Etiology Of Arrest Research Articles

Abstract 213: Remote Ischemic Conditioning To Enhance Resuscitation After Cardiac Arrest

Introduction: Restoration of blood flow after out-of-hospital cardiac arrest (OHCA) induces inflammation that causes cellular injury and death. Remote ischemic conditioning (RIC) consists of brief episodes of ischemia then reperfusion to a limb. Trials in animal models in cardiac arrest and in humans with acute infarction show RIC reduces RI. Objective: We sought to demonstrate the feasibility and safety of RIC in patients resuscitated from OHCA and transported to hospital. Methods: Single site 2-arm, single blind randomized feasibility trial comparing a treatment group receiving RIC versus usual care following OHCA. For patients allocated to the intervention group, RIC was performed via 3 cycles of 5-minutes inflation then 5-minutes deflation of a blood pressure cuff applied to an upper extremity. Included were adults resuscitated from OHCA with non-traumatic etiology of arrest, spontaneous circulation present upon emergency department arrival, no response to verbal commands and ongoing or planned induced hypothermia. Excluded were those with: ST-elevation on first 12-lead ECG obtained after return of spontaneous circulation, do not attempt resuscitation (DNAR) status, drowning or hypothermia as cause of arrest, dialysis fistula in either upper extremity or pre-existing amputation of upper extremity, pregnancy or incarcerated status. The primary outcome was attrition, i.e., the proportion of patients enrolled and not on allocated therapy for the study duration. Results: N=30 patients were enrolled (n=14 control, n=16 intervention). Mean age was 52.5 ± 16.2 years. Twenty-seven percent had female gender and 27% had a shockable first recorded rhythm. There was 0% attrition amongst enrolled patients. Other outcomes are summarized (Table). Conclusions: Application of RIC after OHCA is feasible and safe. An adequately powered trial is required to assess whether RIC is effective at decreasing morbidity and mortality after CA. TABLE: OUTCOMES

Abstract 12: Identifying Emergency Medical Service Agencies In Black And Hispanic Communities With High Cardiac Arrest Survival Rates

Background: Black and Hispanic individuals have lower survival rates for out-of-hospital cardiac arrest (OHCA). Whether there are Emergency Medical Service (EMS) agencies in Black and Hispanic communities with high survival rates for OHCA is unknown but critical to identifying strategies to reduce racial and ethnic disparities in OHCA survival. Methods: Within the Cardiac Arrest Registry to Enhance Survival, we identified adults with non-traumatic OHCA during 2015-2019. EMS agencies were categorized as working in Black/Hispanic communities if >50% of residents in their catchment area were Black or Hispanic. Using hierarchical logistic regression, we calculated risk-standardized survival rates (RSSR) to hospital admission for OHCA in each EMS agency, adjusted for patients’ age, sex, witnessed arrest status, presumed arrest etiology, initial cardiac arrest rhythm, and arrest location. We then examined the distribution of EMS agencies that work in Black/Hispanic communities across quartiles of OHCA survival. Results: Among 764 EMS agencies (258,342 OHCAs), the median RSSR was 27.4% with an absolute difference of >10% across quartiles (median 22.4% in the lowest vs. 32.9% in the highest quartile; 191 EMS agencies in each quartile). There were 82 EMS agencies working in Black/Hispanic communities overall, with 26 (31.7%) in the lowest RSSR quartile and 15 (18.3%) in the highest. After further adjustment for agency-level rates of bystander CPR, EMS response time and termination of resuscitation practices, there remained 29 (35.4%) EMS agencies in the lowest RSSR quartile and 16 (19.5%) in the highest. Conclusion: EMS agencies working in Black and Hispanic communities have lower prehospital survival for OHCA, although high-performing agencies exist. Identifying best practices at EMS agencies with the highest prehospital survival rates, particularly among agencies serving Black and Hispanic communities, has the potential to improve overall OHCA survival and reduce existing survival disparities.

Understanding Etiologies of Cardiac Arrest: Seeking Definitional Clarity.

