Favorable Neurological Function Research Articles

Door-to-Needle Time for Extracorporeal Cardiopulmonary Resuscitation and Neurological Outcomes in Out-of-Hospital Cardiac Arrest: A Nationwide Study.

Extracorporeal cardiopulmonary resuscitation (ECPR) is an option for refractory cardiac arrest, and immediate initiation after indication is recommended. However, the practical goals of ECPR preparation (such as the door-to-needle time) remain unclear. This study aimed to elucidate the association between the door-to-needle time and neurological outcomes of out-of-hospital cardiac arrest. This is a post hoc analysis of a nationwide multicenter study on out-of-hospital cardiac arrest treated with ECPR at 36 institutions between 2013 and 2018 (SAVE-J [Study of Advanced Cardiac Life Support for Ventricular Fibrillation with Extracorporeal Circulation in Japan] II study). Adult patients without hypothermia (≥32 °C) in whom circulation was not returned at ECPR initiation were included. The probability of favorable neurological function at 30 days (defined as Cerebral Performance Category ≤2) was estimated using a generalized estimating equations model, in which institutional, patient, and treatment characteristics were adjusted. Estimated probabilities were then calculated according to the door-to-needle time with 3-minute increments, and a clinical threshold was assumed. Among 1298 patients eligible for this study, 136 (10.6%) had favorable neurological function. The estimated probability of favorable outcomes was highest in patients with 1 to 3 minutes of door-to-needle time (12.9% [11.4%-14.3%]) and remained at 9% to 10% until 27 to 30 minutes. Then, the probability dropped gradually with each 3-minute delay. A 30-minute threshold was assumed, and shorter door-to-extracorporeal membrane oxygenation/low-flow time and fewer adverse events related to cannulation were observed in patients with door-to-needle time <30 minutes. The probability of favorable functions after out-of-hospital cardiac arrest decreased as the door-to-needle time for ECPR was prolonged, with a rapid decline after 27 to 30 minutes. URL: https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000041577; Unique identifier: UMIN000036490.

Early intramuscular adrenaline administration is associated with improved survival from out-of-hospital cardiac arrest

BackgroundEarly administration of adrenaline is associated with improved survival after out-of-hospital cardiac arrest (OHCA). Delays in vascular access may impact the timely delivery of adrenaline. Novel methods for administering adrenaline before vascular access may enhance survival. The objective of this study was to determine whether an initial intramuscular (IM) adrenaline dose followed by standard IV/IO adrenaline is associated with improved survival after OHCA. Methods Study DesignWe conducted a before-and-after study of the implementation of an early, first-dose IM adrenaline EMS protocol for adult OHCAs. The pre-intervention period took place between January 2010 and October 2019. The post-intervention period was between November 2019 and May 2024. SettingSingle-center urban, two-tiered EMS agency. ParticipantsAdult, nontraumatic OHCA meeting criteria for adrenaline use. InterventionSingle dose (5 mg) IM adrenaline. All other care, including subsequent IV or IO adrenaline, followed international guidelines. Main Outcomes and MeasuresThe primary outcome was survival to hospital discharge. Secondary outcomes were time from EMS arrival to the first dose of adrenaline, survival to hospital admission, and favorable neurologic function at discharge. ResultsAmong 1405 OHCAs, 420 (29.9%) received IM adrenaline and 985 (70.1%) received usual care. Fifty-two patients received the first dose of adrenaline through the IV or IO route within the post-intervention period and were included in the standard care group analysis. Age was younger and bystander CPR was higher in the IM adrenaline group. All other characteristics were similar between IM and standard care cohorts. Time to adrenaline administration was faster for the IM cohort [(median 4.3 min (IQR 3.0–6.0) vs. 7.8 min (IQR 5.8–10.4)]. Compared with standard care, IM adrenaline was associated with improved survival to hospital admission (37.1% vs. 31.6%; aOR 1.37, 95% CI 1.06–1.77), hospital survival (11.0% vs 7.0%; aOR 1.73, 95% CI 1.10–2.71) and favorable neurologic status at hospital discharge (9.8% vs 6.2%; aOR 1.72, 95% CI 1.07–2.76). ConclusionIn this single-center before-and-after implementation study, an initial IM dose of adrenaline as an adjunct to standard care was associated with improved survival to hospital admission, survival to hospital discharge, and functional survival. A randomized controlled trial is needed to fully assess the potential benefit of IM adrenaline delivery in OHCA.

Epidemiology and outcome of out-of-hospital cardiac arrest in Salt Lake City: Sex-based investigations.

