European Resuscitation Council Research Articles

Performance of a guideline-recommended algorithm for prognostication of poor neurological outcome after cardiac arrest

PurposeTo assess the performance of a 4-step algorithm for neurological prognostication after cardiac arrest recommended by the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM).MethodsRetrospective descriptive analysis with data from the Target Temperature Management (TTM) Trial. Associations between predicted and actual neurological outcome were investigated for each step of the algorithm with results from clinical neurological examinations, neuroradiology (CT or MRI), neurophysiology (EEG and SSEP) and serum neuron-specific enolase. Patients examined with Glasgow Coma Scale Motor Score (GCS-M) on day 4 (72–96 h) post-arrest and available 6-month outcome were included. Poor outcome was defined as Cerebral Performance Category 3–5. Variations of the ERC/ESICM algorithm were explored within the same cohort.ResultsThe ERC/ESICM algorithm identified poor outcome patients with 38.7% sensitivity (95% CI 33.1–44.7) and 100% specificity (95% CI 98.8–100) in a cohort of 585 patients. An alternative cut-off for serum neuron-specific enolase, an alternative EEG-classification and variations of the GCS-M had minor effects on the sensitivity without causing false positive predictions. The highest overall sensitivity, 42.5% (95% CI 36.7–48.5), was achieved when prognosticating patients irrespective of GCS-M score, with 100% specificity (95% CI 98.8–100) remaining.ConclusionThe ERC/ESICM algorithm and all exploratory multimodal variations thereof investigated in this study predicted poor outcome without false positive predictions and with sensitivities 34.6–42.5%. Our results should be validated prospectively, preferably in patients where withdrawal of life-sustaining therapy is uncommon to exclude any confounding from self-fulfilling prophecies.

A Cross-International Study to Evaluate Knowledge and Attitudes Related to Basic Life Support among Undergraduate Nursing Students-A Questionnaire Study.

Practicing the algorithms of basic life support (BLS) is essential in order to take adequate measures to save lives, and future nursing staff should be advanced when it comes to performing lifesaving activities. The purpose of the study was to analyse the theoretical and practical knowledge of nursing students (within the undergraduate course) with regards to the basic life support (BLS). The study has a prospective, comparative and descriptive nature. Three countries that educate nursing students within the undergraduate course participated in the project. Data was collected with the use of a questionnaire based on the guidelines of the European Resuscitation Council (ERC 2015). The study was carried out among a total of 748 respondents from three countries: Poland (n = 189, 25.3%), Lithuania (n = 500, 66.8%) and Spain (n = 59; 7.9%). The average age of respondents was 23.41 (SD ± 5.90). The average score obtained by the respondents who answered the questions was 11.13 with a standard deviation of SD ± 2.29. The conducted study revealed that a substantial number of the respondents who participated in the study obtained an average result concerning theoretical and practical knowledge of BLS. It was also confirmed that the additional education in the form of first aid training courses has a major impact on improving the levels of knowledge among the students in each of the analysed country.

COVID-19: long-term effects on the community response to cardiac arrest?

COVID-19: long-term effects on the community response to cardiac arrest?

Serum GFAP and UCH-L1 for the prediction of neurological outcome in comatose cardiac arrest patients

ObjectiveNeurological outcome prediction is crucial early after cardiac arrest. Serum biomarkers released from brain cells after hypoxic-ischaemic injury may aid in outcome prediction. The only serum biomarker presently recommended in the European Resuscitation Council prognostication guidelines is neuron-specific enolase (NSE), but NSE has limitations. In this study, we therefore analyzed the outcome predictive accuracy of the serum biomarkers glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase-L1 (UCH-L1) in patients after cardiac arrest. MethodsSerum GFAP and UCH-L1 were collected at 24, 48 and 72 h after cardiac arrest. The primary outcome was neurological function at 6-month follow-up assessed by the cerebral performance category scale (CPC), dichotomized into good (CPC1-2) and poor (CPC3-5). Prognostic accuracies were tested with receiver-operating characteristics by calculating the area under the receiver-operating curve (AUROC) and compared to the AUROC of NSE. Results717 patients were included in the study. GFAP and UCH-L1 discriminated between good and poor neurological outcome at all time-points when used alone (AUROC GFAP 0.88–0.89; UCH-L1 0.85–0.87) or in combination (AUROC 0.90–0.91). The combined model was superior to GFAP and UCH-L1 separately and NSE (AUROC 0.75–0.85) at all time-points. At specificities ≥95%, the combined model predicted poor outcome with a higher sensitivity than NSE at 24 h and with similar sensitivities at 48 and 72 h. ConclusionGFAP and UCH-L1 predicted poor neurological outcome with high accuracy. Their combination may be of special interest for early prognostication after cardiac arrest where it performed significantly better than the currently recommended biomarker NSE.

