Etiology Of Arrest Research Articles

Successful extracorporeal membrane oxygenation for heart failure after adolescent idiopathic scoliosis surgery.

Spine surgery, particularly deformity correction, is associated with a high risk of peri-operative or post-operative complications, and these complications can lead to catastrophic consequences. This case report will present the etiology and treatment process of the peri-operative cardiac arrest during scoliosis correction surgery. In this report, we present a case of cardiac arrest during posterior correction surgery in a 17-year-old female patient with adolescent idiopathic scoliosis. The patient was successfully treated using extracorporeal membrane oxygenation and an intra-aortic balloon pump. We have discussed the potential causes of peri-operative cardiac arrest, including thromboembolism (VAE/PE), electrolyte imbalance (Hyper/Hypokalemia or Acidosis), hypovolemia, hypothermia, and cardiogenic shock related to neurogenic-stunned myocardium. There are many etiologies should be considered in peri-operative cardiac arrest during posterior correction spine surgery, such as venous air embolism and electrolyte imbalance. Stress cardiomyopathy, which occurs after stressful conditions, such as surgery should also be considered. Surgeons must consider these etiologies when faced with critical situations, and the successful treatment of such cases relies on team collaboration and prompt intervention.

Abstract Sa1103: Utility of early Computed Tomography after out-of-hospital cardiac arrest resuscitation

Background: Initial care after out-of-hospital cardiac arrest (OHCA) poses major challenges to clinical teams due to diverse arrest etiologies and the potential need for time-sensitive interventions. Emergency department-based evaluation of these patients is crucial for identifying treatable causes of arrest. Recent data from one academic hospital highlights the potential importance of initial broad computed tomography (CT) immediately following resuscitation. Objective: To assess the ability of early post-arrest CT imaging to diagnose potential etiologies and sequelae of OHCA. Methods: We employed a registry of consecutive OHCA cases admitted to 3 hospitals within the University of Pennsylvania Health System between 1/2019-10/2020, collecting demographic, arrest, and post-arrest clinical data. Inclusion criteria included age >18 y, OHCA with return of spontaneous circulation (ROSC). We abstracted CT data including findings, contrast use, and timing, and subsequent clinical notes to assess for interventions performed based on CT findings from the EHR. KDIGO definition was used for acute kidney injury (AKI). SAS software was used for data analysis. Results: A total of 161 OHCA patients were included (mean age 60.8±15.6y; 42% female). Initial shockable rhythms were present in 16%, with 70% witnessed and 39% receiving bystander CPR. 154 patients survived to admission, and 41 survived to discharge. 117 patients underwent CT imaging in the ED: 117 underwent head CT, 87 chest CT, and 64 abdomen/pelvis CT. Median time to any first CT was 2.0h (IQR:1.4,2.8). Intracranial hemorrhage was diagnosed in 5/117 patients (4.3%); 3 received conservative therapy. Cerebral edema was found in 30/117 patients (25.6%), 10 received treatment. Pulmonary embolism was diagnosed in 8/87 cases (9.2%), 7 of which were acute and treated pharmacologically and/or mechanically. Aspiration and/or pneumonia, pneumonitis, bronchitis, bronchiolitis was found on 65/84 cases (74.7%), 30 received antibiotics. Deep venous thrombosis was detected in 3/64 patients (4.7%), 2 received anticoagulation. We found no significant differences in AKI rates with the use of contrast compared to patients receiving no contrast (p=0.93). Conclusion: These results confirm and extend other reports emphasizing the potential value for routine use of CT imaging post-ROSC. Implementing larger scale prospective studies comparing such protocols and standard-of-care is important to determine impact on OHCA outcomes.

Time-dependent association of grey-white ratio on early brain CT predicting outcomes after cardiac arrest at hospital discharge

