Good Neurological Function Research Articles

Early neurologic examination is not reliable for prognostication in post–cardiac arrest patients who undergo therapeutic hypothermia

BackgroundRecent advances in post–cardiac arrest (CA) care including therapeutic hypothermia (TH) have improved survival and favorable neurologic outcomes for survivors of CA. Survivors often present with deep coma and lack of brainstem reflexes, which are generally associated with adverse outcomes in many disease processes. Little is known regarding the role of initial emergency department (ED) neurological examination and its potential for prognostication. ObjectivesThe purpose of this study is to determine if components of a standardized neurologic examination are reliable prognosticators in patients recently resuscitated from CA. We hypothesize that lack of neurologic function does not reliably predict an adverse outcome and, therefore, should not be used to determine eligibility for TH. MethodsA standardized neurologic examination was performed in the ED on a prospective, convenience cohort of post-CA patients presenting to a CA resuscitation center who would undergo a comprehensive postarrest care pathway that included TH. Data such as prior sedation or active neuromuscular blockade were documented to evaluate for the presence of possible confounders. Examination findings were then compared with hospital survival and neurologic outcome at discharge as defined by the cerebral performance category (CPC) score as documented in the institutional TH registry. ResultsForty-nine subjects were enrolled, most of whom presented comatose with a Glasgow Coma Scale of 3 (n=41, 83.7%). Nineteen subjects (38.8%) had absence of all examination findings, of which 4 of 19 (21.1%) survived to hospital discharge. Of those with at least 1 positive examination finding, 13 of 30 subjects (43.3%) survived to hospital discharge. Subgroup analysis showed that 9 of the 19 patients with absence of brainstem reflexes did not have evidence of active neuromuscular blockade at the time of the examination; 2 of 9 (22.1%) survived to hospital discharge. Eight of these subjects in this group had not received any prior sedation; 1 of 8 (12.5%) survived to hospital discharge. Only 1 of the 17 subjects who survived was discharged with poor neurologic function with a CPC score=3, whereas all others who survived had good neurologic function, CPC score=1. ConclusionIn this cohort of patients treated in a comprehensive postarrest care pathway that included TH, absence of neurologic function on initial ED presentation was not reliable for prognostication. Given these findings, clinicians should refrain from using the initial ED neurological examination to guide the aggressiveness of care or in counseling of family members regarding anticipated outcome.

Cardiac arrest secondary to acute coronary syndrome: a 4-year observational study of patient characteristics and outcomes.

Cardiac arrest due to ischaemia is frequently the first manifestation of cardiovascular disease. We sought to describe the characteristics and outcomes of patients admitted to the Intensive Care Unit (ICU) with a diagnosis of cardiac arrest secondary to acute coronary syndrome (ACS). We performed a retrospective analysis of patients admitted to the intensive care unit over a 4year period. Baseline demographic characteristics, the use of therapeutic hypothermia, rates of percutaneous coronary intervention, co-morbidities and baseline left ventricular function were all documented. Outcomes included Glasgow Coma Scale (GCS) at time of discharge from the ICU, survival to hospital discharge, 6months survival and left ventricular function at 6months. We identified 31 admissions to the ICU following cardiac arrest due to ACS during the study period. 71% of patients survived to hospital discharge and all of these were still alive at 6months. 65% had good neurological function (GCS>13) when discharged from ICU. Mean left ventricular ejection fraction remained stable at 6months. A significant proportion of patients admitted to the intensive care unit with a diagnosis of cardiac arrest secondary to acute coronary syndrome survive to hospital discharge with meaningful recovery in neurological and cardiac function.

Time to start of cardiopulmonary resuscitation and the effect of target temperature management at 33 °C and 36 °C

IntroductionThe optimal temperature during targeted temperature management (TTM) for comatose patients resuscitated from out-of-hospital cardiac arrest is unknown. It has been hypothesized that patients with long no-flow times, for example those without bystander CPR would have the most to gain from temperature management at lower temperatures. MethodsWe analysed data from an international clinical trial randomizing cardiac arrest patients to targeted temperature management at 33°C and 36°C for an interaction between no-flow time and intervention group, with neurological function at six months after cardiac arrest as the primary outcome. A cerebral performance category (CPC) score of 1 or 2 was considered a good outcome. ResultsNo-flow time (min) was associated with poor neurological outcome (OR 1.13, 95% confidence interval 1.06–1.20, p<0.001). There was no statistically significant interaction between no flow-time and intervention group (p=0.11), which may imply that the non-superior effect of 33°C was consistent for all no-flow times. Bystander CPR was not independently associated with neurological function. ConclusionsTTM at 33°C compared to 36°C was not associated with an increased probability of a good neurological function for patients with longer no-flow times.