Cardiac arrest leading to death and sudden cardiac death (SCD) may refer implicitly to situations in which death is unexpected and primarily of cardiac cause. National and international societies have published differing definitions for the various terms relating to cardiac arrest and SCD. We highlight the controversies in defining SCD, including the lack of a universal definition, the heterogeneity in the operationalization of the term "sudden," and limitations of time-based systems of SCD classification. We discuss the importance of a standardized methodology for classifying cardiac arrest as recommended by the World Health Organization (WHO) that should include use of multisource evidence (eg, coroner, autopsy, and toxicology reports) for confirming or refuting a cardiac cause of arrest. We reveal how a universal definition of SCD has been incorrectly attributed to the WHO and how this has been perpetuated in the literature. We make the case that definitional clarity is essential to understanding epidemiology, evaluating novel treatments, forming international collaboration, and innovating public health prevention strategies. We propose a practical schema to categorize cardiac arrest events to describe and study this population more accurately.

Increase in end-tidal carbon dioxide after defibrillation predicts sustained return of spontaneous circulation during out-of-hospital cardiac arrest

IntroductionGuidelines recommend monitoring end-tidal carbon dioxide (ETCO2) during out-of-hospital cardiac arrest (OHCA), though its prognostic value is poorly understood. This study investigated the relationship between ETCO2 and return of spontaneous circulation (ROSC) after defibrillation in intubated non-traumatic OHCA patients. MethodsThis retrospective, observational cohort analysis included adult OHCA patients who received a defibrillation shock during treatment by an urban EMS agency from 2015 to 2021. Peak ETCO2 values were determined for the 90-second periods before and after the first defibrillation in an intubated patient (shock of interest [SOI]). Values were analyzed for association between the change in ETCO2 from pre- to post-shock and the presence of ROSC on the subsequent pulse check. ResultsOf 518 eligible patients, mean age was 61, 72% were male, 50% had a bystander-witnessed arrest, and 62% had at least one episode of ROSC. The most common arrest etiology was medical (92%). Among all patients, peak ETCO2 during resuscitation prior to SOI was 36.8 mmHg (18.6). ETCO2 increased in patients who achieved ROSC immediately after SOI (from 38.3 to 47.6 mmHg; +9.3 CI: 6.5, 12.1); patients with sustained ROSC experienced the greatest increase in ETCO2 after SOI (from 37.8 to 48.2 mmHg; +10.4 CI: 7.2, 13.6), while ETCO2 in patients who did not achieve ROSC after SOI rose (from 36.4 to 37.8 mmHg; +1.4 CI: −0.1, 2.8). ConclusionsETCO2 rises after defibrillation in most patients during cardiac arrest. Patients with sustained ROSC experience larger rises, though the majority experience rises of less than 10 mmHg.

The difference between arterial pCO2 and etCO2 after cardiac arrest – Outcome predictor or marker of unfavorable resuscitation circumstances?