BackgroundCerebral edema after cardiac arrest can be quantified by the ratio of grey matter to white matter radiodensity (GWR) on computed tomography (CT). Severe edema predicts worse outcomes. We hypothesized the sensitivity and false positive rate of GWR predicting outcomes change over the first 24 h post-arrest. MethodsWe performed a single-center retrospective cohort study including patients resuscitated from cardiac arrest between January 2010 and December 2023 who were unresponsive to verbal commands. We excluded patients who arrested from a primary traumatic or neurological etiology and those without brain imaging within 24 h of arrest. We divided patients into groups based on time from arrest to CT, then quantified the performance of GWR dichotomized at < 1.10 and < 1.20, predicting in-hospital mortality and death by neurologic criteria (DNC). ResultsWe included 2,204 patients with mean age 59 (SD 16) years. Overall, 1651 (75 %) died in the hospital, of whom 248 (11 %) progressed to DNC. Sensitivity of GWR < 1.10 and GWR < 1.20 for predicting in-hospital mortality increased over the first four hours post-arrest, reaching a maximum of 25 % after five hours, while false positive rates remained < 5 % at all time points. Similar temporal trends were observed with DNC, although absolute values of sensitivity and false positive rate (FPR) varied. ConclusionThe sensitivity and FPR of early GWR predicting in-hospital mortality and DNC after resuscitation from cardiac arrest varies over the initial post-arrest period. Reduced GWR on brain CTs is most sensitive for in-hospital mortality when obtained more than four hours post-arrest and for DNC when obtained between four and five hours. However, FPR remained execellent throughout, making early reductions in GWR a specific marker of poor outcome regardless of timing. While brain CTs obtained within the first 24 h post-arrest may be indicated to evaluate for neurologic etiologies of arrest, they may be less informative as an independent marker of prognosis.

Survivability of young sudden cardiac arrest by aetiology: insights from a state-wide adjudicated cardiac arrest registry

Abstract Background Identifying factors to improve survival following out-of-hospital cardiac arrest (OHCA) is important. Many OHCA registries do not document the underlying cause of OHCA and therefore cannot provide insights according to specific arrest aetiology. The aim of this study was to assess survivability of OHCA according to arrest aetiology. Methods A state-wide registry identified all patients aged 1 to 50 years who experienced OHCA in Victoria, Australia from April 2019 to April 2023. OHCA was ambulance-defined with cause of OHCA determined by adjudication against autopsy or hospital data. OHCA aetiology was classified into four categories; non-cardiac, coronary, cardiomyopathy or other cardiac (including unascertained cause). Results 2686 patients experienced OHCA (non-cardiac=1305, 48.6%, coronary=585, 21.8%, cardiomyopathy=250, 9.3%, other cardiac=537(282 unascertained), 20.0%), of whom 250 (9.3%) survived. Patients in the coronary group were older (median 45 years [interquartile range 40-48 years], p=0.0001), more likely to be male (83.6%, p&amp;lt;0.0001), have a witnessed arrest (44.6%, p&amp;lt;0.0001) and have an initial shockable rhythm (48.2%, p&amp;lt;0.0001) when compared to other categories. Using the non-cardiac group as the reference group, adjusted odds ratio of survival (95% CI) were 1.65 (0.86-3.19) for cardiomyopathy, 2.51 (1.55-4.07) for other cardiac and 4.03 (2.51-6.49) for coronary causes of OHCA. Conclusion Odds of survival to hospital discharge following OHCA were four times higher in OHCA of coronary aetiology when compared with non-cardiac OHCA. Ongoing research into OHCA according to aetiology is needed to define subgroups, benchmark resuscitation performance more appropriately and identify patterns according to specific aetiologies to improve survival outcomes.

6692 Proarrhythmic Risk Of Hypoglycemia; A Case Of Insulin-Induced Hypoglycemia Provoking Torsade De Pointes-Cardiac Arrest