Association between serum uric acid levels and prognosis in acute ischemic stroke: a prospective case study

Objective To investigate the association between serum uric acid (SUA)levels and outcome in acute ischemic stroke. Methods A total of 388 acute ischemic stroke patients were included in the prospective case study.Data on demographic characteristics, risk factors for life style, history of disease, the admission SUA and outcome at discharge were collected for all participants. Results Mean serum uric acid levels were (284.5±83.6) μmol/L in the normal uric acid? group, and( 455.3±78.1 )μmol/L in the high uric acid group(P<0.01). There were significant differences in National Institutes of Health Stroke Scale (NIHSS) score at two weeks between the high UA group and the normal UA group〔(11.0±6.0) vs. (11.0±5.3), P=0.048〕, and also in early neurological improvement (P=0.048). A significant difference was found in serum uric acid level between patients with good versus poor neurological function outcome(P=0.045). Conclusions There is the association between admission serum uric acid levels and outcome in acute ischemic stroke. Elevated serum uric acid level predicts a lower chance of a poor outcome in acute ischemic stroke. Key words: Stroke; Uric acid; Prognosis

German in-hospital emergency registry: A two years analysis

Introduction: Since January 2013, the German Resuscitation Registry database includes – in addition to in-hospital resuscitation (51 participating hospitals) – also data on in-hospital emergency management (38 hospitals). To date the data base contains 5252 data sets. Methods: Registry data were collected anonymously and subsequently analysed. Results: The medical emergency team (MET) was called for resuscitation 2802 times. Circulatory arrest was due to cardiac conditions in 55.4% (n=1552) and respiratory conditions in 23.6% (n=660). Sepsis, bleeding and metabolic derangement were less than 5%. ROSC was achieved in 1753 patients (62.6%), 12% going homewith good neurological function. Most frequent locations for CPR were the ward (55%), IMC/ICU (18%), and emergency room (13%). 487 patients (19%) had no independent life before resuscitation, 63% of patients (1662) presentedwith significant pre-existing conditions (PC). 15% of patients were healthy or has minor limitations. 2450 times the MET was called to in-hospital emergency management without resuscitation. Such emergency situations occurred 1056 time (43.2%) on the ward, 368 time (15%) in the diagnostic suite and 429 time (17.5%) somewhere else on the hospital premises. The most frequent indications for emergency calls were respiratory compromise (n=973) hemodynamic instability (n=921) and neurological deterioration (n=677). 231 patients (10.6%) had no independent life before this emergency, 50.9% of patients (n=1113) presented with significant pre-existing conditions. All participating hospitals receive a yearbook with a thorough analysis of more than 100 variables including benchmarking. Discussion and conclusion: In half of hospitals, emergency teams are requested for resuscitation only. Actually, such teams should be called way before CPR becomes necessary, to initiate preventive measures. All in-hospital patients should receive vital-signs monitoring, appropriate for the severity of their condition. In Germany, structures need to be established to actually obviate the need for CPR and eliminate unexpected deaths; such structures should include early warning scores and standardized alarm criteria. The German in-hospital registry is a tool for quality improvement in patient safety and treatment.

Outcomes for out-of-hospital cardiac arrests across 7 countries in Asia: The Pan Asian Resuscitation Outcomes Study (PAROS)