Is jugular bulb oximetry monitoring associated with outcome in out of hospital cardiac arrest patients?

Cerebral protection against secondary hypoxic-ischemic brain injury is a key priority area in post-resuscitation intensive care management in survivors of cardiac arrest. Nevertheless, the current understanding of the incidence, diagnosis and its’ impact on neurological outcome remains undetermined. The aim of this study was to evaluate jugular bulb oximetry as a potential monitoring modality to detect the incidences of desaturation episodes during post-cardiac arrest intensive care management and to evaluate their subsequent impact on neurological outcome. We conducted a prospective, observational study in unconscious adult patients admitted to the intensive care unit who had successful resuscitation following out of hospital cardiac arrest of presumed cardiac causes. All the patients were treated as per European Resuscitation Council 2015 guidelines and they received jugular bulb catheter. Jugular bulb oximetry measurements were performed at six hourly intervals. The neurological outcomes were evaluated on 90th day after the cardiac arrest by cerebral performance categories scale. Forty patients met the eligibility criteria. Measurements of jugular venous oxygen saturation were performed for 438 times. Altogether, we found 2 incidences of jugular bulb oxygen saturation less than 50% (2/438; 0.46%), and 4 incidences when it was less than 55% (4/438; 0.91%). The study detected an association between SjVO2 and CO2 (r = 0.26), each 1 kPa increase in CO2 led to an increase in SjvO2 by 3.4% + / − 0.67 (p < 0.0001). There was no association between SjvO2 and PaO2 or SjvO2 and MAP. We observed a statistically significant higher mean SjvO2 (8.82% + / − 2.05, p < 0.0001) in unfavorable outcome group. The episodes of brain hypoxia detected by jugular bulb oxygen saturation were rare during post-resuscitation intensive care management in out of hospital cardiac arrest patients. Therefore, this modality of monitoring may not yield any additional information towards prevention of secondary hypoxic ischemic brain injury in post cardiac arrest survivors. Other factors contributing towards high jugular venous saturation needs to be considered.

High-quality chest compressions are possible during intra-hospital transport, but depend on provider position: A manikin study.

Treatment of reversible causes of cardiac arrest often requires intrahospital transportation during ongoing resuscitation. But high-quality chest compression with minimal interruption is the most essential prerequisite for an optimal outcome after cardiac resuscitation. We aimed to evaluate chest compression quality according to the provider position during intrahospital transportation. Manikin observational study. German Tertiary Care Hospital. A total of 20 paramedics (eight female, 12 male); average professional experience 4.8 ± 3.1 years since their initial enrolment for training. Participants performed chest compressions during simulated intrahospital transportation in four groups: provider kneeling beside manikin on the floor (control group), walking next to the bed (group 1), kneeling on the bed beside the manikin (group 2), kneeling astride the manikin on the bed (group 3). Quality metrics as European Resuscitation Council Guidelines 2015. Subsequently, the participants were asked to assess their own subjective feelings of safety, comfort and strain, and to recommend one position. The quality of chest compression in the control group and groups 2 and 3 did not differ significantly. Group 1 performed significantly worse in terms of the correct hand placement on the chest (P = 0.044 vs. control group) and compression depth (P = 0.004 vs. control group, P = 0.035 vs. group 2, P = 0.006 vs. group 3). Transport speed was faster in groups 2 and 3 vs. group 1 (P < 0.05 vs. group 1, P < 0.05 vs. group 2). The majority of participants rated position 1 as unsafe (90%), unpleasant (100%) and exhausting (100%). They predominantly favoured position 3 (70%). Performing guideline-compliant chest compressions during intra-hospital transportation is feasible with an appropriate provider position. Our results suggest, kneeling beside or astride the patient on the bed enables high-quality chest compressions, faster transport and is perceived by the providers as more pleasant. 'Walking next to the bed' while performing chest compressions should be avoided.