Abstract Disclosure: A.M. San Hernandez: None. A. Adelkhanova: None. H. Ashraf: None. J. Aguayo Herrera: None. M.F. Siddiqui: None. Introduction: Torsade de Pointes is a life-threatening polymorphic ventricular tachycardia which is associated with QTc prolongation caused by medications, metabolic and electrolyte abnormalities. Very few cases of hypoglycemia causing QTc prolongation and Torsades de Pointes have been reported in the literature. Although the mechanism is unclear, the effects of low blood glucose have been proposed to induce a sympathetic response, hypokalemia and calcium disturbances. We report a case of an insulin-induced hypoglycemia causing Torsades de Pointes cardiac arrest, highlighting the proarrhythmic risk of hypoglycemia. Case presentation: A 57-year-old female with a history of Insulin-dependent Type 2 Diabetes Mellitus (DM) was brought in by EMS due to severe symptomatic hypoglycemia (POC blood glucose of 30 mg/dL), requiring treatment with dextrose. Patient reported reduced oral intake due to vomiting for 1 week and continued insulin administration without self-monitoring of blood glucose. Laboratory work up on presentation revealed severe hypoglycemia VBG= 55 mg/dL and mild hypomagnesemia Mg=1.4mg/dL (Ref Range 1.7-2.2mg/dl) which was treated. There was no hypokalemia or hypocalcemia. ECG showed sinus rhythm with prolonged QTc interval of 573ms and non-specific ST changes.Few hours later, patient developed torsades de pointes, requiring ACLS resuscitation. ROSC was achieved after two rounds of CPR. Patient received dextrose infusion to maintain euglycemic state. She was not taking any QTc prolonging medication. There was no history of autoimmune disease. Except for hypoglycemia, no other metabolic abnormality could be identified. Cardiac and pulmonary etiologies of cardiac arrest were ruled out. Post-ROSC ECG showed sinus tachycardia with normalization of QTc to 454ms. Thus, Insulin-induced hypoglycemia was appointed as the main culprit for her cardiac arrest, in the setting of QTc prolongation. Patient received diabetes self-management and hypoglycemia education. Conclusion: Several studies support strong correlation between hypoglycemia and arrhythmic events during bedtime in people with diabetes “The dead in bed syndrome”. Hypoglycemia causes an acquired long QT syndrome independent of other risk factors such as cardiac autonomic neuropathy. Possible mechanisms include; sympathoadrenal activation, which regulates potassium, calcium and chloride channels or altered autonomic regulation caused by hypoglycemia itself regardless of the effect of insulin or hypokalemia. QT prolongation is a risk factor for sudden cardiac death by causing torsades de pointes ventricular tachycardia (VT).People with insulin dependent diabetes are at high risk of hypoglycemia and should be cautioned about the proarrhythmic risk of hypoglycemia. Education is crucial, and Continuous glucose monitor (CGM) is a valuable tool to be use in such a patient population. Presentation: 6/3/2024

Ischemic Post-Conditioning in a Rat Model of Asphyxial Cardiac Arrest.

Ischemic post-conditioning (IPoC) has been shown to improve outcomes in limited pre-clinical models. As down-time is often unknown, this technique needs to be investigated over a range of scenarios. As this tool limits reperfusion injury, there may be limited benefit or even harm after short arrest and limited ischemia-reperfusion injury. Eighteen male Wistar rats underwent 7 min of asphyxial arrest. Animals randomized to IPoC received a 20 s pause followed by 20 s of compressions, repeated four times, initiated 40 s into cardiopulmonary resuscitation. If return of spontaneous circulation (ROSC) was achieved, epinephrine was titrated to mean arterial pressure (MAP) of 70 mmHg. Data were analyzed using t-test or Mann-Whitney test. Significance set at p ≤ 0.05. The rate of ROSC was equivalent in both groups, 88%. There was no statistically significant difference in time to ROSC, epinephrine required post ROSC, carotid flow, or peak lactate at any timepoint. There was a significantly elevated MAP with IPoC, 90.7 mmHg (SD 13.9), as compared to standard CPR, 76.7 mmHg (8.5), 2 h after ROSC, p = 0.03. IPoC demonstrated no harm in a model of short arrest using a new arrest etiology for CPR based IPoC intervention in a rat model.

The role of magnesium in cardiac arrest.

Cardiac arrest is a leading cause of death globally. Only 25.8% of in-hospital and 33.5% of out-of-hospital individuals who achieve spontaneous circulation following cardiac arrest survive to leave the hospital. Respiratory failure and acute coronary syndrome are the two most common etiologies of cardiac arrest. Effort has been made to improve the outcomes of individuals resuscitated from cardiac arrest. Magnesium is an ion that is critical to the function of all cells and organs. It is often overlooked in everyday clinical practice. At present, there have only been a small number of reviews discussing the role of magnesium in cardiac arrest. In this review, for the first time, we provide a comprehensive overview of magnesium research in cardiac arrest focusing on the effects of magnesium on the occurrence and prognosis of cardiac arrest, as well as in the two main diseases causing cardiac arrest, respiratory failure and acute coronary syndrome. The current findings support the view that magnesium disorder is associated with increased risk of cardiac arrest as well as respiratory failure and acute coronary syndrome.

Evaluation of the factors affecting mortality after cardiac arrest - do lactate and procalcitonin concentrations have any implications?