BackgroundThe Pan Asian Resuscitation Outcomes Study (PAROS) Clinical Research Network (CRN) was established in collaboration with emergency medical services (EMS) agencies and academic centers in Japan, Singapore, South Korea, Malaysia, Taiwan, Thailand, and UAE-Dubai and aims to report out-of-hospital cardiac arrests (OHCA) and provide a better understanding of OHCA trends in Asia. Methods and resultsThis is a prospective, international, multi-center cohort study of OHCA across the Asia-Pacific. Each participating country provided between 1.5 and 2.5 years of data from January 2009 to December 2012. All OHCA cases conveyed by EMS or presenting at emergency departments were captured.66,780 OHCA cases were submitted to the PAROS CRN; 41,004 cases were presumed cardiac etiology. The mean age OHCA occurred varied from 49.7 to 71.7 years. The proportion of males ranged from 57.9% to 82.7%. Proportion of unwitnessed arrests ranged from 26.4% to 67.9%. Presenting shockable rhythm rates ranged from 4.1% to 19.8%. Bystander cardiopulmonary resuscitation (CPR) rates varied from 10.5% to 40.9%, however <1.0% of these arrests received bystander defibrillation. For arrests that were with cardiac etiology, witnessed arrest and VF, the survival rate to hospital discharge varied from no reported survivors to 31.2%. Overall survival to hospital discharge varied from 0.5% to 8.5%. Survival with good neurological function ranged from 1.6% to 3%. ConclusionsSurvival to hospital discharge for Asia varies widely and this may be related to patient and system differences. This implies that survival may be improved with interventions such as increasing bystander CPR, public access defibrillation and improving EMS.

Managing cardiac arrest with refractory ventricular fibrillation in the emergency department: Conventional cardiopulmonary resuscitation versus extracorporeal cardiopulmonary resuscitation

AimRefractory ventricular fibrillation, resistant to conventional cardiopulmonary resuscitation (CPR), is a life threatening rhythm encountered in the emergency department. Although previous reports suggest the use of extracorporeal CPR can improve the clinical outcomes in patients with prolonged cardiac arrest, the effectiveness of this novel strategy for refractory ventricular fibrillation is not known. We aimed to compare the clinical outcomes of patients with refractory ventricular fibrillation managed with conventional CPR or extracorporeal CPR in our institution. MethodThis is a retrospective chart review study from an emergency department in a tertiary referral medical center. We identified 209 patients presenting with cardiac arrest due to ventricular fibrillation between September 2011 and September 2013. Of these, 60 patients were enrolled with ventricular fibrillation refractory to resuscitation for more than 10min. The clinical outcome of patients with ventricular fibrillation received either conventional CPR, including defibrillation, chest compression, and resuscitative medication (C-CPR, n=40) or CPR plus extracorporeal CPR (E-CPR, n=20) were compared. ResultsThe overall survival rate was 35%, and 18.3% of patients were discharged with good neurological function. The mean duration of CPR was longer in the E-CPR group than in the C-CPR group (69.90±49.6min vs 34.3±17.7min, p=0.0001). Patients receiving E-CPR had significantly higher rates of sustained return of spontaneous circulation (95.0% vs 47.5%, p=0.0009), and good neurological function at discharge (40.0% vs 7.5%, p=0.0067). The survival rate in the E-CPR group was higher (50% vs 27.5%, p=0.1512) at discharge and (50% vs 20%, p=0. 0998) at 1 year after discharge. ConclusionsThe management of refractory ventricular fibrillation in the emergency department remains challenging, as evidenced by an overall survival rate of 35% in this study. Patients with refractory ventricular fibrillation receiving E-CPR had a trend toward higher survival rates and significantly improved neurological outcomes than those receiving C-CPR.

Malignant EEG patterns in cardiac arrest patients treated with targeted temperature management who survive to hospital discharge

Background and purposeCardiac arrest patients treated with targeted temperature management (TTM) have improved neurological outcomes, however mortality remains high. EEG monitoring improves detection of malignant EEG patterns (MEPs), however their prevalence in patients surviving to hospital discharge is unknown. Design/methodsWe examined consecutive cardiac arrest subjects who received TTM and continuous EEG monitoring at one academic center. Only subjects surviving to hospital discharge were included in the analysis. MEPs were defined as seizures, status epilepticus, myoclonic status epilepticus, or generalized periodic discharges. Subjects with suppression-burst (SB) without concomitant MEPs were categorized as having a “pure” SB pattern. Demographic, survival, hospital discharge disposition, and neurological function data were recorded retrospectively. Outcomes were assessed using the Glasgow-Pittsburgh Cerebral Performance Category (CPC). A CPC score of 1–2 was considered “good” neurological function, and a CPC of 3–4 “poor”. ResultsOf 364 admissions due to cardiac arrest screened, 120 (29.9%) survived to hospital discharge and met inclusion criteria. MEPs and pure SB were observed in 19 (15.8%) and 22 (18.3%) survivors respectively. Two subjects with MEP and eight subjects with pure SB had good neurological function at discharge, however all SB cases were confounded by the use of anesthetic agents. Presence of MEPs was not an independent predictor of poor neurological function (p=0.1). ConclusionsMEPs are common among cardiac arrest patients treated with induced hypothermia who survive to hospital discharge. Poor neurological function at discharge was not associated with MEPs. Prospective studies assessing the role of EEG monitoring in cardiac arrest prognostication are warranted.