IntroductionIn former studies, the arterio-alveolar carbon dioxide gradient (ΔCO2) predicted in-hospital mortality after initially survived cardiac arrest. As early outcome predictors are urgently needed, we evaluated ΔCO2 as predictor for good neurological outcome in our cohort. MethodsWe retrospectively analyzed all patients ≥18 years of age after non-traumatic in- and out of hospital cardiac arrest in the year 2018 from our resuscitation database. Patients without advanced airway management, incomplete datasets or without return of spontaneous circulation were excluded. The first arterial pCO2 after admission and the etCO2 in mmHg at the time of blood sampling were recorded from patient's charts. We then calculated ΔCO2 (pCO2 – etCO2). For baseline analyses, ΔCO2 was dichotomized into a low and high group with separation at the median. Good neurological outcome on day 30, expressed as Cerebral Performance Category 1–2, defined our primary endpoint. Survival to 30 days was used as secondary endpoint. ResultsOut of 302 screened patients, 128 remained eligible for analyses. ΔCO2 was lower in 30-day survivors with good neurological outcome (12.2 mmHg vs. 18.8 mmHg, p = 0.009) and in 30-day survivors (12.5 mmHg vs. 20.0 mmHg, p = 0.001). In patients with high ΔCO2, a cardiac etiology of arrest was found less often. They had a higher body mass index, longer duration of resuscitation, higher amounts of epinephrine, lower pO2 levels but both higher pCO2 and blood lactate levels, resulting in lower blood pH and HCO3− levels at admission.In a crude binary logistic regression analysis, ΔCO2 was associated with 30-day neurological outcome (OR = 1.041 per mmHg of ΔCO2, 95% CI 1.008–1.074, p = 0.014). This association persisted after the adjustment for age, sex, witnessed arrest and shockable first rhythm. However, after addition of the duration of resuscitation or the cumulative epinephrine dosage to the model, ΔCO2 lost its association. ConclusionΔCO2 at admission after a successfully resuscitated cardiac arrest is associated with 30 days survival with good neurological outcome. However, a higher ΔCO2 may rather be a surrogate for unfavorable resuscitation circumstances than an independent outcome predictor.

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.

Unexpected Cardiac Arrest during Spinal Anesthesia

Intraoperative cardiac arrest in the operating room (CAIOR) is an unexpected and potentially serious event. Two types of CAIOR must be distinguished: those directly attributable to anesthesia and CAIOR of other etiologies, notably surgical. The incidence of CAIOR directly attributable to anesthesia is between 0.5 and 1.86 per 10,000 anesthesias, Through the clinical case of a 62-year-old woman who presented a per operative caradiac arrest during a spinal anesthesia for operative hysteroscopy, and through a review of the literature, we will expose the risk factors of CAIOR, as well as the main etiologies. Symptomatic and etiological treatments must be implemented as soon as possible to avoid the mainly neurological consequences of circulatory failure. The management is based on symptomatic treatment with effective cardiopulmonary resuscitation, especially associated with the etiological treatment of cardiac arrest. But sometimes, the etiology of the cardiac arrest remains unidentified, and the treatment is therefore essentially symptomatic. The mortality rate of CAIOR remains high, the crude mortality rate observed 90 days after CAIOR is estimated at 48% (14) The survival of patients after CAIOR is intimately linked to the precocity and quality of their initial initial management.

Special consideration in neonatal resuscitation

Delivery room resuscitation of neonates is performed according to evidence-based neonatal resuscitation guidelines. Neonatal resuscitation guidelines focus on the resuscitation of newborns suffering from perinatal asphyxia. Special considerations are needed when resuscitating newborns in locations other than the delivery room and for newborns with congenital anomalies. In this review, we examine the resuscitation of newborns at home and in the emergency department and highlight special considerations for resuscitating newborns with specific congenital anomalies. In addition, we explore the resuscitation of neonates in the neonatal intensive care unit and discuss the potential use of pediatric advanced life support guidelines. Finally, we highlight the importance of simulation to prepare teams for neonatal resuscitations. This review aims to prepare healthcare professionals in all disciplines caring for neonates at risk for requiring resuscitation under special circumstances.1Evidence-based neonatal resuscitation guidelines focus on resuscitation newborns suffering from perinatal asphyxia in the delivery room.2Modification of neonatal resuscitation guidelines is needed for newborn resuscitations outside the delivery room and to address certain congenital anomalies.3When resuscitating critically ill neonates in the intensive care unit suffering from arrest etiologies not covered in neonatal guidelines, teams may consider using pediatric advanced life support guidelines.4Simulation is a central part of neonatal resuscitation training and should be used to prepare for neonatal resuscitation in all circumstances.5With preparation and practice for special circumstances, healthcare teams can improve the quality of resuscitation for all neonates.