Mortality and morbidity rates are very high in patients admitted to the Intensive Care Unit (ICU) after cardiac arrest. In this study, we aimed to determine the mortality rates, risk factors, and predictive factors for mortality in post-cardiac arrest patients admitted to the ICU. Following approval from the Ethics Committee, we conducted a retrospective review of patient files for individuals over the age of 18 who received treatment for cardiac arrest in the ICU from January 2017 to June 2020. Demographic data of the patients, comorbidities, arrest location, etiology of arrest, duration of hospitalization, CPR duration, APACHE 2 scores, pH and HCO3 measurements in initial blood gases, lactate levels (1st, 6th, 12th, 24th hour), change in lactate levels (24-1), rate of lactate change, procalcitonin (PRC) levels (1st and 24th hour), change in PRC levels (24-1), rate of PRC change, and blood glucose levels were recorded. The patients were divided into two groups (survivors and non-survivors groups). 151 patients were included in the study. pH and HCO3 levels were lower in the non-survivors group than in the survivors group. Initial PRC levels were similar in both groups, but the 24th-hour PRC levels were higher, and the changes in PRC levels in the first 24 hours were greater in the non-survivors group. The lactate changes in the first 24 hours were higher in the non-survivors group. The receiver operating characteristic (ROC) curve showed that the HCO3 levels, 1st-, 6th-, 12th-, and 24th-hour lactate levels, and changes in lactate levels had predictability for mortality. In logistic regression analysis, we found that high 24th-hour lactate levels and changes in lactate levels were independent risk factors for mortality. Considering PRC and lactate levels, along with clinical examination and laboratory findings, may improve the accuracy of determining the prognosis of patients experiencing cardiac arrest.

The Current Discussion Regarding End-of-Life Care for Patients with Out-of-Hospital Cardiac Arrest with Initial Non-Shockable Rhythm: A Narrative Review.

Despite recent advances in resuscitation science, outcomes in patients with out-of-hospital cardiac arrest (OHCA) with initial non-shockable rhythm remains poor. Those with initial non-shockable rhythm have some epidemiological features, including the proportion of patients with a witnessed arrest, bystander cardiopulmonary resuscitation (CPR), age, and presumed etiology of cardiac arrest have been reported, which differ from those with initial shockable rhythm. The discussion regarding better end-of-life care for patients with OHCA is a major concern among citizens. As one of the efforts to avoid unwanted resuscitation, advance directive is recognized as a key intervention, safeguarding patient autonomy. However, several difficulties remain in enhancing the effective use of advance directives for patients with OHCA, including local regulation of their use, insufficient utilization of advance directives by emergency medical services at the scene, and a lack of established tools for discussing futility of resuscitation in advance care planning. In addition, prehospital termination of resuscitation is a common practice in many emergency medical service systems to assist clinicians in deciding whether to discontinue resuscitation. However, there are also several unresolved problems, including the feasibility of implementing the rules for several regions and potential missed survivors among candidates for prehospital termination of resuscitation. Further investigation to address these difficulties is warranted for better end-of-life care of patients with OHCA.

Brain computed tomography after resuscitation from in-hospital cardiac arrest

BackgroundFew data characterize the role of brain computed tomography (CT) after resuscitation from in-hospital cardiac arrest (IHCA). We hypothesized that identifying a neurological etiology of arrest or cerebral edema on brain CT are less common after IHCA than after resuscitation from out-of-hospital cardiac arrest (OHCA). MethodsWe included all patients comatose after resuscitation from IHCA or OHCA in this retrospective cohort analysis. We abstracted patient and arrest clinical characteristics, as well as pH and lactate, to estimate systemic illness severity. Brain CT characteristics included quantitative measurement of the grey-to-white ratio (GWR) at the level of the basal ganglia and qualitative assessment of sulcal and cisternal effacement. We compared GWR distribution by stratum (no edema ≥1.30, mild-to-moderate <1.30 and >1.20, severe ≤1.20) and newly identified neurological arrest etiology between IHCA and OHCA groups. ResultsWe included 2,306 subjects, of whom 420 (18.2%) suffered IHCA. Fewer IHCA subjects underwent post-arrest brain CT versus OHCA subjects (149 (35.5%) vs 1,555 (82.4%), p < 0.001). Cerebral edema for IHCA versus OHCA was more often absent (60.1% vs. 47.5%) or mild-to-moderate (34.3% vs. 27.9%) and less often severe (5.6% vs. 24.6%). A neurological etiology of arrest was identified on brain CT in 0.5% of IHCA versus 3.2% of OHCA. ConclusionsAlthough severe edema was less frequent in IHCA relative to OHCA, mild-to-moderate or severe edema occurred in one in three patients after IHCA. Unsuspected neurological etiologies of arrest were rarely discovered by CT scan in IHCA patients.