Prior research indicates sex disparities in the incidence and outcomes of out-of-hospital cardiac arrest (OHCA). This study investigates the presence of such differences in Salt Lake City, Utah. We analyzed data from the Salt Lake City Fire Department (2008‒2023). We included adults with non-traumatic OHCA. We calculated the annual incidence of OHCA and examined sex-specific survival outcomes using multivariable logistic regression, adjusting for OHCA characteristics known to be associated with survival. The annual incidence of OHCA was 76 per 100,000 person-years. Among the 894 OHCA cases included in the analysis, 67.5% were males, 37.3% achieved return of spontaneous circulation (ROSC), and 13.6% survived hospital discharge. Unadjusted analysis revealed that males had significantly higher OHCA in public locations (43.9%vs. 28.6%), witnessed arrests (54.5%vs. 47.8%), and shockable rhythms (33.3%vs. 22.9%). Males also showed higher rates of ROSC (37.5%vs. 36.9%), hospital discharge survival (14.5%vs. 11.7%), and neurologically intact survival. After adjusting for the OHCA characteristics, there was no significant differences between males and females in ROSC, survival to hospital discharge, and favorable neurological function with adjusted odds ratios (male vs. female) of 0.92 (95% confidence interval [CI] 0.73‒1.16), 0.85 (95% CI 0.59‒1.22), and 0.92 (95% CI 0.62‒1.40), respectively. Approximately, 128 adults suffer OHCA in Salt Lake City annually. Males initially showed higher crude survival rates, but after adjusting for OHCA characteristics, no significant sex differences in survival outcomes were found. Enhancing OHCA characteristics could benefit both sexes. Investigations into the relationship between sex- and region-specific factors influencing OHCA outcomes are needed.

Analysis of the factors influencing prognosis of the adult in-hospital cardiac arrest

To explore the factors influencing prognosis of patients with in-hospital cardiac arrest (IHCA). A retrospective observational study was conducted. The clinical data of patients who developed IHCA and underwent cardiopulmonary resuscitation (CPR) at the Second Xiangya Hospital of Central South University from January 1, 2016, to December 31, 2022 were analyzed. The patients' information, including gender, age, medical history, pre-cardiac arrest related parameters [1-hour pre-cardiac arrest neurological function, 24-hour pre-cardiac arrest hemoglobin (Hb) levels, 1-hour pre-cardiac arrest vital signs], initial CPR-related factors (implementation time and location, initial rhythm, ventilation method, defibrillation and resuscitation drugs) as well as restoration of spontaneous circulation (ROSC) related parameters (vital signs at ROSC and 1 hour after ROSC, 24-hour post-cardiac arrest Hb, and IHCA events), were collected through the hospital's electronic medical record system. The clinical data were compared between ROSC and non-ROSC patients as well as between patients with favorable neurological function [cerebral performance category (CPC) grades 1-2] and unfavorable neurological function (CPC grades 3-5) at 28 days. The factors with statistical significance in univariate analysis and clinical significance were enrolled in a binary multivariate Logistic regression model to analyze the influencing factors of ROSC and neurological function at 28 days after ROSC. The predictive value of factors influencing neurological function at 28 days was assessed using receiver operator characteristic curve (ROC curve). A total of 277 IHCA-CPR patients were enrolled, of which 230 achieved ROSC (83.0%) and 47 were not achieved (17.0%). Compared with non-ROSC patients, ROSC patients had lower prevalence of cerebrovascular disease history and proportion of adrenaline usage, but a higher proportion of initial shockable rhythms. In the multivariate Logistic regression analysis, it was found that using a bag-mask ventilation+endotracheal intubation (compared with a bag-mask ventilation alone) was beneficial for achieving ROSC in IHCA-CPR patients [odds ratio (OR) = 2.895, 95% confidence interval (95%CI) was 1.204-6.962, P = 0.018], while a initial non-shockable rhythm was not conducive to achieving ROSC in IHCA-CPR patients (OR = 0.349, 95%CI was 0.147-0.831, P = 0.017). Among the 230 ROSC patients, 42 had good neurological function at 28 days (18.3%), and 188 had poor neurological function (81.7%). Compared with the patients with good neurological function, the patients with the poor neurological function were older and had a higher prevalence of 1-hour pre-cardiac arrest neurological dysfunction and low perfusion, initial non-shockable rhythms, endotracheal intubation, and usage of adrenaline, vasopressors and sodium bicarbonate, a lower proportion of defibrillation and antiarrhythmic medication usage as well as lower 24-hour post-cardiac arrest Hb levels. The multivariate Logistic regression analysis revealed that female (OR = 6.449, 95%CI was 1.837-22.642, P = 0.004), older age (OR = 1.054, 95%CI was 1.017-1.093, P = 0.004), 1-hour pre-cardiac arrest neurological dysfunction (OR = 25.044, 95%CI was 2.737-229.169, P = 0.004), 1-hour pre-cardiac arrest low perfusion (OR = 3.880, 95%CI was 1.306-11.524, P = 0.028), endotracheal intubation (compared with a bag-mask ventilation; OR = 8.712, 95%CI was 1.402-54.141, P = 0.020) and face mask+endotracheal intubation during CPR (compared with a bag-mask ventilation; OR = 11.089, 95%CI was 3.482-35.320, P = 0.000), IHCA events > 1 time (OR = 4.221, 95%CI was 1.249-14.226, P = 0.020) were positively associated with poor neurological function at 28 days, which were independent risk factors those were not conducive to 28-day neurological function recovery after ROSC in IHCA-CPR patients. In contrast, usage of antiarrhythmic medication (OR = 0.345, 95%CI was 0.134-0.890, P = 0.028) and 24-hour post-cardiac arrest Hb (OR = 0.983, 95%CI was 0.966-0.999, P = 0.043) were negatively associated with poor neurological function at 28 days, which were protective factors those were beneficial for the recovery of neurological function. ROC curve analysis showed that the area under the ROC curve (AUC) of 24-hour post-cardiac arrest Hb for predicting poor neurological function at 28 days after ROSC in IHCA-CPR patients was 0.659 (95%CI was 0.577-0.742), with a cut-off value of 99.5 g/L (sensitivity was 76.2%, specificity was 57.8%). Defibrillation and tracheal intubation during CPR are crucial for IHCA patients. It was also observed that patients with low Hb (< 99.5 g/L should be of high concern), older age, 1-hour pre-cardiac arrest neurological function and hypoperfusion, and IHCA events > 1 time were significantly related to unfavorable neurological outcome in adult resuscitated patients with IHCA.

