns, and post-cardiac arrest outcomes in pediatric patients. A prospective observational study was conducted in the pediatric intensive care unit and included 41 post-cardiac arrest patients who underwent EEG and serum sampling for NSE and S100B. The participants were aged 1 month to 18 years who experienced cardiac arrest and underwent CPR after a sustained return of spontaneous circulation for ≥48 h. Approximately 19.5% (n = 8) of patients survived until ICU discharge. Convulsions and sepsis were significantly associated with higher mortality (relative risk: 1.33 [95% CI = 1.09-1.6] and 1.99 [95% CI = 0.8-4.7], respectively). Serum NSE and S100B levels were not statistically associated with the outcome (p = 0.278 and 0.693, respectively). NSE levels were positively correlated with the duration of CPR. EEG patterns were significantly associated with the outcome (p = 0.01). Non-epileptogenic EEG activity was associated with the highest survival rate. Post-cardiac arrest syndrome is a serious condition with a high mortality rate. Management of sepsis and convulsions affects prognosis. We believe that NSE and S100B may have no benefit in survival evaluation. EEG can be considered for post-cardiac arrest patients.

1168: ASSOCIATION OF BLOOD PRESSURE WITH NEUROLOGIC OUTCOME AFTER PEDIATRIC CARDIAC ARREST RESUSCITATION

Introduction: Post cardiac arrest blood pressure < 5th percentile for age is associated with worse survival to discharge. There are limited data on the impact of mean arterial pressure (MAP) on favorable neurologic outcome. We hypothesized, in the first 6-hours post-return of spontaneous circulation (ROSC), that a minimum documented MAP >5th percentile is associated with better neurologic outcomes. Methods: Prospective, multi-center, observational study using data from the Pediatric Resuscitation Quality Collaborative (pediRES-Q). Children (< 18 years) who achieved ROSC (without ECMO) following index in-hospital or out-of-hospital cardiac arrest and survived ≥6 hours were included. Minimum documented MAP within the first 6 hours of ROSC was percentile adjusted for age based on normative data and categorized into 6 groups: Group I= < 5th percentile; II= 5–24th; III= 25–49th; IV= 50–74th; V= 75–94th; and VI= ≥95th. Primary outcome was favorable neurologic status at hospital discharge, defined as PCPC score ≤2 or no change from pre-arrest baseline. Multivariable logistic regression was performed to estimate the association of favorable outcome with MAP group, controlling for illness category (surgical-cardiac vs. other), shockable rhythm, weekend/night arrest, age, CPR duration, and clustering by site. Results: 787 patients were included: median [Q1,Q3] age 17.9 [4.8,90.6] months; male 58%; OHCA 21%; shockable rhythm 13%; CPR duration 7 [3,16] min; favorable neurologic outcome 54%. Median lowest documented MAP percentile for the favorable outcome group was 13 [3,43] versus 8 [1,37] for the unfavorable group. The distribution of blood pressures by MAP group was I: 37%, II: 28%, III: 13%, IV: 11%, V: 7%, and VI: 4%. Compared with patients in Group I (< 5%ile), those in Groups II, III, and IV had significantly higher odds of favorable outcome (aOR, 1.84 [95% CI, 1.24, 2.73]; 2.20 [95% CI, 1.32, 3.68]; 1.90 [95% CI, 1.12, 3.25]). There was no statistically significant association between Groups V or VI and favorable outcome (aOR, 1.44 [95% CI, .75, 2.80]; 1.11 [95% CI, .47, 2.59]). Conclusions: In the first 6-hours post-return of spontaneous circulation (ROSC) after pediatric cardiac arrest, a lowest documented MAP >5th percentile (specifically 5th to 74th percentile) is associated with better neurologic outcomes.