Effect of prehospital induction of mild hypothermia on 3-month neurological status and 1-year survival among adults with cardiac arrest: long-term follow-up of a randomized, clinical trial.

BackgroundRandomized trials of prehospital cooling after cardiac arrest have shown that neither prehospital cooling nor targeted temperature management differentially affected short‐term survival or neurological function. In this follow‐up study, we assess the association of prehospital hypothermia with neurological function at least 3 months after cardiac arrest and survival 1 year after cardiac arrest.Methods and ResultsThere were 508 individuals who were discharged alive from hospitals in King County, Washington; 373 (73%) were interviewed by telephone 123±43 days after the initial event. Overall, 59% of the treatment group and 58% of the control group had Cerebral Performance Category (CPC) 1 or 2 (P=0.70), and 50% of the treatment group and 49% of the control group had slight disability or better by the Modified Rankin Scale (MRS; (P=0.35). One‐year survival was 87% in the treatment group and 84% in the control group (P=0.42). Of those with CPC 1 at hospital discharge, 68% had CPC 1 or 2 at follow‐up, and 59% had MRS of slight disability or better. Of 41 patients with CPC 3 or 4 at discharge, only 12% had CPC 2 at follow‐up, and just 5% had MRS of slight disability or better. One‐year survival was 92% for CPC 1 at discharge, but only 40% for CPC 4.ConclusionIn addition to excellent survival, patients who had good neurological function at discharge continued to have good function at least 3 months after the event.Clinical Trial RegistrationURL: Clinicaltrials.gov. Unique identifier: NCT00391469

Abstract T P295: Neurological Recovery Following Out-of-hospital Cardiac Arrest: Role of Hypothermia

Introduction: Every year about 70% of coronary heart disease deaths in the United States occur out of hospital, usually presenting as ‘sudden death’ due to cardiac arrest. Despite the improvement of survival with advanced cardiac interventions, mortality remains high. Therapeutic hypothermia (TH) has been shown to be neuroprotective after cardiac arrest. We explored factors associated with good recovery of neurological function following out-of-hospital cardiac arrest (OHCA). Methods: This retrospective study included review of electronic medical records from a major healthcare system in Northeast Indiana. Individuals who suffered OHCA from January 2011 to June 2014 were included. Neurological function was evaluated by Modified Rankin Scale (mRS) at discharge. The neurological outcome was defined as good (mRS 0-3), poor (mRS 4-5), and deceased (mRS 6) to assess the association of examined variables. Results: Among the 111 patients meeting inclusion criteria, the mortality at discharge was 68.6% in TH-treated patients and 84% in normothermia patients. For almost half (47.5%) of the patients undergoing TH who died prior to discharge, brain-related causes were the primary cause of death. 21 patients who had imaging or pathological examinations all showed evidences of ischemic brain injury. Among TH-treated survivors, patients with return of spontaneous cardiac rhythm (ROSC) within 20 minutes of onset were 1.4 times the odds more likely to have a good neurological outcome at discharge (p=0.02). Patients with ventricular fibrillation had 2 times the odds more likely retaining good neurological function at discharge after receiving TH treatment (p=0.012). The time to initiate TH (mean 2.3 ± 1.5 hours) and time to reach target temperature (mean 7.2 ± 2.3 hours) were not associated with neurological outcome at discharge. Conclusions: Initial rhythm and time to ROSC were identified as reliable predictors of good neurological function following OHCA. TH has been found to be insufficient in preventing brain injury. This study emphasizes the need for future studies to develop new neuroprotective strategies to improve survival among OHCA patients.