The association of regional cerebral oximetry and neurologically intact survival in a porcine model of cardiac arrest

BackgroundThe objective of this study was to determine if regional cerebral oximetry (rSO2) assessed during CPR would be predictive of survival with favorable neurological function in a prolonged model of porcine cardiac arrest. This study also examined the relative predictive value of rSO2 and end-tidal carbon dioxide (ETCO2), separately and together. MethodsThis study is a post-hoc analysis of data from a previously published study that compared conventional CPR (C-CPR) and automated head-up positioning CPR (AHUP-CPR). Following 10 min of untreated ventricular fibrillation, 14 pigs were treated with either C-CPR (C-CPR) or AHUP-CPR. rSO2, ETCO2, and other hemodynamic parameters were measured continuously. Pigs were defibrillated after 19 min of CPR. Neurological function was assessed 24 h later. ResultsThere were 7 pigs in the neurologically intact group and 7 pigs in the poor outcomes group. Within 6 min of starting CPR, the mean difference in rSO2 by 95% confidence intervals between the groups became statistically significant (p < 0.05). The receiver operating curve for rSO2 to predict survival with favorable neurological function reached a maximal area under the curve value after 6 min of CPR (1.0). The correlation coefficient between rSO2 and ETCO2 during CPR increased towards 1.0 over time. The combined predictive value of both parameters was similar to either parameter alone. ConclusionSignificantly higher rSO2 values were observed within less than 6 min after starting CPR in the pigs that survived versus those that died. rSO2 values were highly predictive of survival with favorable neurological function.

Abstract 385: Comparison of Rapid Implementation of Automated Head and Thorax Elevation With Active Compression Decompression Cardiopulmonary Resuscitation and an Impedance Threshold Device versus National Outcome Data: A Prospective Observational Study

Background: Pre-clinical work has shown automated head and thorax elevation with active compression decompression CPR and an impedance threshold device (AHUP-CPR) improved 24-hour neurological survival. Propensity matched studies of out-of-hospital-cardiac arrest (OHCA) patients have shown a time dependent association between survival to hospital discharge (SHD) and application of AHUP CPR.Hypothesis: Rapid application of AHUP CPR for OHCA will have a higher incidence of SHD compared to national data. Methods: This is an ongoing prospective observational study of patients from an AHUP-CPR registry of non-traumatic adult OHCA receiving AHUP CPR as part of first responder care. OHCA patients from pre-hospital sites that consistently implemented rapid AHUP CPR were included. Patient demographics, arrest characteristics, ROSC, SHD, and SHD with favorable neurological function, defined as a Cerebral Performance Category score of 1 or 2, were recorded. Data are reported as means ± SD. Combined 2021 and 2022 data from the Cardiac Arrest Registry to Enhance Survival (CARES) were used for comparison of the primary study endpoint, SHD, and secondary endpoints. Chi-square testing was used to compare outcomes. Results: Of 11 registry sites, 7 (US States AL, FL, IL, MN, OK, TN, VA) met inclusion criteria and 1457 patients from January 2020 to June 2023 were enrolled. Average age was 65 ± 16.4 years, 61.8% (901) were male, and 71% (1035) received AHUP CPR. Average time (mm:ss) from 9-1-1 call to start of CPR was 9:52 (6:47) and time to start of AHUP CPR was 12:59 (5:51). Presenting rhythms were: asystole 47.8% (696), PEA 25.8% (376), and VF 20.5% (298). For all AHUP patients, SHD was 13.6% (198) versus 9.2% (26316/286525) for CARES (p &lt; 0.0001). SHD with favorable neurological function was higher for AHUP (10.3% (150) versus 7.3% for CARES (20889), p &lt; 0.0001) and ROSC (29.4% (428) vs 27.0% (77301), p = 0.039). Conclusions: In an unadjusted analysis, the incidence of SHD, ROSC, and neurologically favorable SHD with rapid implementation of AHUP-CPR was higher than nationally reported data. These results support prior findings of a time sensitive association between survival and time to AHUP-CPR. Additional analyses and study are needed for confirmation.