35: EXTRACORPOREAL LIFE SUPPORT AFTER SUCCESSFUL RESUSCITATION FROM PEDIATRIC IN-HOSPITAL CARDIAC ARREST

Introduction: Over 15,000 children experience in-hospital cardiac arrest (IHCA) each year in the United States. Following the return of spontaneous circulation (ROSC) for most children, the focus turns to providing high quality post-resuscitation care. Extracorporeal life support (ECLS) can be used in the post-arrest period to restore adequate hemodynamics, however the use of post-arrest ECLS is not well described. This study aimed to describe patients who receive post-arrest ECLS to support the development of evidence-based guidelines for this therapy. Methods: Multi-center retrospective study of pediatric patients in the prospectively collected Pediatric Resuscitation Quality (pediRES-Q) Collaborative database, a multicenter international collaborative of children’s hospitals. All patients ≤ 18 years of age in the pediRES-Q database who received ECLS after an initial IHCA between July 1, 2015 and June 2, 2021 were included. Patients were excluded if they received extracorporeal cardiopulmonary resuscitation, defined as cannulation and initiation of ECLS during the IHCA and return of circulation with ELCS. Primary outcome was survival to intensive care unit (ICU) discharge. Results: A total of 56 patients were included, median age was 0.8 years (IQR 0.1-5 years). The most common illness category was medical cardiac (18 patients, 32%) followed by surgical cardiac (14 patients, 25%). Among the cohort, 31 (55%) patients were cannulated via the neck vessels, 10 (18%) through an open chest, and 6 (11%) via femoral vessels. The Pediatric ICU was the most common location, (28 patients, 50%) and the majority of patients were on a vasoactive agent at the time of their arrest (33 patients, 59%). The most common initial rhythm when CPR began was pulseless electrical activity (20 patients, 36%) patients followed by bradycardia (17 patients, 30%) and median duration of CPR was 38 minutes (IQR 19-56 minutes). 30 patients (54%) survived to ICU discharge, 25 (83%) of whom had a good neurologic outcome (PCPC ≤ 2 or unchanged from baseline). Conclusions: More than half of patients who required ECLS in the post-arrest period survived to discharge, with over 80% with good neurologic outcome. Further investigation is needed to support the development of guidelines for initiation of ECLS in the post-arrest period.

634: GLOBAL LONGITUDINAL STRAIN IS ASSOCIATED WITH MORTALITY AFTER PEDIATRIC CARDIAC ARREST

Introduction: Depressed left ventricular function is associated with mortality after pediatric cardiac arrest (CA). Echocardiographic global longitudinal strain (GLS) is more sensitive for poor outcomes than ejection fraction (EF) and shortening fraction (SF), with few studies in children. We aimed to identify the frequency of impaired GLS after pediatric CA and its association with hospital mortality. We hypothesized abnormal GLS is associated with mortality. Methods: This is a retrospective single-center cohort study of children < 18 years of age treated in the pediatric intensive care unit after in- and out-of-hospital CA, with echocardiogram performed within 24 hours of admission between 2013-2020. Patients with congenital heart disease, extracorporeal support, or inability to measure GLS were excluded. EF and SF measurements were abstracted and GLS measured post hoc by an investigator blinded to outcome. Abnormal left ventricular GLS was defined as >-18%. Correlation between GLS, EF and SF were calculated with Spearman’s rho. Logistic regression tested association of GLS with mortality. Area under the receiver operator characteristic (AUROC) curve was calculated for discriminative utility of GLS, EF, and SF with mortality. Results: GLS was measured in 124 subjects and abnormal in 49 (40%). Subjects with abnormal GLS were older (median 8 vs 2 years, p< 0.001), had more ventricular tachycardia/fibrillation as initial rhythm (18% vs 4%, p=0.008) and higher maximum troponin in 24 hours (median 2.6 ng/mL vs 0.5, p=0.002). There was no difference between arrest location or CPR duration based on GLS. Subjects with abnormal GLS had lower median EF (43% vs 63%) and SF (24% vs 37%), with strong inverse correlation between GLS and EF (rho -0.76) and SF (rho -0.71), all p< 0.001. Abnormal GLS had higher mortality (57% vs 33%, p=0.009) and GLS was associated with mortality when controlling for age and initial rhythm [aOR 1.17 per 1% increase in GLS (95% CI 1.09-1.26), p< 0.001]. GLS (AUROC 0.69), EF (0.71) and SF (0.71) had similar discrimination for mortality. Conclusions: Post-arrest GLS is a novel complementary metric, strongly correlated with EF and SF and associated with mortality. Future prospective studies should investigate the prognostic utility of GLS alongside SF and EF.