Long-term survival in patients treated with mechanical circulatory support for refractory out-of-hospital cardiac arrest

Abstract Funding Acknowledgements Type of funding sources: None. Background Mechanical circulatory support (MCS) is used increasingly in the setting of refractory out-of-hospital cardiac arrest (OHCA). However, limited data exist on long-term survival. Purpose To investigate the long-term outcome in patients receiving MCS compared to patients with return of spontaneous circulation (ROSC) at hospital admission. Methods Retrospective, observational single centre study from 2015-2019. The study included all patients who achieved ROSC on admission and patients receiving MCS for refractory OHCA defined as either veno-arterial extracorporeal membrane oxygenation or Impella support. Kaplan-Meier survival analysis were performed to evaluate long-term survival in both groups and compared with the log-rank test. Results A total of 698 patients with ROSC on admission and 101 patients receiving MCS were included. Acute myocardial infarction was the most common aetiology of arrest in both groups. There were no differences in witnessed arrest, bystander cardiopulmonary resuscitation or initial presenting rhythm. Low-flow time was substantially longer in the MCS group compared to the ROSC group (median 105 (IQR, 94-123) minutes versus median 15 (IQR, 8-22) minutes, p < 0.001). The 5-day mortality rate was 63% in the MCS group versus 24% in the ROSC group. Long-term survival from day 6 to day 90 was 71% in the MCS group and 83% in the ROSC group, p = 0.072. Conclusions In conclusion, the risk of death within the first 5 days was higher for OHCA patients treated with MCS than in patients with ROSC on admission. Among patients surviving the first 5 days, 90-day mortality was low in both groups.

Pediatric Advanced Life Support in a Neonatal Context.

Pediatric Advanced Life Support in a Neonatal Context.

Outcomes of cardiopulmonary resuscitation in patients with pulmonary arterial hypertension.

Over the past 20 years, despite significant advancements in pulmonary arterial hypertension (PAH) medical therapy, many patients require admission to the hospital and are at risk for in‐hospital cardiac arrest (IHCA). Prior data found poor survival in PAH patients after cardiac arrest. The purpose of this study was to explore post‐IHCA outcomes in PAH patients receiving advanced medical therapies. This is a single‐center retrospective study of PAH patients who underwent cardiopulmonary resuscitation for IHCA between July 2005 and May 2021. Patients were identified through an internal cardiac arrest database. Twenty six patients were included. Half of the cohort had idiopathic PAH, with 54% of patients on combination therapy, 27% on monotherapy, and 19% of patients on no therapy. Mean right atrial pressure, mean pulmonary artery pressure, cardiac index, and pulmonary vascular resistance were 13 ± 6 mmHg, 57 ± 13 mmHg, 2.0 ± 0.7 L/min/m2, and 14.5 ± 7.6 Wood units, respectively. Most common etiology of cardiac arrest was circulatory collapse. Initial arrest rhythm in all but one patient was pulseless electrical activity. Six patients (23%) achieved return of spontaneous circulation (ROSC) and one patient (4%) survived to hospital discharge. Rates of ROSC and survival to discharge after IHCA are poor in patients with PAH. Even patients with mild hemodynamics had low likelihood of survival. In patients who are lung transplant candidates, there should be early consideration of extracorporeal support before cardiac arrest.

Thrombolytic therapy in cardiac arrest caused by cardiac etiologies or presumed pulmonary embolism: An updated systematic review and meta‐analysis