Abstract 107: Accelerated Intramuscular Epinephrine and Survival in Adult, Non-Traumatic Out-of-Hospital Cardiac Arrest: A Before-After Study

Introduction: Survival after out-of-hospital cardiac arrest is poor. Treatment with early epinephrine is associated with improved survival but delays in vascular access may impact its timely delivery. Outcomes may be improved by novel methods to administer epinephrine prior to vascular access. We previously established that intramuscular epinephrine reduced time from 911 call to drug administration. Aim: To determine whether accelerated intramuscular epinephrine (IM-Epi) is associated with improved OHCA survival compared with standard IV/IO epinephrine. Methods: We conducted a before-after analysis of the implementation of an IM-Epi EMS protocol. We included adult OHCAs treated by the Salt Lake City Fire Department. Interventions were: pre-IM Epi (Jan 2010-Nov 2019), standard care IV or IO epinephrine; post-IM Epi (Dec 2019-Mar 2023), a single dose of 5 mg IM epinephrine prior to the initiation of IV/IO access. All other care followed standard ACLS, including additional dosing of epinephrine via IV/IO. Using multivariable logistic regression, we determined the association between IM-Epi and hospital survival, ROSC, and good neurologic function adjusted for Utstein variables. Results: Among 1,283 OHCAs, 307 (23.9%) received IM-Epi and 976 (76.1%) received usual care. Groups had similar sex, witnessed arrest, arrest location, initial rhythm, and response time, but younger age (57.3 vs. 59.5 years old; p=0.05) and higher bystander CPR (68.3% vs. 56.0%; &lt;0.001) in the IM-Epi group. Time to epinephrine administration was faster for the IM-Epi group (12.0 vs. 15.3 min; &lt;0.001). IM-Epi was associated with improved hospital survival (adjusted OR, 1.87; 95% CI, 1.12-3.10) and good neurologic outcome at discharge (adjusted OR, 1.76; 95% CI 1.02-3.01). IM-Epi first was not associated with differential rates of ROSC (adjusted OR, 1.02; 95% CI, 0.78-1.35) when compared to standard IV/IO first administration. Conclusion: In this before-and-after analysis, IM-Epi was associated with increased survival to hospital discharge and favorable neurologic function compared to standard care IV and IO epinephrine. Prospective randomized trials are needed to determine whether the observed effects of IM-Epi in OHCA improves outcomes.

The Impact of Prehospital and Hospital Care on Clinical Outcomes in Out-of-Hospital Cardiac Arrest.

Background: In recent years, several actions have been made to shorten the chain of survival in out-of-hospital cardiac arrest (OHCA). These include placing defibrillators in public places, training first responders, and providing dispatcher-assisted CPR (DA-CPR). In this work, we aimed to evaluate the impact of these changes on patients' outcomes, including achieving return of spontaneous circulation (ROSC), survival to discharge, and survival with favorable neurological function. Methods: We retrospectively retrieved data of all calls to the national emergency medical service in Ashdod city, Israel, of individuals who underwent OHCA at the age of 18 and older between the years 2018 and 2021. Data was collected on prehospital and hospital interventions. The association between pre-hospital and hospital interventions to ROSC, survival to discharge, and neurological outcomes was evaluated. Logistic regression was used for multivariable analysis. Results: During the years 2018-2021, there were 1253 OHCA cases in the city of Ashdod. ROSC was achieved in 207 cases (32%), survival to discharge was attained in 48 cases (7.4%), and survival with favorable neurological function was obtained in 26 cases (4%). Factors significantly associated with good prognosis were shockable rhythm, witnessed arrest, DA-CPR, use of AED, and treatment for STEMI. All patients that failed to achieve ROSC outside of the hospital setting had a poor prognosis. Conclusions: This study demonstrates the prognostic role of the initial rhythm and the use of AED in OHCA. Hospital management, including STEMI documentation and catheterization, was also an important prognostication factors. Additionally, when ROSC is not achieved in the field, hospital transfer should be considered.

Abstract 234: Increased Likelihood Of Survival For Patients Presenting With Non-shockable Cardiac Arrest And Treated With A Device-assisted Head-up CPR Bundle

Introduction: Despite receiving conventional (C) CPR and other standard treatments, almost all out-of-hospital cardiac arrest (OHCA) patients with non-shockable presentations will still die. As non-shockable presentations comprise nearly 80% of all OHCA cases, alternative treatment strategies are clearly indicated. Hypothesis: Compared to C-CPR controls, treatment with AHUP CPR (defined as the combination of an automated head up positioning [AHUP] device, an impedance threshold device [ITD], and manual and/or automated suction cup-based CPR), increases the probability of survival (SURV) to hospital discharge as well as neurologically favorable survival (N-SURV) for OHCA patients with (first recorded) non-shockable presentations. Methods: Prospectively collected data were obtained from a national AHUP CPR registry from 5 early adopting first responder EMS agencies that routinely initiated immediate AHUP CPR and tracked OHCA outcomes. Comparisons were made to C-CPR controls using individual patient data from high-performing prehospital systems participating in the NIH-funded Resuscitation Outcomes Consortium ROC-PRIMED and ResQTrial studies. AHUP and C-CPR patients presenting with a non-shockable rhythm were matched for the same discrete time interval from the 9-1-1 call to EMS CPR start time and propensity score for the key baseline covariables associated with outcome (e.g., age, sex, bystander-witnessed, bystander CPR) with a 1:1 ratio. Neuro-intact survival was defined as a modified Rankin Scale &lt; 3 or Cerebral Performance Category 1 or 2. Results: AHUP CPR treatment in non-shockable rhythm cases (n=380) was associated with increased unadjusted SURV rates of 7.4% vs 3.1% for C-CPR controls (1,852): Odds ratios (OR) and 95% confidence intervals [CI] = 2.46 [1.33-3.92]. After propensity matching, AHUP CPR was associated with increased SURV and N-SURV vs C-CPR controls: OR[CI] were 2.84[1.35-5.96] and 3.87[1.27-11.78], respectively. Also, the faster AHUP was initiated, the greater the benefit. Conclusions: This analysis provides strong clinical evidence of higher likelihood of survival, including favorable neurological function, for the vast majority of OHCA patients who present with a non-shockable rhythm by using AHUP CPR.