OXYGEN CONCENTRATION DURING PATIENT TRANSPORTATION IN THE AMBULANCE OF THE EMS

European Resuscitation Council Guidelines for Resuscitation 2010 and Advanced Life Support Provider Course teaches that the open oxygen supply must be removed from the patient during defibrillation to the distance of minimum of 1 meter. Scientific articles describe few incidents of fire during defibrillation in oxygen – enriched atmospheres. It was performed a series of measurement of the oxygen concentration in the ambulance vehicle of 10 cubic meters. The measurements were made in parked vehicle. Patient was seated on the stretchers and oxygen was applied with oxygen mask on high flow (15 l per minute). The oxygen concentration was measured on different places in the ambulance car – the patient’s face, on the chest, on the wall in front of the car, on the wall in the rear and on the celling. We measured temperature, atmospheric pressure and humidity together with oxygen concentration. The result of our study showed that the oxygen concentration has risen from 20.9 % at all locations of the ambulance. In certain locations the concentration has increased at least to 30 %. It has prepared recommendations for defibrillation during oxygen administration according to the literature and our study.

Indications, procedure and outcome of prehospital emergency resuscitative thoracotomy-asystematic literature search

Prehospital resuscitative thoracotomy (PHRT) is acontroversially discussed measure for the acute treatment of traumatic cardiac arrest (TCA) recommended by the current guidelines of the European Resuscitation Council (ERC). The aim of this work is the comprehensive presentation and summary of the available literature with the underlying hypothesis that the available publications show the feasibility and survival following PHRT in patients with TCA with a good neurological outcome. Asystematic literature search was performed in the databases PubMed, EMBASE, Google Scholar, Springer LINK and Cochrane. The study selection, data extraction and evaluation of bias potential were performed independently by two authors. The outcome of patients with TCA after PHRT was selected as the primary endpoint. A total of 4616 publications were found of which 21publications with atotal of 287 patients could be included in the analyses. For adetailed descriptive analysis, 15publications with atotal of 205 patients were suitable. The TCA of these patients was most commonly caused by pericardial tamponade, thoracic vascular injuries and severe extrathoracic multiple injuries. In 24% of the cases TCA occurred in the presence of the emergency physician. Clamshell thoracotomy (53%) was used preclinically more often than anterolateral thoracotomy (47%). Of the PHRT patients after TCA 12% (25/205) left the hospital alive, 9% (n = 19/205) with good neurological outcome and 1% (n = 3/205) with poor neurological outcome (according to the Glasgow outcome scale, GOS). The prognosis of TCA seems to be much better than has long been assumed. Decisive for the success of resuscitation efforts in TCA seems to be the immediate, partly invasive treatment of all reversible causes. The measures for TCA recommended by the ERC resuscitation guidelines, seem to be poorly implemented, especially in the preclinical setting. Acontroversy regarding the recommendations of the guidelines is the question of whether aPHRT can be successfully implemented and if the comprehensive introduction in Germany seems to be meaningful. Despite the recommendation of the guidelines, this systematic review and meta-analysis underlines the lack of high-quality evidence on PHRT, whereby asurvival probability to hospital discharge of 12% was reported, of which 75% had a good neurological outcome. The risk of bias of the results in individual publications as well as in this review is high. Further systematic research in the field of preclinical trauma resuscitation is particularly necessary also for acceptance of the guidelines.