BackgroundMany cardiac arrest cases are encountered annually worldwide, with poor survival. The use of systemic thrombolysis during cardiopulmonary resuscitation for the treatment of cardiac arrest remains controversial. ObjectivesEvaluate the safety and efficacy of systemic thrombolysis in patients with cardiac arrest due to presumed or confirmed pulmonary embolism or cardiac etiology. MethodsWe searched the PubMed and Cochrane databases from inception through April 2021 to identify relevant randomized controlled trials and observational studies. The primary efficacy and safety outcomes were survival to hospital discharge and reported bleeding, respectively. Sensitivity analysis was performed on the basis of study design and etiology of cardiac arrest. ResultsEleven studies were included, with 4696 patients (1178 patients received systemic thrombolysis, and 3518 patients received traditional therapy). There was a higher rate of survival to hospital discharge in patients who received systemic thrombolysis versus no systemic thrombolysis (risk ratio [RR], 1.35; 95% confidence interval [CI], 0.95‐1.91). There were also higher rates of survival at 24 hours (RR, 1.24; 95% CI, 0.97‐1.59) and hospital admission (RR, 1.53; 95% CI, 1.04‐2.24), and return of spontaneous circulation (ROSC) (RR, 1.34; 95% CI, 1.05‐1.71) with the use of systemic thrombolysis. Impacts on survival to discharge and survival at 24 hours were not statistically significant. Patients receiving systemic thrombolysis had a 65% increase in bleeding events compared with no systemic thrombolysis (RR, 1.65; 95% CI, 1.20‐2.27). ConclusionSystemic thrombolysis in cardiac arrest did not improve survival to hospital discharge and led to more bleeding events. However, it increased the rates of hospital admission and ROSC achievement.

Importance of genetic testing in unexplained cardiac arrest.

AimsGenetic testing is recommended in specific inherited heart diseases but its role remains unclear and it is not currently recommended in unexplained cardiac arrest (UCA). We sought to assess the yield and clinical utility of genetic testing in UCA using whole-exome sequencing (WES).Methods and resultsSurvivors of UCA requiring external defibrillation were included from the Cardiac Arrest Survivor with Preserved Ejection fraction Registry. Whole-exome sequencing was performed, followed by assessment of rare variants in previously reported cardiovascular disease genes. A total of 228 UCA survivors (mean age at arrest 39 ± 13 years) were included. The majority were males (66%) and of European ancestry (81%). Following advanced clinical testing at baseline, the likely aetiology of cardiac arrest was determined in 21/228 (9%) cases. Whole-exome sequencing identified a pathogenic or likely pathogenic (P/LP) variant in 23/228 (10%) of UCA survivors overall, increasing the proportion of ‘explained’ cases from 9% only following phenotyping to 18% when combining phenotyping with WES. Notably, 13 (57%) of the 23 P/LP variants identified were located in genes associated with cardiomyopathy, in the absence of a diagnosis of cardiomyopathy at the time of arrest.ConclusionsGenetic testing identifies a disease-causing variant in 10% of apparent UCA survivors. The majority of disease-causing variants was located in cardiomyopathy-associated genes, highlighting the arrhythmogenic potential of such variants in the absence of an overt cardiomyopathy diagnosis. The present study supports the use of genetic testing including assessment of arrhythmia and cardiomyopathy genes in survivors of UCA.

Etiologies of In-hospital cardiac arrest: A systematic review and meta-analysis

BackgroundEtiologies of in-hospital cardiac arrest (IHCA) in general wards may differ from etiologies of out-of-hospital cardiac arrest (OHCA) given the different clinical characteristics of these patient populations. An appreciation for the causes of IHCA may allow the clinician to appropriately target root causes of arrest. MethodsMEDLINE/PubMed, EMBASE, and Google Scholar were queried from inception until May 31, 2021. Studies reporting etiologies of IHCA were included. A random effects meta-analysis of extracted data was performed using Review Manager 5.4. ResultsOf 12,451 citations retrieved from the initial literature search, 9 were included in the meta-analysis. The most frequent etiologies of cardiac arrest were hypoxia (26.46%, 95% confidence interval [CI] 14.19–38.74%), acute coronary syndrome (ACS) (18.23%, 95% CI 13.91–22.55%), arrhythmias (14.95%, 95% CI 0–34.93%), hypovolemia (14.81%, 95% CI 6.98–22.65%), infection (14.36%, 95% CI 9.46–19.25%), and heart failure (12.64%, 95% CI 6.47–18.80%). Cardiac tamponade, electrolyte disturbances, pulmonary embolism, neurological causes, toxins, and pneumothorax were less frequent causes of IHCA. Initial rhythm was unshockable (pulseless electrical activity or asystole) in 69.83% of cases and shockable (ventricular tachycardia or ventricular fibrillation) in 21.75%. ConclusionThe most prevalent causes of IHCA among the general wards population are hypoxia, ACS, hypovolemia, arrythmias, infection, heart failure, three of which (arrhythmia, infection, heart failure) are not part of the traditional “H’s and T’s” of cardiac arrest. Other causes noted in the “H’s and T’s” of advanced cardiac life support do not appear to be important causes of IHCA.