Comparison of in-hospital outcomes of acute myocardial infarction between patients with cardiogenic shock and with cardiac arrest.

In-hospital mortality of acute myocardial infarction (AMI) complicated with cardiogenic shock (CS) remains high. Also, in-hospital mortality of AMI complicated with cardiac arrest (CA) has been reported to be highest among any AMI. However, there were few reports that compared in-hospital mortality directly between AMI complicated with CS and complicated with CA. The purpose of this study was to compare in-hospital outcomes between AMI complicated with CS and complicated with CA. We retrospectively included 195 AMI patients complicated by CS or CA, and divided those into the CA group (n = 109) and the CS group (n = 86). We also subdivided the CA group into CA with persistent CS (n = 83) and CA without persistent CS (n = 26). One-third of the study population died during the index admission. In-hospital death was more frequently observed in the CA group (45.0%) than in the CS group (20.9%) (p < 0.001). In-hospital mortality was highest in the CA with persistent CS group (68.7%), followed by the CS group (20.9%), and least in the CA without persistent CS group (11.5%) (p < 0.001). Favorable neurological function was more frequently observed in the CA without persistent CS group (76.9%) and the CS group (74.4%) than in the CA with persistent CS group (27.7%) (p < 0.001). In conclusion, in-hospital mortality was higher in AMI patients with CA than in those with CS. However, when we divided AMI patients with CA into those with and without persistent CS, in-hospital mortality was lowest in CA without persistent CS, followed by CS, and highest in CA with persistent CS.

How effective is extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest? A systematic review and meta-analysis.

Extracorporeal cardiopulmonary resuscitation (ECPR) has gained increasing as a promising but resource-intensive intervention for out-of-hospital cardiac arrest (OHCA). There is little data to quantify the impact of this intervention and the patients likely to benefit from its use. We conducted a meta-analysis of the literature to assess the survival benefit associated with ECPR for OHCA. We searched PubMed, Embase, and Scopus databases to identify relevant observational studies and randomized control trials. We used the Newcastle-Ottawa Scale and Cochrane risk-of-bias tool to assess studies' quality. We performed random-effects meta-analysis for the primary outcome of survival to hospital discharge and used meta-regressions to assess heterogeneity. We identified 1287 articles, reviewed the full text of 209 and included 44 in our meta-analysis. Our analysis included 3097 patients with OHCA. Patients' mean age was 52, 79% were male, and 60% had primary ventricular fibrillation/ventricular tachycardia arrest. We identified a survival-to-discharge rate of 24%; 18% survived with favorable neurologic function. 30- and 90-days survival rates were both around 18%. The majority of included articles were high quality studies. Extracorporeal cardiopulmonary resuscitation is a promising but resource-intensive intervention that may increase rates of survival to hospital discharge among patients who experience OHCA.

EMS agencies with high rates of field termination of resuscitation and longer scene times also have high rates of survival

AimOut-of-hospital cardiac arrest (OOHCA) management dichotomizes strategies to (1) “scoop-and-run” to a higher level of care or (2) “treat on the X” with the goal of return of spontaneous circulation (ROSC) before transport, with field termination of resuscitation (FTOR) of unsuccessful resuscitations. We hypothesized that EMS agencies with greater average time on-scene and higher rates of field termination of resuscitation would have more favorable outcomes. MethodsThe Cardiac Arrest Registry to Enhance Survival (CARES) was used to identify OOHCA cases from 2013 to 2018. Agencies in the top and bottom quartiles of on-scene time were categorized as high (HiOST) and low (LoOST); in the top and bottom quartiles of field termination rate were categorized as high (HiTOR) and low (LoTOR). Generalized estimating equation models compared top and bottom quartiles. ResultsWe classified 95 agencies as HiOST (average > 25.1 min) or LoOST (average < 19.3 min). We classified 95 agencies as HiTOR (average > 46.5% FTOR) or LoTOR (average < 23.5% FTOR). Controlling for agency characteristics, HiOST had a higher survival to discharge for transported patients (28.1% vs 23.1%, OR = 2.8, 95 %CI 2.1–3.6, p < 0.001), ROSC on emergency department arrival, and favorable neurologic outcome than LoOST. HiTOR had a higher survival to discharge for transported patients (25.6% vs 19.3%, OR = 3.3, 95 %CI 2.5–4.4, p < 0.001), ROSC on emergency department arrival, and favorable neurologic outcome than LoTOR. ConclusionEMS agencies with higher rates of FTOR and longer on-scene times for patients with OOHCA have higher overall patient survival, ROSC, and favorable neurologic function.

Should We Prolong the Observation Period for Neurological Recovery After Cardiac Arrest?