Rescue under ongoing CPR from an upper floor: evaluation of three different evacuation routes and mechanical and manual chest compressions: a manikin trial

BackgroundIf transport under ongoing cardiopulmonary resuscitation (CPR) from an upper floor is indicated, the ideal CPR-method and evacuation route is unknown hitherto. We aimed to elaborate a strategy for evacuation of patients under ongoing CPR from an upper floor, comparing three different evacuation routes and manual and mechanical chest compressions.MethodsA CPR-training manikin recording CPR-quality was placed on the fifth floor and was evacuated to an ambulance via lift, turntable ladder, or staircase. Chest compressions were performed manually or with a mechanical CPR-device. Efficiency endpoints were compression depth and frequency, sufficiency of chest release, compared with European Resuscitation Council (ERC) Guidelines, and duration of the evacuation. Adverse outcomes were disconnection/dislocation of devices and hazards/accidents to the personnel.ResultsFor all evacuation routes, compression depth and frequency were significantly more compliant with ERC-guidelines under mechanical CPR. Manual CPR was associated with considerable deviations from correct compression depth and frequency. Chest release only slightly differed between groups. Evacuation via lift under mechanical CPR was fastest and evacuation via turntable ladder under manual CPR was slowest. No device disconnections or accidents occurred, but hazard to personnel was perceived during evacuation via ladder under manual CPR.ConclusionsIn this study, a mechanical CPR-device proved to deliver better CPR-quality during evacuation from an upper floor. If a lift accessible with a stretcher is available, this route should be preferred, regardless of manual or mechanical CPR. Turntable ladders can only be meaningfully used with mechanical CPR, otherwise CPR-quality is poor and hazard to the personnel is increased. Not all evacuation routes may be useable in a specific real-life scenario.Trial registrationGerman Clinical Trials Registry, www.drks.de, registration number DRKS00012885, registration date 17.08.2017.

Survival in Seattle: the Cardiac Arrest Survival Summit

Survival in Seattle: the Cardiac Arrest Survival Summit

Professionalizing peer instructor skills in basic life support training for medical students: A randomized controlled trial

Background:The Radboud university medical center designed an obligatory basic life support and first‐aid course for first‐year medical students.Objectives:We evaluated the value of an additional train‐the‐trainer course following European Resuscitation Council guidelines, which focuses on practical basic life support training and providing feedback, in comparison with standard in‐service instructor training.Methods:This study was a prospective randomized controlled trial. A total of 10 intervention instructors, 14 control instructors, and 337 first‐year medical students participated in the study. Students, blinded for the type of instructor, completed questionnaires evaluating the quality of the basic life support training (theoretical and practical) and provided feedback. The secondary endpoint was the basic life support examination to assess whether the instructors’ training influenced the quality of the participants’ basic life support.Results:The response rate of the questionnaire was 82% on average. No differences were found between intervention and control group concerning theoretical basic life support training. The intervention instructors scored significantly higher on practical basic life support training according to student evaluations (p &lt; 0.001). The pass rate on basic life support examinations did not differ significantly (p = 0.669). Appreciation of given feedback was independent of instructors’ educational training.Conclusion:This study is the first to establish that the 12‐h train‐the‐trainer course following European Resuscitation Council guidelines improves students’ appreciation of practical basic life support training. The additional course did not influence appreciation of theoretical basic life support training or perceived feedback.

A summative assessment of theoretical and practical competencies in BLS-AED-An empirical research methodology to obtain quantitative results

Background and objective: The evaluation in basic life support (BLS) and automated external defibrillator (AED) training courses is mostly formative. The objective of the study was to evaluate a quantitative assessment with an established cut-off level of 7 out of 10.Methods: The course was designed in accordance with the European Resuscitation Council (ERC). For the evaluation a high-fidelity manikin was available (Laerdal® Resusci Anne QCPR). A multiple-choice questionnaire (MCQ) was used to test knowledge, and the practical skills with a high-fidelity manikin.Results: About 68.2% and 34.1% obtained a score greater than 7 in knowledge and skills as evaluated by the nurse educator, immediately after the training. When the skills illustrated by the manikin were included, the results fell to 11.4% and 2.3%, respectively.Conclusions: A summative assessment of theoretical and practical competencies with a cut-off level of 7 demonstrates that global competency in BLS-AED is not achieved and some other strategies should be introduced in the current courses.