Abstract 273: Epinephrine Dose Distribution And Impact On Survival After Extracorporeal Cardiopulmonary Resuscitation In Children

Background: Although AHA guidelines recommend a fixed epinephrine (epi) dosing frequency during cardiac arrest, it is unknown if a fixed dosing practice is both utilized and effective for EPCR events in children. We hypothesized that 1) epi dosing would not be uniformly distributed during ECPR events and 2) a strategy of limiting epi doses during ECPR would be associated with better survival to hospital discharge (SHD). Methods: This was a multicenter retrospective cohort study of ECPR after in-hospital cardiac arrest in children (&lt; 18 years) between 2012 - 2019. Patient and arrest event details as well as epi dose and time-stamps were recorded. In patients with a CPR duration of ≥ 30 minutes, dosing strategies were categorized as either “frequent epi” (FE; average epi dosing interval of ≤ 5 mins/dose during the first 30 mins of CPR) or “limited epi” (LE; average dosing interval of ≤ 5 mins/dose for the first 10 mins followed by &gt; 5 mins/dose through 30 mins). The primary outcome was SHD. Results: A total of 191 patients from 5 centers were included; overall SHD was 43% (82/191). Epi doses were not evenly distributed, with 66% (919/1385) of doses being given during the first half of CPR. Mean number of epi doses was similar between survivors and non-survivors in the first 10 mins (2.7 doses). After 10 mins, survivors received fewer doses than non-survivors per each 10 min interval (Figure). In the subset of patients that received ≥ 30 mins of CPR (n=147) the LE group had higher SHD [48% (14/52) vs. 27% (46/95), p=0.01] and improved odds of SHD after adjusting for age, sex, illness category, time of day, first pulseless rhythm and CPR duration [OR (95% CI) 4.2 (1.5-11.7); p =0.008]. Conclusion: In contrast to AHA guidelines, epi dosing was not evenly distributed during events in this multicenter study of pediatric in-hospital ECPR. For children with CPR duration ≥ 30 minutes a strategy of limiting epi doses was associated with improved SHD.

Abstract 280: Extracorporeal Cardiopulmonary Resuscitation Outcomes In Children Without Underlying Cardiac Disease

Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR) has been associated with improved outcomes compared to conventional CPR (CCPR) in children with underlying cardiac disease. There are limited data on ECPR survival outcomes in the non-cardiac population. Hypothesis: ECPR will be associated with improved survival to discharge in children without underlying cardiac disease with prolonged CPR. Methods: Retrospective cohort study using the AHA Get With The Guidelines® - Resuscitation registry of children (&lt;18 years) without cardiac disease who received ≥30 minutes of CPR for in-hospital cardiac arrest between 2000-2020. Weighted propensity scores were used to balance ECPR and CCPR groups based on hospital and patient characteristics. Multivariable logistic regression incorporating these scores tested the association of ECPR with survival to discharge. A Bayesian logistic regression model was used to estimate the probability of a positive effect from ECPR. A secondary analysis explored temporal trends in ECPR relative to the index year of 2000. Results: Of 875 patients, 159 received ECPR and 716 received CCPR (median age 1 year, primary diagnosis respiratory insufficiency, median CPR duration 45 minutes for full cohort). Survival to discharge was similar between the ECPR group (21.4%) compared to the CCPR group (16.2%) in both the univariable analysis (p= 0.13) and the propensity-weighted multivariable logistic regression (aOR 1.44 [CI 0.85-2.44, p= 0.173]. The Bayesian model estimated an 85.1% probability of a positive effect of ECPR on survival to discharge. ECPR use increased over time (test for trend p&lt;0.001). Conclusion: In children without cardiac disease who required ≥30 minutes of CPR, ECPR usage significantly increased in the last 20 years. Compared to CCPR, ECPR was not associated with a statistically significant increase in survival to discharge. However, a Bayesian model estimated weak evidence of a positive survival effect of ECPR.