OBJECTIVES:To evaluate whether the recommended observation period of 7 days for cardiac arrest survivors is sufficient for conscious recovery and to identify the variables associated with eventual neurologic recovery among patients with delayed awakening.DESIGN:A retrospective cohort study.SETTING:A single tertiary medical center.PATIENTS:Five-hundred twenty-nine nontraumatic adult cardiac arrest survivors with prearrest favorable neurologic function (Cerebral Performance Category 1–2) who survived to hospital discharge during 2011–2019.INTERVENTIONS:The enrolled patients were classified into favorable (Cerebral Performance Category 1–2) and poor (Cerebral Performance Category 3–4) neurologic recovery according to their neurologic function at hospital discharge. Among patients with favorable neurologic recovery, those who recovered within 7 days were assigned to the early recovery group or after 7 days as the late recovery group.MEASUREMENTS AND MAIN RESULTS:There were 395 patients exhibiting favorable neurologic recovery (n = 357 in the early group, n = 38 in late group) and 134 patients exhibiting poor neurologic recovery (poor recovery group). Among patients who remained unconscious on day 7, delayed awakening was associated with male sex (odds ratio [OR], 3.905; 95% CI, 1.153–13.221), prehospital return of spontaneous circulation (OR, 7.628; 95% CI, 2.084–27.922), therapeutic hypothermia (OR, 4.320; 95% CI, 1.624–11.488), and extracorporeal cardiopulmonary resuscitation (OR, 4.508; 95% CI, 1.414–14.371). Being transferred from another hospital, however, was less likely to be associated with delayed awakening (OR, 0.061; 95% CI, 0.009–0.431). The median duration for patients to regain clear consciousness in the late recovery group was 12.12 days. No patient who recovered consciousness had an unfavorable electroencephalography pattern, however, in patients with poor recovery, the 7-day electroencephalography showed 45 patients with generalized suppression (33.6%), two with burst suppression (1.5%), 14 with seizure/epileptic discharge (10.5%), and one with status epilepticus (0.7%).CONCLUSIONS:Up to 9.6% of cardiac arrest patients with favorable outcomes recover consciousness after the recommended 7 days of observation, indicating the observation time of 7 days seems justified but longer duration may be needed. The results of the culturally and clinically isolated population may limit the application to other population.

Prehospital Tibial Intraosseous Drug Administration is Associated with Reduced Survival Following Out of Hospital Cardiac Arrest: A study for the CARES Surveillance Group

BackgroundRecent reports have questioned the efficacy of intraosseous (IO) drug administration for out-of-hospital cardiac arrest (OHCA) resuscitation. Our aim was to determine whether prehospital administration of resuscitative medications via the IO route was associated with lower rates of return of spontaneous circulation (ROSC) and survival to hospital discharge than peripheral intravenous (IV) infusion in the setting of OHCA. MethodsWe obtained data on all OHCA patients receiving prehospital IV or IO drug administration from the three most populous counties in Michigan over three years. Data was from the Michigan Cardiac Arrest Registry to Enhance Survival (CARES) database. The association between route of drug administration and outcomes was tested using a matched propensity score analysis. ResultsFrom a total of 10,626 OHCA patients, 6869 received parenteral drugs during their prehospital resuscitation (37.8% by IO) and were included in analysis. Unadjusted outcomes were lower in patients with IO vs. IV access: 18.3% vs. 23.8% for ROSC (p < 0.001), 3.2% vs. 7.6% for survival to hospital discharge (p < 0.001), and 2.0% vs. 5.8% for favorable neurological function (p < 0.001). After adjustment, IO route remained associated with lower odds of sustained ROSC (OR 0.72, 95% CI 0.63–0.81, p < 0.001), hospital survival (OR 0.48, 95% CI 0.37–0.62, p < 0.001), and favorable neurological outcomes (OR 0.42, 95% CI 0.30–0.57, p < 0.001). ConclusionIn this cohort of OHCA patients, the use of prehospital IO drug administration was associated with unfavorable clinical outcomes.

Abstract 274: Drugs and Cardiac Arrest: Suffocate the Brain, Spare the Body?

Background: Nearly 70,000 people die of a drug overdose every year. Yet, how drug induced cardiac arrests differ from presumed cardiac etiology cardiac arrests is not well described. In animal models, asphyxial arrests resemble drug induced arrests, demonstrating better hemodynamic profiles yet worse neurologic recovery. Theoretically, this is caused by hypoxemic but preserved perfusion prior to ultimate arrest. But, this has not been studied in humans. We hypothesize that drug induced cardiac arrests will have higher incidence of return of spontaneous circulation (ROSC) in all comers, yet worse neurologic recovery among hospitalized patients. Methods: From a large institutional dataset capturing all patients with out-of-hospital cardiac arrests admitted from 2011 to 2019, we assess the prevalence and outcomes of cardiac arrests, by drug-use status. Patients were excluded if the arrest was trauma induced, occurred in an extended care facility/nursing home, or if treatment was initiated at another medical center. The primary outcome was ROSC in all comers, and the secondary outcome was favorable neurologic function among those surviving to admission. Multivariable logistic regression was used to assess factors associated with differences in outcomes, accounting for traditional cardiac risk factors and arrest characteristics. Results: In total, 436 patients (57±10 years, 31.7% female, 58.5% non-white, 49.3% hypertensive, 28.4% diabetics, and 21.1% preceding coronary disease) were identified, including 94 (21.6%) with drug induced cardiac arrest. Of that total group 101 (23.2%) survived, to admission, 26.6% of the drug induced group and 22.2% of the presumed cardiac cohort, demonstrating no difference in ROSC (P=0.32). Among those that survived to admission, 8% (2/25) of the drug induced group had a favorable neurologic outcome, compared to 29.0% (22/76) of the cardiac induced group (P= 0.03). Following adjustment, the presence of presenting drug induced cardiac arrest remained associated with lower rates of neurologic recovery [OR 7.3 (1.03-51.6) P= 0.04]. There was no difference in survival to discharge. Conclusion: Drug induced cardiac arrest is associated with worse neurologic outcomes than presumed cardiac etiology cardiac arrests.

Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury

Traumatic brain injury (TBI) is the leading cause of death and disability due to trauma. Early administration of tranexamic acid may benefit patients with TBI. To determine whether tranexamic acid treatment initiated in the out-of-hospital setting within 2 hours of injury improves neurologic outcome in patients with moderate or severe TBI. Multicenter, double-blinded, randomized clinical trial at 20 trauma centers and 39 emergency medical services agencies in the US and Canada from May 2015 to November 2017. Eligible participants (N = 1280) included out-of-hospital patients with TBI aged 15 years or older with Glasgow Coma Scale score of 12 or less and systolic blood pressure of 90 mm Hg or higher. Three interventions were evaluated, with treatment initiated within 2 hours of TBI: out-of-hospital tranexamic acid (1 g) bolus and in-hospital tranexamic acid (1 g) 8-hour infusion (bolus maintenance group; n = 312), out-of-hospital tranexamic acid (2 g) bolus and in-hospital placebo 8-hour infusion (bolus only group; n = 345), and out-of-hospital placebo bolus and in-hospital placebo 8-hour infusion (placebo group; n = 309). The primary outcome was favorable neurologic function at 6 months (Glasgow Outcome Scale-Extended score >4 [moderate disability or good recovery]) in the combined tranexamic acid group vs the placebo group. Asymmetric significance thresholds were set at 0.1 for benefit and 0.025 for harm. There were 18 secondary end points, of which 5 are reported in this article: 28-day mortality, 6-month Disability Rating Scale score (range, 0 [no disability] to 30 [death]), progression of intracranial hemorrhage, incidence of seizures, and incidence of thromboembolic events. Among 1063 participants, a study drug was not administered to 96 randomized participants and 1 participant was excluded, resulting in 966 participants in the analysis population (mean age, 42 years; 255 [74%] male participants; mean Glasgow Coma Scale score, 8). Of these participants, 819 (84.8%) were available for primary outcome analysis at 6-month follow-up. The primary outcome occurred in 65% of patients in the tranexamic acid groups vs 62% in the placebo group (difference, 3.5%; [90% 1-sided confidence limit for benefit, -0.9%]; P = .16; [97.5% 1-sided confidence limit for harm, 10.2%]; P = .84). There was no statistically significant difference in 28-day mortality between the tranexamic acid groups vs the placebo group (14% vs 17%; difference, -2.9% [95% CI, -7.9% to 2.1%]; P = .26), 6-month Disability Rating Scale score (6.8 vs 7.6; difference, -0.9 [95% CI, -2.5 to 0.7]; P = .29), or progression of intracranial hemorrhage (16% vs 20%; difference, -5.4% [95% CI, -12.8% to 2.1%]; P = .16). Among patients with moderate to severe TBI, out-of-hospital tranexamic acid administration within 2 hours of injury compared with placebo did not significantly improve 6-month neurologic outcome as measured by the Glasgow Outcome Scale-Extended. ClinicalTrials.gov Identifier: NCT01990768.

Low PCSK-9 levels Are Associated with Favorable Neurologic Function after Resuscitation from out of Hospital Cardiac Arrest.

Endotoxemia after cardiopulmonary resuscitation (CPR) is associated with unfavorable outcome. Proprotein convertase subtilisin/kexin type-9 (PCSK–9) regulates low-density lipoprotein receptors, which mediate the hepatic uptake of endotoxins. We hypothesized that PCSK–9 concentrations are associated with neurological outcome in patients after CPR. Successfully resuscitated out-of-hospital cardiac arrest patients were included prospectively (n = 79). PCSK–9 levels were measured on admission, 12 h and 24 h thereafter, and after rewarming. The primary outcome was favorable neurologic function at day 30, defined by cerebral performance categories (CPC 1–2 = favorable vs. CPC 3–5 = unfavorable). Receiver operating characteristic curve analysis was used to identify the PCSK–9 level cut-off for optimal discrimination between favorable and unfavorable 30-day neurologic function. Logistic regression models were calculated to estimate the effect of PCSK–9 levels on the primary outcome, given as odds ratio (OR) and 95% confidence interval (95%CI). PCSK–9 levels on admission were significantly lower in patients with favorable 30-day neurologic function (median 158 ng/mL, (quartiles: 124–225) vs. 207 ng/mL (174–259); p = 0.019). The optimally discriminating PCSK–9 level cut-off was 165 ng/mL. In patients with PCSK–9 levels ≥ 165 ng/mL, the odds of unfavorable neurological outcome were 4.7-fold higher compared to those with PCSK–9 levels < 165 ng/mL. In conclusion, low PCSK–9 levels were associated with favorable neurologic function.