Trends in presumed drug overdose out-of-hospital cardiac arrests in San Francisco, 2015–2023

IntroductionEstimates of the prevalence of drug-related out of hospital cardiac arrest (OHCA) vary, ranging from 1.8% to 10.0% of medical OHCA. However, studies conducted prior to the recent wave of fentanyl deaths likely underestimate the current prevalence of drug-related OHCA. We evaluated recent trends in drug-related OHCA, hypothesizing that the proportion of presumed drug-related OHCA treated by emergency medical services (EMS) has increased since 2015. MethodsWe conducted a retrospective analysis of OHCA patients treated by EMS providers in San Francisco, California between 2015 and 2023. Participants included OHCA cases in which resuscitation was attempted by EMS. The study exposure was the year of arrest. Our primary outcome was the occurrence of drug-related OHCA, defined as the EMS impression of OHCA caused by a presumed or known overdose of medication(s) or drug(s). ResultsFrom 2015 to 2023, 5044 OHCA resuscitations attended by EMS (average 561 per year) met inclusion criteria. The median age was 65 (IQR 50–79); 3508 (69.6%) were male. The EMS impression of arrest etiology was drug-related in 446/5044 (8.8%) of OHCA. The prevalence of presumed drug-related OHCA increased significantly each year from 1% in 2015 to 17.6% in 2023 (p-value for trend = 0.0001). After adjustment, presumed drug-related OHCA increased by 30% each year from 2015-2023. ConclusionDrug-related OHCA is an increasingly common etiology of OHCA. In 2023, one in six OHCA was presumed to be drug related. Among participants less than 60 years old, one in three OHCA was presumed to be drug related.

Analysis of factors affecting the return of spontaneous circulation in elderly patients with out-of-hospital cardiac arrest

To investigate the factors that influence the return of spontaneous circulation (ROSC) in elderly patients suffering from out-of-hospital cardiac arrest (OHCA). A retrospective study was used to collect the clinical data of OHCA patients admitted to the emergency center of Zhengzhou People's Hospital from July 2016 to July 2019 based on the pre-hospital emergency database of Utstein model. Patients' gender, age, cardiac arrest (CA) etiology, presence or absence of bystander cardiopulmonary resuscitation (CPR), emergency response time, initial cardiac rhythm, ventilation method, use of epinephrine, defibrillation and ROSC were included. The patients were divided into elderly and young groups according to whether age ≥ 60 years old, and the differences in various indicators between the two groups were compared. Univariate Logistic regression analysis was used to analyze the relationship between emergency response time and ROSC in elderly patients and multivariate Logistic regression analysis was used to identify factors influencing ROSC in elderly patients. A total of 3 429 adult OHCA patients were enrolled in this study, including 2 105 elderly patients (61.39%), and 1 324 young and middle-aged patients (38.61%). Compared to the young group, the proportion of females, non-cardiac causes and asystole as the initial rhythm was higher in the elderly group, the emergency response time was shorter, the rate of defibrillation and tracheal intubation, and the success rate of ROSC were lower (all P < 0.05). Among them, the proportion of cardiac arrest as the initial rhythm in elderly male patients was significantly higher than that of young male patients (P < 0.05); the proportion of non-cardiac causes in elderly female patients was significantly higher than that of young female patients, and the proportion of defibrillation was significantly lower than that of young female patients (all P < 0.05). Multivariate Logistic regression analysis showed that cardiac arrest as the initial rhythm was strongly associated with ROSC in elderly male patients [odds ratio (OR) = 0.126, 95% confidence interval (95%CI) was 0.045-0.352, P < 0.05]. Univariate Logistic regression analysis of the relationship between emergency response time and ROSC in elderly patients showed that although there was no significant difference in the ROSC success rate among elderly patients with various emergency response times, an emergency response time within 10 minutes was beneficial for ROSC in elderly patients. The success rate of ROSC is very low in elderly OHCA patients aged ≥60 years. Although the CPR-related indicators of elderly patients are significantly different from those of young patients, there are gender differences. The association between the elderly male patients and cardiac arrest as the initial rhythm is stronger, while OHCA caused by non-cardiac diseases is more common and defibrillable rhythm is less common in elderly female patients. It may be more beneficial for elderly patients to shorten the emergency response time and increase bystander CPR.

Provider Perceptions Regarding Cardiopulmonary Resuscitation in Surgical Patients with Frailty.