Pulseless electrical activity and asystolic cardiac arrest in infants: identifying factors that influence outcomes.

There is limited information on pulseless electrical activity (PEA)/asystolic cardiac arrest (CA) in the infant population. The aim is to describe the incidence and factors associated with outcomes in infants with PEA/asystolic CA. Single-center retrospective chart review study of infants less than one year of age who suffer in-hospital PEA/asystolic CA from January 1 2011 to June 30 2019. The primary outcome was the return of spontaneous circulation. The secondary outcome was survival to discharge. CA occurred in 148 infants and PEA/asystolic was found in 38 (26%). Of those 29 (76%) achieved ROSC, and 12 (32%) survived to discharge. Infants on inotrope support or receiving longer duration of chest compressions and epinephrine had increase mortality. All infants with respiratory etiology of arrest survived to hospital discharge. PEA/asystolic CAs are uncommon. Poor prognostic indicators include the need for pre-arrest inotrope support and increased duration of chest compressions.

In COVID-19 Patients Who Suffer In-Hospital Cardiac Arrest, Cardiopulmonary Resuscitation Outcomes May Be Impacted by Arrest Etiology and Local Pandemic Conditions.

OBJECTIVES:The utility and risks to providers of performing cardiopulmonary resuscitation after in-hospital cardiac arrest in COVID-19 patients have been questioned. Additionally, there are discrepancies in reported COVID-19 in-hospital cardiac arrest survival rates. We describe outcomes after cardiopulmonary resuscitation for in-hospital cardiac arrest in two COVID-19 patient cohorts.DESIGN:Retrospective cohort study.SETTING:New York-Presbyterian Hospital/Columbia University Irving Medical Center in New York, NY.PATIENTS:Those admitted with COVID-19 between March 1, 2020, and May 31, 2020, as well as between March 1, 2021, and May 31, 2021, who received resuscitation after in-hospital cardiac arrest.INTERVENTIONS:None.MEASUREMENT AND MAIN RESULTS:Among 103 patients with coronavirus disease 2019 who were resuscitated after in-hospital cardiac arrest in spring 2020, most self-identified as Hispanic/Latino or African American, 35 (34.0%) had return of spontaneous circulation for at least 20 minutes, and 15 (14.6%) survived to 30 days post-arrest. Compared with nonsurvivors, 30-day survivors experienced in-hospital cardiac arrest later (day 22 vs day 7; p = 0.008) and were more likely to have had an acute respiratory event preceding in-hospital cardiac arrest (93.3% vs 27.3%; p < 0.001). Among 30-day survivors, 11 (73.3%) survived to hospital discharge, at which point 8 (72.7%) had Cerebral Performance Category scores of 1 or 2. Among 26 COVID-19 patients resuscitated after in-hospital cardiac arrest in spring 2021, 15 (57.7%) had return of spontaneous circulation for at least 20 minutes, 3 (11.5%) survived to 30 days post in-hospital cardiac arrest, and 2 (7.7%) survived to hospital discharge, both with Cerebral Performance Category scores of 2 or less. Those who survived to 30 days post in-hospital cardiac arrest were younger (46.3 vs 67.8; p = 0.03), but otherwise there were no significant differences between groups.CONCLUSIONS:Patients with COVID-19 who received cardiopulmonary resuscitation after in-hospital cardiac arrest had low survival rates. Our findings additionally show return of spontaneous circulation rates in these patients may be impacted by hospital strain and that patients with in-hospital cardiac arrest preceded by acute respiratory events might be more likely to survive to 30 days, suggesting Advanced Cardiac Life Support efforts may be more successful in this subpopulation.