Abstract 304: Cerebral Near-infrared Spectroscopy During Pediatric In-hospital Cardiac Arrest: A Multicenter, Observational Study

Introduction: Cerebral regional oxygen saturation (crS0 2 ) measured by near-infrared spectroscopy (NIRS) during CPR is associated with outcomes in adults, but there is limited pediatric data. Hypothesis: Median crSO 2 during pediatric in-hospital cardiac arrest (IHCA) is associated with return of spontaneous circulation (ROSC) and survival to hospital discharge (SHD). Methods: Pediatric IHCA events from 2015-2022 with ≥ 1min CPR and intra-arrest crS0 2 reported by 3 sites in the pediRES-Q registry were included. ROSC was defined as return of spontaneous circulation for ≥ 20 mins without ECMO. We analyzed the association of ROSC for all events and SHD for index events only with median crS0 2 and percent crS0 2 measurements above a priori thresholds during 1) the entire event, 2) the first 5 mins, and 3) the final 5 mins by Fisher’s exact test, Wilcoxon rank sum test, and multivariable logistic regression with Firth bias correction. Results: There were 106 IHCA events in 81 patients. Median age was 0.3 yrs [0.06,0.85], 43% had cyanotic heart disease, and SHD in 61% (49/81). For all events, median CPR duration was 8 mins [3.25, 32] and ROSC was achieved in 62% (66/106). Higher median crSO 2 for the entire event, the first 5 mins, and the last 5 mins was significantly associated with ROSC and SHD (Table). Events with ROSC had significantly higher percent crS0 2 measurements ≥ 30% and 40% for the entire event. Patients with SHD had significantly higher percent crSO 2 measurements ≥ 30%, 40%, 50%, and 60% for the entire event (Table). Multivariable analysis controlling for age (aOR 1.02 [CI 1.01,1.05] p=0.012) and cyanotic heart disease (aOR 1.03 [CI 1.01,1.05] p=0.008) showed median crS0 2 was independently associated with ROSC. Conclusions: Higher median crSO 2 (measured by cerebral NIRS) during pediatric IHCA was significantly associated with increased rate of ROSC and SHD. Studies evaluating intra-arrest cerebral rSO 2 may provide insight and possibly serve as a predictor of ROSC and SHD.

Effect of extracellular signal-regulated kinase inhibitor on calpain in rat cerebral cortex after cardiopulmonary resuscitation

To explore the effect of extracellular signal-regulated kinase (ERK) inhibitor PD98059 on calpain-related proteins in the brain, and to understand the pathophysiological changes of calpain in cerebral ischemia/reperfusion injury (CIRI). Forty-two rats were divided into sham operation (Sham) group (n = 6), model group (n = 12), dimethyl sulfoxide (DMSO) control group (n = 12), and PD98059 group (n = 12) by random number table. The rat model of CIRI induced by cardiac arrest-cardiopulmonary resuscitation (CA-CPR) was reproduced by transesophageal electrical stimulation to induce ventricular fibrillation. In the Sham group, only the basic operations such as anesthesia, tracheal intubation, and arteriovenous catheterization were performed without CA-CPR. The rats in the DMSO control group and PD98059 group were injected with DMSO or PD98059 0.30 mg/kg via femoral vein, respectively, 30 minutes after the restoration of spontaneous circulation (ROSC), and rats in the Sham group and model group were given the same amount of normal saline. The duration of CPR, 24-hour survival rate and neurological deficit score (NDS) after ROSC were recorded. Hematoxylin-eosin (HE) staining and Nissl staining were used to observe the pathological changes of the cerebral cortex. The expressions of phosphorylated ERK (p-ERK), ERK, calpastatin, calpain-1, and calpain-2 were detected by Western blotting. The co-expression of p-ERK and calpain-2 was detected by double immunofluorescence. There were no significant differences in the duration of CPR and 24-hour survival rate among all groups. In the model group, the nuclei of the cerebral cortex were obviously deformed and pyknotic, cells vacuoles and tissues were arranged disorderly, Nissl corpuscles were significantly reduced, NDS scores were also significantly reduced, level of ERK phosphorylation was increased, and calpain-2 protein was significantly up-regulated compared with the Sham group. There was no significant difference in the above parameters between the DMSO control group and the model group. After intervention with PD98059, the pathological injury of brain tissue was significantly improved, Nissl corpuscles were significantly increased, the NDS score was significantly higher than that in the model group [75.0 (72.0, 78.0) vs. 70.0 (65.0, 72.0), P < 0.05], the level of ERK phosphorylation and calpain-2 protein expression were significantly lower than those in the model group [p-ERK (p-ERK/ERK): 0.65±0.12 vs. 0.92±0.05, calpain-2 protein (calpain-2/GAPDH): 0.73±0.10 vs. 1.07±0.14, both P < 0.05], while there was no significant difference in the expressions of calpastatin and calpain-1 in the cerebral cortex among all the groups. Double immunofluorescence staining showed that p-ERK and calpain-2 were co-expressed in cytosol and nucleus, and the co-expression rate of p-ERK and calpain-2 in the model group was significantly higher than that in the Sham group [(38.6±4.3)% vs. (9.2±3.5)%, P < 0.05], while it was significantly lowered in the PD98059 group compared with the model group [(18.2±7.0)% vs. (38.6±4.3)%, P < 0.05]. ERK together with calpain-2 participated in CIRI induced by CA-CPR. PD98059 inhibited the expression of calpain-2 and ERK phosphorylation. Therefore, ERK/calpain-2 may be a novel therapeutic target for CIRI.