To characterize the perceptions of surgeons, anesthesiologists, and geriatricians regarding perioperative CPR in surgical patients with frailty. The population of patients undergoing surgery is growing older and more frail. Despite a growing focus on goal-concordant care, frailty assessment, and debate regarding the appropriateness of cardiopulmonary resuscitation (CPR) in patients with frailty, providers' views regarding frailty and perioperative CPR are unknown. We performed qualitative thematic analysis of transcripts from semi-structured interviews of anesthesiologists (8), surgeons (10), and geriatricians (9) who care for high-risk surgical patients at two academic medical centers in Boston, MA. The interview guide elicited clinicians' understanding of frailty, approach to decision-making regarding perioperative CPR, and perceptions of perioperative CPR in frail surgical patients. We identified 5 themes: perceptions of perioperative CPR in patients with frailty vary by provider specialty; judgments regarding appropriateness of CPR in surgical patients with frailty are typically multifactorial and include patient goals, age, comorbidities, and arrest etiology; resuscitation in patients with frailty is sometimes associated with moral distress; biases such as ableism and ageism may skew clinicians' perceptions of appropriateness of perioperative CPR in patients with frailty; and evidence to guide risk stratification for patients with frailty undergoing perioperative CPR is inadequate. Anesthesiologists, surgeons, and geriatricians offer different accounts of frailty's relevance to judgments regarding CPR in surgical patients. Divergent views regarding frailty and perioperative CPR may impede efforts to deliver goal-concordant care and suggest a need for research to inform risk stratification, predict patient-centered outcomes, and understand the role of potential biases such as ageism and ableism.

EuReCa Serbia 2014-2023: Analysis of data on noninitiation of CPR in relation to etiology of cardiac arrest

EuReCa Serbia 2014-2023: Analysis of data on noninitiation of CPR in relation to etiology of cardiac arrest

Peripartum Cardiac Arrest with Terminal QRS Distortion: A Case Report.

Peripartum cardiac arrest is increasing in incidence. While pulmonary embolism (PE) remains an important cause of peripartum morbidity and mortality, other cardiovascular emergencies such as myocardial infarction (MI) are now the leading cause of pregnancy-related death. Emergency physicians (EP) need to be well versed in subtle electrocardiographic (ECG) signs of coronary ischemia to better care for peripartum patients in cardiac arrest. A 38-year-old gravida 2 parity1 female three days post-partum presented in cardiac arrest. After approximately 12minutes of Advanced Cardiac Life Support including electric defibrillation, the patient experienced sustained return of spontaneous circulation. The physician team was primarily concerned for PE based on an initial ECG demonstrating terminal QRS distortion in V2 but no ST-segment elevation myocardial infarction (STEMI). Computed tomography angiography (CTA) of the chest did not reveal PE. Repeat ECG after CTA demonstrated STEMI criteria, and the patient was emergently taken to the cardiac catheterization laboratory where she was found to have 99% occlusion of the left anterior descending artery. Emergency physicians should have a high index of suspicion for MI when managing peripartum patients in cardiac arrest. The ECG findings specific for coronary-occlusive acute MI but not included in the classic STEMI criteria increase accuracy and prevent delays in diagnosis; however, the clinical uptake of this paradigm has been slow. Early recognition of terminal QRS distortion can help EPs more rapidly diagnose the etiology of cardiac arrest.

Thrombolytics in Cardiac Arrest from Pulmonary Embolism: A Systematic Review and Meta Analysis.

During cardiopulmonary resuscitation, intravenous thrombolytics are commonly used for patients whose underlying etiology of cardiac arrest is presumed to be related to pulmonary embolism (PE). We performed a systematic review and meta-analysis of the existing literature that focused on the use of thrombolytics for cardiac arrest due to presumed or confirmed PE. Outcomes of interest were return of spontaneous circulation (ROSC), survival to hospital discharge, neurologically-intact survival, and bleeding complications. Thirteen studies with a total of 803 patients were included in this review. Most studies included were single-armed and retrospective. Thrombolytic agent and dose were heterogeneous between studies. Among those with control groups, intravenous thrombolysis was associated with higher rates of ROSC (OR 2.55, 95% CI = 1.50-4.34), but without a significant difference in survival to hospital discharge (OR 1.41, 95% CI = 0.79-2.41) or bleeding complications (OR 2.21, 0.95-5.17). Use of intravenous thrombolytics in cardiac arrest due to confirmed or presumed PE is associated with increased ROSC but not survival to hospital discharge or change in bleeding complications. Larger randomized studies are needed. Currently, we recommend continuing to follow existing consensus guidelines which support use of thrombolytics for this indication.