Preporuke Resuscitacionog saveta Srbije za primenu mera resuscitacije tokom COVID-19 pandemije

The COVID-19 pandemic is caused by a virus where we have lack of knowledge about. This new situation led to the need to provide high-quality resuscitation to all patients with COVID-19 infection, but also with highest-quality and most appropriate personal protection for all medical professionals with the risk from the infection. Within our program activities, the Serbian Resuscitation Council, as lead professional organization, made efforts focused in creating and implementing recommendations related to cardiopulmonary resuscitation (CPR) under the COVID-19 pandemic. These recommendations are applicable for treatments and procedures during CPR, ethical issues, and CPR training conduction at COVID-19 pandemic, in collaboration with the European Resuscitation Council and other partner organizations, which are part of the network of national councils for resuscitation medicine in Europe. In the forthcoming period of time, these recommendations might be a subject of modification to be inline with more deeper and wider knowledge, based on scientific researches, about the SARS-COV-2, and it will be reviewed and updated on regular base.

ACLS protocol for Acute Coronary Syndrome

Background:- The American Heart Association (AHA) and European Resuscitation Council (ERC) developed the most recent ACLS Guidelines in 2010 using the comprehensive review of resuscitation literature performed by the International Liaison Committee on Resuscitation (ILCOR), and these were updated in 2015 and 2018. Acute coronary syndrome (ACS) refers to a spectrum of clinical presentations ranging from those for ST-segment elevation myocardial infarction (STEMI) to presentations found in non– ST-segment elevation myocardial infarction (NSTEMI) or in unstable angina. Aim of the study: impart both cognitive knowledge and psychomotor skills of ACLS to provide a standardized care in cardiac arrest victims by accordance of the specific guidelines. Conclusion: Practitioner’s experts would apply the ACLS protocol for cardiac arrest, and once the patient’s return of spontaneous circulation Restore (ROSC). However, we will start post-cardiac arrest care along with the treatment of ACS algorithm.

Implementacja wytycznych Europejskiej Rady Resuscytacji – pomiar temperatury głębokiej w zespołach ratownictwa medycznego w Europie

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Podsiadło P, Darocha T, Kosiński S, Sanak T, Cebula G, Gałązkowski R. Implementation of European Resuscitation Council guidelines: measurement of core body temperature in Emergency Medical Services in Europe. Medical Studies/Studia Medyczne. 2020;36(1):14-17. doi:10.5114/ms.2020.94083. APA Podsiadło, P., Darocha, T., Kosiński, S., Sanak, T., Cebula, G., & Gałązkowski, R. (2020). Implementation of European Resuscitation Council guidelines: measurement of core body temperature in Emergency Medical Services in Europe. Medical Studies/Studia Medyczne, 36(1), 14-17. https://doi.org/10.5114/ms.2020.94083 Chicago Podsiadło, Paweł, Tomasz Darocha, Sylweriusz Kosiński, Tomasz Sanak, Grzegorz Cebula, and Robert Gałązkowski. 2020. "Implementation of European Resuscitation Council guidelines: measurement of core body temperature in Emergency Medical Services in Europe". Medical Studies/Studia Medyczne 36 (1): 14-17. doi:10.5114/ms.2020.94083. Harvard Podsiadło, P., Darocha, T., Kosiński, S., Sanak, T., Cebula, G., and Gałązkowski, R. (2020). Implementation of European Resuscitation Council guidelines: measurement of core body temperature in Emergency Medical Services in Europe. Medical Studies/Studia Medyczne, 36(1), pp.14-17. https://doi.org/10.5114/ms.2020.94083 MLA Podsiadło, Paweł et al. "Implementation of European Resuscitation Council guidelines: measurement of core body temperature in Emergency Medical Services in Europe." Medical Studies/Studia Medyczne, vol. 36, no. 1, 2020, pp. 14-17. doi:10.5114/ms.2020.94083. Vancouver Podsiadło P, Darocha T, Kosiński S, Sanak T, Cebula G, Gałązkowski R. Implementation of European Resuscitation Council guidelines: measurement of core body temperature in Emergency Medical Services in Europe. Medical Studies/Studia Medyczne. 2020;36(1):14-17. doi:10.5114/ms.2020.94083.