Outcome of cardiorespiratory arrest in patients with respiratory diseases in emergency department: A prospective observational study

Introduction: Cardiopulmonary arrest (CPA) is the cessation of effective ventilation and circulation. It is also known as cardiac arrest or circulatory arrest. In adults, it is most likely to be caused by a primary cardiac event. The most common electrical mechanism which is responsible for 50 to 80% of cardiopulmonary arrest is ventricular fibrillation (VF). The cardiopulmonary arrest could be reversed by two main interventions, i.e., early CPR and early automated external defibrillation (AED). Objective: To study the rate of survival to discharge after in-hospital cardiac arrest and its associated factors in an emergency department of a tertiary care hospital. Materials and Methods: This is a prospective and observational study was conducted in the Tertiary Care Teaching Hospital over a period of 1 year. It is a 700-bedded tertiary care referral hospital, located in Hyderabad, India, with an average of 100 emergency cases per day. Patients elder than 12 years, who have sustained cardiac arrest after reaching the ED but before being admitted into the specialty wards were included. Who suffered witnessed cardiac arrest, after arrival in the emergency department. A semi-structured questionnaire was used to collect data. Results: Of 60 patients, 15 (25%) were discharged fully conscious, whereas 45 (75%) patients died. Age, sex, comorbidities, and cause of arrest did not show any statistically significant association with the outcome (P&gt;0.05 for all). The duration of CPR was significantly lower in survivors (3.80 ±1.90 min) compared with non survivors (10.31 ± 6.41 min) (P&lt;0.001). GCS was significantly higher in survivors group compared with non-survival groups (11.38±0.3 vs 3.68±1.20, P&lt;0.001). Conclusion: These results suggest that out-of-hospital cardiac arrest among patients has a very poor prognosis, especially when efforts at resuscitation continue for longer than 20 minutes and require more than two doses of epinephrine.

Pre-hospital CPR after traumatic arrest: Outcomes at a level 1 pediatric trauma center