Incidence and treatment of posttraumatic cauda equina herniation following lumbar burst fracture

Objective To investigate the incidence and treatment of posttraumatic cauda equina herniation associated with lumbar fracture. Methods A retrospective analysis was performed on 416 patients admitted due to lumbar burst fracture between June 1, 2008 and June 1, 2011. All the patients had been operated on via anterior or posterior approaches. Data collected included demographics, injury mechanism, radiographs, surgical procedures, outcomes and follow-up. Incidence of cauda equina herniation was documented. Results All surgeries were uneventful. Cauda equina herniation was observed in 49 patients (11.8%) during surgical exploration. Anterior surgery was done on 115 patients and found 7.8% incidence of cauda equina herniation (9/115). Posterior surgery was done on 301 patients and found 13.3% incidence of cauda equina herniation (40/301). There were 40 patients combined with laminar fracture and 38 of them had cauda equina herniation with the incidence rate of 95%. Among the 49 patients with cauda equina herniation, 44 (90%) had neurological deficit and 5(10%) were found with good neurological function but significant proportion of cauda equina rootlets entrapped in the lamina fracture. Conclusions Lumbar burst fracture combined with neurological deficit and laminar fracture may increase the risk of posttraumatic cauda equina herniation and should be paid attention. Operations should be performed with caution to avoid further nerve damage. Key words: Spinal fractures; Lumbar; Cauda equina herniation

Surgical treatment and prognostic factors of cervical intramedullary spinal cord tumors

Objective To summarize our experience in surgical treatment of cervical intramedullary spinal cord tumors and to identify the prognostic factors associated with postoperative neurological status.Methods The clinical data of 65 consecutive patients with cervical intramedullary spinal cord tumors undergoing operation between Jan.2009 and Dec.2013 were retrospectively reviewed.McCormick Scale was applied to evaluate the preoperative and postoperative neurological functions.Multivariate logistic regression analysis was used to determine the independent prognostic factors of postoperative neurological status.Results Laminectomy was performed in 61 patients and unilateral multilevel interlaminar fenestration(UMIF)was applied in 4patients.Of all the 65 patients,48received total resection,4received subtotal resection and 13 received partial resection.The follow-up time was from 4 months to 15 years.The median follow-up time was 68 months.The clinical symptoms were relieved in 42 patients after operation,maintained unchanged in 14 and aggravated in 9.The pain remission rate of the patients was the highest(82.4%),followed by the sphincter dysfunction remission rate(68.8%),and the sensory disturbance remission rate of the patients was the lowest(39.6%).Based on McCormick Scale,the postoperative neurological functions was improved in 18patients(27.7%)and maintained unchanged in 39(60%),while eight patients(12.3%)developed neurological deterioration. Multivariate logistic regression analysis revealed that good preoperative neurological function(OR=19.87,95% CI:4.10-96.23,P=0.000)and total resection(OR=7.40,95% CI:1.34-40.95,P=0.022)were the independent protective factors for postoperative neurological status.Conclusion Microsurgical resection is the firstline treatment for cervical intramedullary spinal cord tumors,which can achieve a satisfying outcome in most cases.Preoperative neurological status and surgical extent are significantly associated with the postoperative functional outcome of patients.

The Surgical Treatment Principles of Atlantoaxial Instability Focusing on Rheumatoid Arthritis.

Object. This retrospective review was conducted to determine the surgical treatment principle for rheumatoid arthritis (RA) patients with atlantoaxial instability (AAI). Methods. Thirteen patients with AAI, including 5 RA patients, received preoperative computed tomography- (CT-) based image-guided navigation system (IGS) in C1 lateral mass-C2 pedicle screw-rod system fixation (LC1-PC2 fixation). These 13 patients were analyzed for 52 screws inserted into C1 and C2. We defined these patients as non-RA group (8 patients, 32 screws) and RA group (5 patients, 20 screws). The neurological status for RA group was evaluated using the Ranawat classification. The causes of AAI, surgical indications, complications, surgical method revolution, and CT-based navigation application are discussed. Results. None of the 13 patients expressed neurological function deterioration. The non-RA group screw accuracy was 100%. In the RA group, 1 RA patient developed left C2 screw loosening at 1+ months after operation due to screw malposition. The screw accuracy for this group was 95%. Conclusions. Higher intraoperative surgical complication rate was described in RA patients. Preoperative CT-based IGS in LC1-PC2 fixation can provide good neurological function and screw accuracy results. However, for higher screw accuracy in RA patients, intraoperative CT-based IGS application may be considered.