Dispečerom vođena resuscitacija - EuReCa_Srbija 2014-2019

Background: There are studies that indicate that dispatcher-guided CPR increases survival in Out-Of-Hospital cardiac arrest (OHCA). In this study, we observed the role of dispatcher lead CPR in OHCA and determined it's influence on return of spontaneous circulation and survival. Method: Data have been collected throughout 2014-2019 EuReCa_Serbia program that have been part of Prospective observational trial of the European Resuscitation Council registered in the trial database - NCT02236819. The association between bystander CPR, and ROSC was determined using Binary Logistic Regression. Statistical significance was determined at the level of p <0.05. Results: The collected results were obtained from 40/179 municipalities, 48.7% of the population in Serbia. In the observed period 6312 OHCA were registered. A witness was present in 3655/6312 (57,91%) patients. Witness-CPR was performed in 365/3655 (9,99%) events, dispatch CPR was applied in 197/365 (53,9%) cases. The calculated chance for the ROSC is 1,2 higher when the dispatcher was leading the CPR compared to cases where the witness-CPR was performed without dispatchers assistance (OR = 1,128; 95%CI = 0,685-1,913). Conclusion: In observed data of the National OHCA Registry Serbia, the results indicate that the outcome was insignificantly improved compared to ROSC and survival rate when dispatch-lead-CPR was performed. There is no specific dispatcher education program in Serbia and that fact should be investigate in purpose of further results and activities.

Cardiopulmonary resuscitation of neonate at delivery room

Improving the cardiopulmonary resuscitation quality in the delivery room is one of the most pressing issues in modern neonatology. Despite the fact that in recent years the number of surviving infants with low and extremely low birth weight has been steadily increasing, the nursing outcome is not enough favourable with unsatisfying quality of life. The cardiopulmonary resuscitation protocols have been regularly updated and upgraded (every five years in the last twenty years). This helps to improve resuscitation outcome. In 2015 the American Heart Association and the European Resuscitation Council issued the new edition of the guidelines on basic and advanced cardiopulmonary resuscitation in children, including infants. The guidelines are believed to improve the quality of resuscitation care in the delivery room and to contribute to a better neurological outcome.

Abstract 139: Does Simplification of Guidelines Improve Retention of BLS Skills 3 Months After Training?

Background: The European Resuscitation Council (ERC) 2015 basic life support (BLS) guidelines introduced a simplified algorithm compared to the ERC 2010 BLS guidelines. This was intended to improve adherence to guidelines and retention of skills. This study aimed to compare the retention of BLS skills 3 months after training using the ERC 2010 or 2015 guidelines. Methods: This was an observational study including video recordings of laypersons being skill tested 3 months after participation in a standardized ERC BLS/AED course using either the ERC 2010 guidelines or the simplified ERC 2015 guidelines. The endpoints were 1) remembering the correct sequence of BLS/AED algorithm, 2) remembering the correct sequence of the BLS/AED algorithm and performing all skills correctly, 3) time to: emergency medical service (EMS) call, first compression, and shock delivery. Results: We analyzed videos of 133 laypersons skill tested 3 months after initial training; 64 trained using the 2010 guidelines (mean ±standard deviation (SD) age: 40 ±11 years, male sex: 19 (30%)) and 69 trained using the 2015 guidelines (age: 44 ±10 years, male sex: 36 (52%)). Participants in the 2015 guidelines group improved the retention of the BLS/AED algorithm compared to the 2010 guidelines group (29 (42%) vs. 10 (16%), relative risk (RR): 2.7 (95% confidence interval (CI): 1.4 - 5.1) P=0.001). Both BLS/AED algorithm and all skills were correctly performed by 13 (19%) vs. 3 (5%) (RR: 4.0 (95% CI: 1.2 - 13.5) P=0.01) in the 2015 and 2010 groups respectively. No significant difference was found in time to EMS call (difference: 3 sec (95% CI: -2 - 9 sec) P=0.27), time to first compression (difference: 4 sec, (95% CI: -3 - 10 sec) P=0.28), and time to first shock (difference: 4 sec (95% CI: -5 - 14 sec) P=0.33) between the groups. Conclusion: BLS/AED training using ERC 2015 guidelines was associated with better skill retention compared to training using ERC 2010 guidelines. There was no difference in time to EMS call, first compression, or shock delivery.