A multicentre survey of paediatric out-of-hospital cardiac arrest incidence, aetiology, and survival in New South Wales over an 11-year period

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Out-of-hospital cardiac arrest (OOHCA) is commonly associated with pulseless ventricular tachycardia and ventricular fibrillation (VT/VF) and cardiac aetiologies. One New South Wales (NSW) ambulance registry reported(1) cardiac aetiologies with a prevalence of 31% among OOHCA cases. Multicentre OOHCA data and NSW’s well-developed services for cardiac genetic predisposition screening motivate us to consider the following study of paediatric OOHCA in this state. Purpose We present a multicentre, retrospective study summarizing the demographics, clinical characteristics, incidence, presenting rhythm, and survival-to-discharge status of paediatric OOHCA cases in NSW over an 11-year period. We also present and categorize diagnostic outcomes for patients presenting with VT/VF. Methods A retrospective case series of 298 patients admitted to one of three NSW PICUs (two in Sydney and one in Newcastle) under 18 years of age and presenting with OOHCA between January 2009 and December 2019. Results Out of 296 paediatric OOHCA patients that survived until PICU admission, 187 (63.2%) were male and 160 (54.1%) survived until hospital discharge. Of those surviving to discharge, 105 (65.6%) were male. Presenting rhythm was asystole or pulseless electrical activity in 240 patients (84.8%, aged 0–17 years, median age 2 years), VT/VF in 41 patients (14.5%, aged 0–16 years, median age 9 years), and complete heart block in 2 patients (0.7%, aged 4–4 years, median age 4 years). Survival was higher in the VT/VF group (82.9%) relative to the asystole and pulseless electrical activity group (50.0%). Of the 41 patients presenting with VT/VF, 13 (31.7%) had a predisposing cardiac condition (2 truncus arteriosus, 1 arrhythmogenic right ventricular cardiomyopathy, 1 double outlet right ventricle, 1 hypoplastic right ventricle, 1 left ventricular non-compaction, 2 asystolic syncope, 2 left ventricular intramyocardial fibroma, 1 familial dilated cardiomyopathy, and 2 undetermined cardiac conditions) and 20 (48.8%) had a genetic condition (9 catecholaminergic polymorphic ventricular tachycardia, 4 hypertrophic cardiomyopathies, 1 Nkx-2.5 mutation, 2 Long QT syndrome, 2 PPA2 mutation, 1 TANGO2 mutation, 1 supraventricular tachycardia). Toxins or trauma were involved in 4 (9.8%) cases, while no cause was determined in 4 (9.8%) other cases. Conclusions Overall, 54.1% of paediatric OOHCA patients admitted to PICU survived until hospital discharge, rising to 82.9% among those with VT/VF. Genetic conditions (48.8%), predominated by CPVT, were present in over one-third of VT/VF cases: this figure confirms the continued need for detailed cardiac/genetic assessment for paediatric OOHCA cases.

Gender disparities among adult recipients of layperson bystander cardiopulmonary resuscitation by location of cardiac arrest in Pan-Asian communities: A registry-based study.