Resuscitative extracorporeal membrane oxygenation for in hospital cardiac arrest: A Canadian observational experience

BackgroundAmong patients with reversible conditions who sustain cardiac arrest, extracorporeal membrane oxygenation (ECMO) may support end organ perfusion while bridging to definitive therapy. MethodsA single center retrospective review (February 2008–September 2013) of adults receiving ECMO for cardiac arrest ≥15min duration refractory to conventional management (E-CPR) or profound cardiogenic shock following IHCA (E-CS) was conducted. The primary outcome was 30-day survival with good neurologic function defined as a cerebral performance category (CPC) of 1–2. Secondary outcomes included intensive care unit (ICU) and hospital length of say, duration of mechanical ventilation, and univariate predictors of 30-day survival with favorable neurologic function. ResultsThirty-two patients (55±11 years, 66% male) were included of which 22 (69%) received E-CPR and 10 (31%) received E-CS following return of spontaneous circulation (ROSC). Cardiac arrest duration was 48.8±21min for those receiving E-CPR and 25±23min for the E-CS group. Patients received ECMO support for 70.7±47.6h. Death on ECMO support occurred in 7 (21.9%) patients, while 7 (21.9%) were bridged to another form of mechanical circulatory support, and 18 (56.3%) were successfully decannulated. ICU length of stay was 7.5 [3.3–14] days and ICU survival occurred in 16 (50%) of patients. 30-Day survival was 5 (50%) in the E-CS group, 10 (45.4%) in the E-CPR group, and 15 (47%) overall. All survivors had CPC 1–2 neurologic status. ConclusionIn this single center experience, the use of resuscitative ECMO was associated with neurologically favorable 30-day survival in 47% of patients with prolonged IHCA (H2012:172).

REGIONAL REGULATION OF BLOOD FLOW PREDICTS SURVIVAL IN EXPERIMENTAL CARDIAC ARREST

Following out-of-hospital cardiac arrest, rates of discharge with good neurological function are low even when guideline based cardiopulmonary resuscitation (CPR) is administered. The relationship between aortic pressure, carotid blood flow and brain perfusion during thoracic compressions is unknown. We assessed the correlation between these variables during CPR in an experimental model. Ten healthy Yorkshire pigs (25-30 kg, 10-12 weeks old, 7 male) were anesthetized and underwent 2-4 minutes of untreated ventricular fibrillation (VF), followed by 3 minutes of CPR, defibrillation (maximum 5 shocks, 150-360 J), and a recovery phase (30 minutes if applicable). Pigs were considered “survivors” if they had sinus rhythm and aortic systolic pressure ≥ 50 mmHg 30 minutes after defibrillation; otherwise they were considered “non-survivors”. CPR was administered as per guidelines using manual ventilation (6 breaths/min with AMBU bag, 100% O2) and mechanical chest compressions (100/min, 5 cm depth with LUCAS compressor). Abdominal aortic pressure, carotid blood flow and direct cerebral interstitial oxygen pressure were measured continuously. Five pigs (50%) survived the cardiac arrest and were in sinus rhythm with adequate aortic pressure after the recovery period. Four of the non-survivors were defibrillated into pulseless electrical activity (sinus rhythm with aortic pressure never exceeding 50 mmHg); the remaining pig could not be defibrillated. During CPR, there were no significant differences between the survivors and the non-survivors respectively in terms of mean systolic aortic pressure (77±21 mmHg vs 54±13 mmHg, P=NS), mean diastolic aortic pressure (25±8 mmHg vs 15±3 mmHg, P=NS), mean systolic carotid blood flow (330±162 mL/min vs. 349±52 mL/min, P=NS), or cerebral oxygen pressure (15±15 torr vs. 7±2 torr, P=NS). During CPR systolic aortic pressure was poorly correlated with systolic carotid blood flow with an R2 value of 0.2 in survivors and 0.008 in non-survivors. However, systolic carotid blood flow was correlated with cerebral brain oxygen tension with an R2 value of 0.7 in survivors and 0.0001 in non-survivors. Despite a standardized resuscitation protocol there were disparate outcomes in this uniform pig population. Although survivors did not have significantly greater pressures or flows during CPR than non-survivors, they did have a greater correlation between carotid flow and brain oxygenation suggesting better local auto-regulation or regional distribution of flow in survivors. This promotes the idea that factors other than thoracic compression strength are important in generating brain oxygen delivery.

Ten-year experience of an invasive cardiology centre with out-of-hospital cardiac arrest patients admitted for urgent coronary angiography.