Improving outcomes from paediatric cardiac arrest in low resource setting

Abstract Introduction Both out of (OHCA) and in hospital (IHCA) pediatric cardiac arrest has traditionally been considered a futile medical condition with dismal outcomes. This is further magnified by resuscitation protocols are typically articulated from the perspective of ideal resource environment without consideration of applicability in district hospitals or non-tertiary centres. Purpose To determine clinical outcomes from both paediatric OHCA and IHCA in low-resource setting and to identify shortcomings in relation to resuscitation in these areas, possible solutions and to suggest future research priorities. Methods This was a multicenter retrospective study in a middle sized city (estimated population 390000) served by a single Emergency Medical Services (EMS) system. All records of OHCA and IHCA under 16 years old were reviewed from the Cardiac Arrest Registry from 2017 to 2022. Data collected included demographic profiles, etiology of cardiac arrest, initial cardiac rhythm, time of initiation of cardiopulmonary resuscitation (CPR) and adrenaline administration by EMS team and duration of CPR. Outcomes of interest included return of spontaneous circulation (ROSC) and survival to hospital discharge (STHD). Results From the 5-year study period, 68 children (mean age of 5.8±1.2 yrs) were included in this study. 22 (32.4%) were infants (&amp;lt;1 year old) and 7 (10.3%) were neonates (&amp;lt;28 days old). Total mortality was observed at 63.2% (n=43). Return of spontaneous circulation (ROSC) was achieved in 40 (58.8%) patients and 33.8% (n=23) survived to hospital discharge. OHCA was witnessed in 52 (83.8%) children from total OHCA and bystander CPR was delivered only in 19 (30.6%) cases. All IHCA were witnessed. Asystole was the most common (n=39) initial rhythm. A delay in initiating cardiopulmonary resuscitation (CPR) and adrenaline administration was observed in 49 cases of OHCA and 1 in IHCA. The median time from emergency call to CPR and from CPR to first adrenaline administration was 20.9±1.2 min and 2.9±1.3 min for OHCA and 0.4±0.2 min and 1.5±0.7min for IHCA [Table 1]. Longer time to CPR and adrenaline administration was associated with lower chance of achieving ROSC and STHD. Using multivariate analyses, fewer adrenaline doses (p&amp;lt;0.05), witnessed cardiac arrest (p=0.001), initial rhythm of ventricular fibrillation (p&amp;lt;0.05) and shorter CPR duration (p=0.007) were good prognostic factors for ROSC and STHD. Conclusion Outcomes from OHCA and IHCA in low resource settings are poor. Unwitnessed arrest, delays in initiation of CPR and adrenaline administration were associated with poor survival. Recognition and identification of at-risk patients, early high-quality CPR and adrenaline administration are imperative to improve mortality. Early recognition and effective resuscitation protocols for children in the community and encouraging bystander CPR should be developed collaboratively with local experts and the EMS team.

A machine learning algorithm to predict a culprit lesion after out of hospital cardiac arrest

Abstract Background Between 50-90% of patients suffering from out-of-hospital cardiac arrest (OHCA) have a primary cardiac aetiology of arrest with the presence of a culprit coronary lesion. However, recent trials have failed to show a benefit from an early invasive angiographic approach following OHCA. Identification of patients with high likelihood of a culprit lesion may enable selection of patients likely to benefit from direct conveyance to cardiac arrest centres and for an early invasive approach. However, electrocardiogram (ECG) following return of spontaneous circulation, the current gold-standard, is a poor predictor of presence of a culprit lesion. Purpose We aimed to develop a machine learning algorithm to predict the presence of a culprit lesion in patients with OHCA. Methods We used a retrospective cohort of 398 patients admitted with primary cardiac aetiology OHCA to a tertiary cardiology centre in the United Kingdom, between May 2012 and December 2017. The primary outcome was the presence of a culprit coronary artery lesion, for which a Gradient Boosting model was optimised to predict. The algorithm was then validated in two independent European cohorts comprising 568 patients (346 and 222 patients respectively). Results The development cohort consisted of 398 patients (median age 64.3 years [IQR 53.3-75.4], 74.6% male), and the two validation cohorts consisted of 346 patients (median age 63.0 years [IQR 55.0-73.0], 81.5% male) and 222 patients (median age 63.0 years [IQR 52.0-74.0], 77.0% male). Of all patients, 85.6% had a witnessed arrest, 69.6% received bystander cardiopulmonary resuscitation, and 77.3% had an initial shockable rhythm. A culprit lesion was observed in 67.4% patients receiving early coronary angiography in the development cohort, and 67.9% and 61.1% in the two validation cohorts respectively. A Gradient Boosting model yielded an algorithm, named KOCAR Culprit Predictor, incorporating nine variables including age, a localising feature on ECG (≥2mm of ST change in contiguous leads), regional wall motion abnormality, history of vascular disease and initial shockable rhythm. This model had an AUC of 0.89 in the development and 0.83/0.81 in the validation cohorts with good calibration (Figure 1), and outperformed the current gold-standard ECG alone (AUC 0.69/0.67/0/67). Conclusions A novel simple machine learning derived algorithm (Figure 2) combining nine variables which are readily available to clinicians can be applied to patients with OHCA to predict a culprit coronary artery lesion with high accuracy. The algorithm, KOCAR Culprit Predictor, outperforms the current gold-standard ECG alone.Figure 1Figure 2