BackgroundThe survival of traumatic cardiopulmonary arrest (TCA) requiring pre-hospital cardiopulmonary resuscitation (P-CPR) is abysmal across age groups. We aim to describe the mechanisms of injury and outcomes of children suffering from TCA leading to P-CPR at our institution. MethodsA retrospective review was conducted to identify children ages 0-17 years who suffered TCA leading to P-CPR at our institution between 5/2009 and 3/2020. For analysis, patients were stratified into those still undergoing CPR at arrival and those who attained pre-hospital return of spontaneous circulation (ROSC). Primary outcome was discharge alive from the hospital. ResultsP-CPR was initiated for 48 patients who had TCA; 23 had pre-hospital ROSC. Of the 25 children undergoing CPR at presentation, none survived to discharge. The median duration of CPR, from initiation to time of death declaration was 34 min [29,50]. Seventeen patients died after resuscitation attempts in the ED, while 8 died after admission to the PICU. Of the 23 patients who attained pre-hospital ROSC, 6 survived to discharge. All survivors required intensive rehabilitation services at discharge and at most recent follow-up, 5 had residual deficits requiring medical attention. ConclusionThere are poor outcomes in children with pre-hospital traumatic cardiopulmonary arrest, particularly in those without pre-hospital ROSC. These data further support the need for standardized guidelines for resuscitation in children with traumatic cardiopulmonary arrest.

Continuous assessment of ventricular fibrillation prognostic status during CPR: Implications for resuscitation

BackgroundVentricular fibrillation (VF) waveform measures reflect myocardial physiologic status. Continuous assessment of VF prognosis using such measures could guide resuscitation, but has not been possible due to CPR artifact in the ECG. A recently-validated VF measure (termed VitalityScore), which estimates the probability (0–100%) of return-of-rhythm (ROR) after shock, can assess VF during CPR, suggesting potential for continuous application during resuscitation. ObjectiveWe evaluated VF using VitalityScore to characterize VF prognostic status continuously during resuscitation. MethodsWe characterized VF using VitalityScore during 60 seconds of CPR and 10 seconds of subsequent pre-shock CPR interruption in patients with out-of-hospital VF arrest. VitalityScore utility was quantified using area under the receiver operating characteristic curve (AUC). VitalityScore trends over time were estimated using mixed-effects models, and associations between trends and ROR were evaluated using logistic models. A sensitivity analysis characterized VF during protracted (100-second) periods of CPR. ResultsWe evaluated 724 VF episodes among 434 patients. After an initial decline from 0–8 seconds following VF onset, VitalityScore increased slightly during CPR from 8–60 seconds (slope: 0.18%/min). During the first 10 seconds of subsequent pre-shock CPR interruption, VitalityScore declined (slope: −14%/min). VitalityScore predicted ROR throughout CPR with AUCs 0.73–0.75. Individual VitalityScore trends during 8–60 seconds of CPR were marginally associated with subsequent ROR (adjusted odds ratio for interquartile slope change (OR) = 1.10, p = 0.21), and became significant with protracted (100 seconds) CPR duration (OR = 1.28, p = 0.006). ConclusionVF prognostic status can be continuously evaluated during resuscitation, a development that could translate to patient-specific resuscitation strategies.

Controversies in Extracorporeal Cardiopulmonary Resuscitation

Extracorporeal cardiopulmonary resuscitation (ECPR) is the emergent deployment of VA-ECMO for refractory cardiac arrest. Observational and randomized trial data show that ECPR may improve outcomes compared to conventional CPR (CCPR), but many questions and controversies remain. Patient selection is a critical determinant of ECPR success. Most institutions implement inclusion/exclusion criteria, but risk scores may be more apt to correctly predict which patients are likely to benefit from ECPR. Good outcomes from ECPR occur more often in patients with an initially shockable rhythm, reversible etiology of arrest, evidence of effective CPR, and shorter durations of conventional CPR. Shorter total CPR duration is consistently associated with neurologically favorable survival, but optimal and upper limit timing at which the benefits of ECPR outweigh the risks continue to be delineated. Data are emerging regarding pre-hospital implementation of ECPR as a strategy to reduce low-flow time. Vascular access for ECPR can be challenging, particularly in the pediatric population. In adults, percutaneous cannulation of the femoral vessels under fluoroscopic guidance and performed by a small group of highly skilled operators may increase success rates and reduce complications. Data are limited regarding post-arrest care for the ECPR patient, particularly regarding temperature management and anticoagulation. Compared to other resource-intensive therapies, ECPR is cost-effective by modern standards.