Prognostic value of repeated thromboelastography measurement for favorable neurologic outcome during targeted temperature management in out-of-hospital cardiac arrest survivors

BackgroundCardiac arrest can activate blood coagulation, which clinically manifests as obstruction of the microcirculation and multiple organ dysfunction. Thromboelastography (TEG) provides a rapid and comprehensive assessment of hemostatic processes, but there are limited data on the use of sequential TEG values during targeted temperature management (TTM) in out-of-hospital cardiac arrest (OHCA) survivors. The aim of this study was to investigate the prognostic value of coagulopathy assessed by repeated TEG to predict neurologically intact survival. MethodsA prospective cohort of consecutive non-trauma OHCA patients who were successfully resuscitated and treated with TTM. Patients with a target temperature of 36 ℃, no TEG data, and who declined appropriate treatment were excluded. TEG was measured at three time points of TTM (initial phase, target phase, and rewarming phase). The primary outcome was 28 day favorable neurologic function, defined as a Cerebral Performance Category of 1 or 2. ResultsA total of 125 patients (mean age, 61 years; 63.2% male) were analyzed. A favorable neurologic outcome at 28 days was seen in 40 patients (32.0%). TEG values of R and LY30 in the initial phase were significantly lower in the favorable neurologic outcome group than in the unfavorable group (5.8 vs. 8.1 and 0.1 vs. 0.7, respectively; p < 0.01). TEG values of R < 5 or LY30 < 7.5 in the initial phase were more frequently seen in the favorable outcomes group than in the unfavorable group (37.5% vs. 12.9%, p = 0.002 and 95.0% vs. 72.9%, p = 0.004, respectively). However, no significant differences were seen between the two groups in other TEG values (R, K, alpha, and MA) in the target and rewarming phases (p > 0.05 for all). Univariate analysis showed higher D-dimer levels, prothrombin time, and activated partial thromboplastin time in the unfavorable outcome group. In the multivariable analysis, TEG values of combination of R < 5 and LY30 < 7.5 in the initial phase were the only coagulation profiles seen to be independently associated with favorable neurologic outcome (OR, 4.508, 95% CI, 1.254–16.210). ConclusionTEG results are available within minutes, and shorted R values or the absence of prolonged LY30 values in the initial phase are an early predictor of neurologically intact survival in successfully resuscitated OHCA patients.

Dispatcher-Assisted Cardiopulmonary Resuscitation: Disparity between Urban and Rural Areas.

Methods Patients with out-of-hospital cardiac arrest (OHCA) were prospectively registered in Taichung. The 29 districts of Taichung city were divided into urban and rural areas based on whether the population density is more than 1,000 people per square kilometer. Prehospital data were collected according to the Utstein-style template, and telephone auditory records were collected by a dispatch center. Results 2,716 patients were enrolled during the study period. 88.4% OHCA occurred in urban areas and 11.6% in rural areas. 74.9% after dispatcher assistance, laypersons performed CPR in urban areas and 67.7% in rural areas (p=0.023). The proportion of laypersons continued CPR until an emergency medical technician's (EMT) arrival was higher in the urban areas (59.57% vs 52.27%, p=0.039). Laypersons continued CPR until an EMT' arrival would increase the chance of return of spontaneous circulation in urban and rural areas, with adjusted odds ratio (aOR) of 1.02, 95% confidence interval (CI) of 0.82–1.27, and aOR of 1.49, 95% CI of 0.80–2.80, respectively. Continued laypersons CPR until the EMT' arrival also improved survival with favorable neurological function, with aOR of 1.16, 95% CI of 0.61–2.20 in urban areas and aOR of 2.90 95% CI of 0.18–46.81 in rural areas. Conclusion Bystanders in urban areas exhibited higher ratio of acceptance of DACPR. However, after DACPR intervention, prognosis improvement was considerably higher in rural areas than in urban areas.

Survival, neurological and safety outcomes after out of hospital cardiac arrests treated by using prehospital therapeutic hypothermia: A systematic review and meta-analysis

Survival after pre-hospital cardiac arrest (PHCA) remains low. Pre-hospital therapeutic hypothermia (PTH) is believed to improve patient's outcomes, but data on efficacy and safety remains scarce. Herein, we aimed to assess the influence of PTH on survival, neurological outcome, and adverse effects in patients with PHCA. A literature search of PubMed CENTRAL, EMBASE, and The Cochrane Central Register of Controlled Trials databases from inception to August 2019 was conducted and retrieved abstracts were independently assessed by two reviewers. The primary outcome was survival to hospital discharge with a favorable neurological outcome. Secondary outcomes were survival to hospital discharge and temperature upon hospital admission. The safety outcomes included pulmonary edema and recurrent arrest during transport to the hospital. We also considered a favorable neurological function to hospital discharge or longest post arrest follow-up. Eleven studies including 4891 patients were included into final analysis. The survival to hospital discharge did not differ between PTH and control group (RR 1.02; 95%CI 0.93 to 1.12). Among 4891 participants (2466 in PTH group and 2425 in control group), 1087 participants (564 vs. 523, respectively) had a favorable neurological outcome. Pulmonary edema occurred in 320 cases in PTH group and 273 in control group with significant heterogeneity (RR 0.90, 95%CI 0.59–1.38; I2 = 80%). The pooled results showed a significant difference in rearrests between the PTH and control group (RR 1.19; 95%CI 1.00 to 1.42). Our analysis demonstrates that PTH does not improve survival at discharge or neurological outcome.