Abstract 101: Effect of Extracorporeal Membrane Oxygenation for Accidental Hypothermia With Absent Vital Signs: A Nationwide Observational Study

Introduction: Patients with accidental hypothermia and absent vital signs are increasingly receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, there is limited knowledge on the efficacy of this advanced rewarming method. Despite the limited evidence, the resuscitation guidelines from the European Resuscitation Council and the American Heart Association both recommended the use of extracorporeal life support in patients with accidental hypothermia and absent vital signs. Hypothesis: We hypothesized that VA-ECMO is associated with lower in-hospital mortality compared with cardiopulmonary resuscitation (CPR) only in patients with accidental hypothermia and absent vital signs. Methods: Using the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2017, we identified patients diagnosed with accidental hypothermia (International Classification of Diseases Tenth Revision code T68) who received closed-chest cardiac massage in hospital on admission day. Patients who received VA-ECMO on admission day were allocated to the VA-ECMO group, and those who received CPR only were allocated to the conventional CPR group. The primary outcome was in-hospital mortality. The secondary outcome was alert consciousness for Japan Coma Scale status at discharge. Propensity score analyses were performed to compare the outcomes between the two groups. Results: We identified 1,624 eligible patients during the 81-month study period. Of these, 19% (314 of 1,624) received VA-ECMO on admission day. Crude in-hospital mortality was 65.3% (205 of 314) and 84.1% (1,102 of 1,310) in the VA-ECMO and conventional CPR groups, respectively. Propensity score-matching analyses demonstrated significantly lower in-hospital mortality (risk difference, –14.1%; 95% confidence interval, –21.9% to –6.3%) and higher proportion of alert consciousness at discharge (risk difference, 8.5%; 95% confidence interval, 2.1% to 15.0%) in the VA-ECMO group compared with the conventional CPR group. Conclusions: VA-ECMO was significantly associated with decreased in-hospital mortality and favorable neurologic outcome compared with conventional CPR in patients with accidental hypothermia and absent vital signs.

Abstract 376: Confounders of Early Processed EEG to Stratify Neurological Injury After Cardiac Arrest

Introduction: Electroencephalographic suppression ratio (SR) measured six hours after resuscitation from cardiac arrest (SR6) can stratify risk of neurological-etiology death (NED) after cardiac arrest. Confounders of this tool for risk stratification have not been described. Hypothesis: Misclassification of risk of NED by SR6 is explained by characteristics of the patient, arrest, or treatment. Methods: Comatose patients prospectively enrolled in an IRB-approved cardiac arrest database were treated by protocol. Patients with brain death or death after withdrawal of life support measures (WLST) due to poor neurological prognosis were considered NED; neuroprognostication follows European Resuscitation Council guidelines. We analyzed patients misclassified by the SR6; high SR that did not suffer NED, or low SR6 that had NED. We reviewed factors associated with misclassification in bivariate analysis, and performed chart review for potential confounders of SR6. Results: Among 364 patients resuscitated from cardiac arrest and with complete data, SR6 predicted NED with AUC 0.89, and an optimal cutoff value of 55.5%. Forty (11%) patients with high SR6 and 17 (5%) with low SR6 were misclassified. In bivariate analysis, factors associated with high SR misclassification were older age 62.6(±14.9) vs. 56.4 (±16) p=0.02, prior neuropathology [20% vs 9.1%, p=0.049], and longer no-flow time (7 [4-9] vs 5 [2-7] minutes, p=0.01). Those associated with low SR misclassification were heart failure [29.4% vs 11.4%, p=0.045] hypertension [82.4% vs 44.6%, P=0.003], obesity [29.4% vs 10.7%, p=0.04], seizures [47.1% vs 21.5%, p=0.03], and higher BMI 33.9 [26.5-36.1] vs 27.8 [23.7-31.3], p=0.04. In chart review, misclassification was associated with early WLST due to family preference, drug or alcohol overdose, seizures, death due to non-neurological cause, preexisting neurological disease, and “favorable” SR6 trajectory. Conclusion: Age, seizures, drug overdose, and non-neurological causes of death may confound accurate neurological risk stratification using processed EEG very early after cardiac arrest. In addition to these “fixed” confounders, a few patients have dynamic SR that improves after 6 hours, and deserve further study.