Abstract 18693: Effect of Mechanical Unloading on Cardiogenic Shock Severity in Venoarterial Extracorporeal Membrane Oxygenation Patients

Introduction: Mechanical unloading (MU) with Intra-aortic balloon pump (IABP) or Impella is commonly used to prevent left ventricular (LV) distension in VA-ECMO patients, but its impact on shock severity is not well described. Methods: Patients treated with VA-ECMO in our hospital between 2016-2022 for cardiogenic shock (CS) due to LV failure not related to cardiac surgery were included if no MU was used or it was instituted within 24h of ECMO cannulation. Patients were grouped according to MU: ECMO alone, ECMO + IABP or ECMO + Impella. Linear mixed effects models adjusting for age, sex, hypertension, acute myocardial infarction (AMI) etiology of shock and pre-ECMO cardiac arrest (CA) were used to assess the impact of MU on hemodynamic and perfusion markers. R version 4 was used for analysis. Results: Among 68 patients included, 18 received ECMO alone, 17 ECMO + IABP, and 33 ECMO + Impella. Age and CA were similar across groups. The Impella group had a higher proportion of men and patients with AMI. Pulmonary artery diastolic pressure was unchanged in all groups. Compared to ECMO alone, MU did not enhance lactate clearance (interaction: IABP p=0.7, Impella p=0.22), but it did improve the vasopressor-inotropic score (IABP p=0.03, Impella p=0.01), serum creatinine (IABP p=0.03, Impella p=0.04), and alanine transaminase (IABP only p=0.02). Survival to decannulation was similar in patients with ECMO alone (50%), Impella (64%) and IABP (65%) (p=0.68). Conclusions: In adults treated with VA-ECMO for CS unrelated to cardiac surgery, LV MU can lead to improvements in CS severity.

Etiology-Based Prognosis of Extracorporeal CPR Recipients After Out-of-Hospital Cardiac Arrest: A Retrospective Multicenter Cohort Study

BackgroundA better understanding of the relative contributions of various factors to patient outcomes is essential for optimal patient selection for extracorporeal cardiopulmonary resuscitation (ECPR) therapy for patients with out-of-hospital cardiac arrest (OHCA). However, evidence on the prognostic comparison based on the etiologies of cardiac arrest is limited. Research QuestionWhat is the etiology-based prognosis of patients undergoing ECPR for OHCA? Study Design and MethodsThis retrospective multicenter registry study involved 36 institutions in Japan and included all adult patients with OHCA who underwent ECPR between January 2013 and December 2018. The primary etiology for OHCA was determined retrospectively from all hospital-based data at each institution. We performed a multivariable logistic regression model to determine the association between etiology of cardiac arrest and two outcomes: favorable neurological outcomes and survival at hospital discharge. ResultsWe identified 1,781 eligible patients, of whom 1,405 (78.9%) had cardiac arrest due to the cardiac causes. Multivariable logistic regression analysis for favorable neurological outcomes showed that accidental hypothermia (adjusted OR = 5.12; 95% CI = 2.98-8.80, P < 0.001) was associated with a significantly higher rate of favorable neurological outcomes than cardiac causes. Multivariable logistic regression analysis for survival showed that accidental hypothermia (adjusted OR = 5.19; 95% CI = 3.15-8.56, P < 0.001) had significantly higher rates of survival than cardiac causes. Acute aortic dissection/aneurysm (adjusted OR = 0.07, 95% CI = 0.02-0.28, P < 0.001) and primary cerebral disorders (adjusted OR = 0.12, 95% CI = 0.03-0.50, P = 0.004) had significantly lower rates of survival than cardiac causes. InterpretationIn this retrospective multicenter cohort study, although most OHCA patients underwent ECPR for cardiac causes, accidental hypothermia was associated with favorable neurological outcomes and survival; in contrast, acute aortic dissection/aneurysm and primary cerebral disorders were associated with non-survival than cardiac causes.