Cardiopulmonary resuscitation duration and favorable neurological outcome after out-of-hospital cardiac arrest: a nationwide multicenter observational study in Japan (the JAAM-OHCA registry)

ObjectiveWe aimed to assess the association between cardiopulmonary resuscitation (CPR duration) and outcomes after OHCA.MethodsThis secondary analysis of a prospective, multicenter, observational study included adult non-traumatic OHCA patients aged ≥ 18 years between June 2014 and December 2017. CPR duration was defined as the time from professional CPR initiation to the time of return of spontaneous circulation or termination of resuscitation. The primary outcome was 1-month survival, with favorable neurological outcomes defined by cerebral performance category 1 or 2. We performed multivariable logistic regression analysis to investigate the association between CPR duration and favorable neurological outcomes. We also investigated the association between CPR duration and favorable neurological outcomes stratified by case features, including the first documented cardiac rhythm, witnessed status, and presence of bystander CPR.ResultsA total of 23,803 patients were included in this analysis. Multivariable logistic regression analysis demonstrated that the probability of favorable neurological outcomes decreased with CPR duration (i.e., 20.8% [226/1084] in the ≤ 20 min group versus 0.0% [0/708] in the 91–120 min group, P for trend < 0.001). Furthermore, the impact of CPR duration differed depending on the presence of case features; those with shockable, witnessed arrest, and bystander CPR were more likely to achieve favorable neurological outcomes after prolonged CPR duration > 30 min.ConclusionThe probability of favorable neurological outcome rapidly decreased within a few minutes of CPR duration. But, the impact of CPR duration may be influenced by each patient’s clinical feature.

AvaLife-A New Multi-Disciplinary Approach Supported by Accident and Field Test Data to Optimize Survival Chances in Rescue and First Aid of Avalanche Patients.

Snow sports in the backcountry have seen a steep increase in popularity, and therefore preparedness for efficient companion and organized rescue is important. While technical rescue skills are widely taught, there is a lack of knowledge regarding first aid for avalanche patients. The stressful and time-critical situation for first responders requires a rule-based decision support tool. AvaLife has been designed from scratch, applying mathematical and statistical approaches including Monte Carlo simulations. New analysis of retrospective data and large prospective field test datasets were used to develop evidence-based algorithms exclusively for the avalanche rescue environment. AvaLife differs from other algorithms as it is not just a general-purpose CPR algorithm which has been slightly adapted for the avalanche patient. The sequence of actions, inclusion of the ≥150 cm burial depth triage criterion, advice to limit CPR duration for normothermic patients to 6 min in case of multiple burials and shortage of resources, criteria for using recovered subjects as a resource in the ongoing rescue, the adapted definition of “injuries incompatible with life”, reasoning behind the utmost importance of rescue breaths, as well as the updated BLS-iCPR algorithm make AvaLife useful in single and multiple burial rescue. AvaLife is available as a companion rescue basic life support (BLS) version for the recreational user and an advanced companion and organized rescue BLS version for guides, ski patrols and mountain rescuers. AvaLife allows seamless interoperability with advanced life support (ALS) qualified medical personnel arriving on site.

Risk Factors and Neurologic Outcomes Associated With Resuscitation in the Pediatric Intensive Care Unit.

In the pediatric intensive care unit (PICU), cardiac arrest (CA) is rare but results in high rates of morbidity and mortality. A retrospective chart review of 223 patients who suffered from in-PICU CA was analyzed from January 2017 to December 2020. Outcomes at discharge were evaluated using pediatric cerebral performance category (PCPC). Return of spontaneous circulation was attained by 167 (74.8%) patients. In total, only 58 (25%) patients survived to hospital discharge, and 49 (21.9%) of the cohort had good neurologic outcomes. Based on multivariate logistic regression analysis, vasoactive–inotropic drug usage before CA, previous PCPC scale >2, underlying hemato-oncologic disease, and total time of CPR were risk factors associated with poor outcomes. Furthermore, we determined the cutoff value of duration of CPR in predicting poor neurologic outcomes and in-hospital mortality in patients caused by in-PICU CA as 17 and 23.5 min respectively.