SummaryBackgroundBystander cardiopulmonary resuscitation (BCPR) is a critical component of the 'chain of survival' in reducing mortality among out-of-hospital cardiac arrest (OHCA) victims. Inconsistent findings on gender disparities among adult recipients of layperson BCPR have been reported in the literature. We aimed to fill this knowledge gap by investigating the extent of gender disparities in a cross-national setting within Pan-Asian communities.MethodsWe utilised data collected from the Pan-Asian Resuscitation Outcomes Study (PAROS), an international, multicentre, prospective study conducted between 2009 and 2018. We included all OHCA cases with non-traumatic arrest aetiology transported by emergency medical services and excluded study sites that did not consistently collect information about the location of cardiac arrest. Logistic regression was used to analyse the association between gender and BCPR, stratified by location.FindingsWe analysed a cohort of 56,192 OHCA cases with an overall BCPR rate of 36.2% (20,329/56,192). At public locations, the BCPR rate was 31.2% (631/2022) for female and 36.4% (3235/8892) for male OHCA victims; while at home, the rate was 38.3% (6838/17,842) for females and 35.1% (9625/27,436) for males. Controlling for site differences and several factors in multivariable logistic regression, we found females less likely to receive BCPR than males in public locations (odds ratio [OR]=0.89, 95% confidence interval [CI]: 0.70–0.99), but more likely to receive BCPR at home (OR=1.16, 95% CI: 1.11–1.21).InterpretationIn Pan-Asian communities, gender differences exist in adult recipients of BCPR and differ between home and public locations. Future studies should account for additional information on bystanders and societal factors to identify targets for interventions.FundingThe study was supported by grants from the National Medical Research Council (NMRC/CSA/0049/2013) and Laerdal Foundation (20040).

Utilization of point-of-care ultrasound and rotational thromboelastometry (ROTEM) in the diagnosis and management of amniotic fluid embolism presenting as post-partum hemorrhage and cardiac arrest

AbstractObjectivesTo describe the integration of point-of-care ultrasound (POCUS) and rotational thromboelastometry (ROTEM) in the diagnosis and management of cardiac arrest secondary to amniotic fluid embolism (AFE).Case presentationA 29-year-old female presented for induction of labor at 39 weeks. Labor was complicated by hemorrhage and subsequent sinus tachycardia pulseless electrical activity (PEA) arrest. Intra-arrest POCUS demonstrated right ventricular dilation and hypokinesis adding to a presumed hemorrhagic arrest etiology. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated at the bedside following the POCUS findings. ROTEM further clarified the etiology of hemorrhage as disseminated intravascular coagulation (DIC), and in combination with the POCUS findings led to a final diagnosis of amniotic fluid embolism with DIC. The patient was maintained on VA-ECMO without heparin in the setting of DIC. She had a complicated hospital course but was discharged home with her healthy child and no residual physical or neurologic deficits.ConclusionsIn the absence of more specific testing modalities the utilization of rapidly available POCUS in conjunction with ROTEM can impact clinical decision making of cardiovascular resuscitation in patients during labor and delivery by narrowing the differential between pulmonary embolism and AFE.

Telemedical Intensivist Consultation During In-Hospital Cardiac Arrest Resuscitation: A Simulation-Based, Randomized Controlled Trial

High-quality leadership improves resuscitation for in-hospital cardiac arrest (IHCA), but experienced resuscitation leaders are unavailable in many settings. Does real-time telemedical intensivist consultation improve resuscitation quality for IHCA? In this multicenter randomized controlled trial, standardized high-fidelity simulations of IHCA conducted between February 2017 and September 2018 on inpatient medicine and surgery units at seven hospitals were assigned randomly to consultation (intervention) or simulated observation (control) by a critical care physician via telemedicine. The primary outcome was the fraction of time without chest compressions (ie, no-flow fraction) during an approximately 4- to 6-min analysis window beginning with telemedicine activation. Secondary outcomes included other measures of chest compression quality, defibrillation and medication timing, resuscitation protocol adherence, nontechnical team performance, and participants' experience during resuscitation participation. No-flow fraction did not differ between the 36 intervention group (0.22 ± 0.13) and the 35 control group (0.19 ± 0.10) resuscitation simulations included in the intention-to-treat analysis (P= .41). The etiology of the simulated cardiac arrest was identified more often during evaluable resuscitations supported by a telemedical intensivist consultant (22/32 [69%]) compared with control resuscitations (10/34 [29%]; P= .001), but other measures of resuscitation quality, resuscitation team performance, and participant experience did not differ between intervention groups. Problems with audio quality or the telemedicine connection affected 14 intervention group resuscitations (39%). Consultation by a telemedical intensivist physician did not improve resuscitation quality during simulated ward-based IHCA. ClinicalTrials.gov; No.: NCT03000829; URL: www. gov.