The aim of the study was to evaluate survival and neurological function of out-of-hospital cardiac arrest (OHCA) patients admitted for urgent coronary angiography (UCA) with a view to percutaneous coronary intervention (PCI). Hospital records of OHCA patients admitted to an invasive cardiology centre (providing 24 h a day/7 days a week service) in 2000-2010 were reviewed retrospectively, and similar data collected in 2011 were reviewed prospectively. Reports from the pre-hospital phase from emergency medical services (EMS) in Krakow were also analysed. Long-term follow-up data were collected by retrieving records from other hospitals (for patients transferred after UCA/PCI) and by phone calls to patients or their relatives. In 2000-2011, 405 OHCA patients were admitted for UCA/PCI. Most (78%) had ventricular fibrillation (VF) or ventricular tachycardia (VT) as the primary mechanism of cardiac arrest (asystole: 13%, pulseless electrical activity: 3%, unknown: 6%). The mean patient age was 61 (range 20-85) years, and 81% were males. On admission, about 70% of patients were unconscious and 11% were in cardiogenic shock. The mean resuscitation time (time to return of spontaneous circulation [ROSC]) was 26.7 (range 1-126) min. ST-T changes seen in an electrocardiogram recorded after ROSC included ST elevation and depression in 52% of cases, only ST depression in 21% of cases, only ST elevation in 17% of cases, unspecific changes (due to intraventricular conduction disturbances) in 7% of cases, negative T waves in 3% of cases, and no changes in 0.5% of cases. Coronary angiography revealed acute coronary occlusion in 48% of cases, critical coronary stenosis (> 90%) in 26% of cases, other significant coronary lesions (> 50% stenosis) in 15% of cases, and non-significant lesions in 11% of cases. An acute coronary syndrome (ACS) was diagnosed in 82% of patients (75% STEMI, 25% NSTEMI), and other cardiac cause (mostly ischaemic cardiomyopathy) was identified in 13% of patients. Among OHCA patients diagnosed with ACS, PCI was performed in 90% and additional 4% underwent coronary artery bypass grafting. Overall success rate of PCI, defined as TIMI 3 flow plus residual stenosis < 50% and resolution of ST elevation after PCI by > 30%, was 70%. Survival to hospital discharge in the entire group of OHCA patients was 63% and 30-day survival with good neurological outcomes (defined as Cerebral Performance Category 1 or 2) was 49%. Among patients who were initially unconscious, those figures were 52% and 33%, respectively. During long-term follow-up (up to 12 years), 49% of patients were alive and 42% had good neurological function (87% of those who survived). In multivariate analysis, independent predictors of survival with good neurological outcomes were preserved consciousness on admission, absence of shock, cardiac arrest witnessed by medical personnel, VF/VT as a primary mechanism of cardiac arrest, and preserved renal function. Successful PCI predicted survival until hospital discharge only when the neurological status of the patients was not taken into account. The most important cause of OHCA is coronary artery disease, in particular ACS. UCA and PCI seem to be important elements of appropriate post-resuscitation care because such treatment could improve survival but it is still unclear whether PCI might influence neurological outcomes as well.

A Case of Commotio Cordis Treated with Therapeutic Hypothermia

BackgroundTherapeutic hypothermia is used as a neuroprotective strategy for patients who have persistent neurologic compromise after return of spontaneous circulation from cardiac arrest. The 2010 American Heart Association Guidelines recommend the use of therapeutic hypothermia in adult cardiac arrest patients when the initial rhythm is ventricular fibrillation. These recommendations are based on primary research in patients with a cardiac cause of their ventricular fibrillation. Case ReportA 43-year-old male was brought to our emergency department (ED) with commotio cordis. He was struck in the chest with a baseball bat, after which he collapsed at the scene and was pulseless. Return of spontaneous circulation was achieved after defibrillation by treating paramedics, and the patient remained comatose on arrival to the ED. He was transferred to the intensive care unit and treated with therapeutic hypothermia at target temperature of 32−34°C. He was extubated on day 3, and discharged home on day 8 with good neurologic function. Why Should An Emergency Physician Be Aware of This?We report a case of commotio cordis in which the adult patient was treated with therapeutic hypothermia and had a favorable outcome. To our knowledge, this is the first reported case of its kind. Evidence for the use of therapeutic hypothermia is incomplete in patients with a traumatic cause of cardiac arrest, such as commotio cordis, despite probable similarities in the pathophysiology of anoxic brain injury. Our case illustrates that there may be benefit from use of therapeutic hypothermia for a broader population than is currently recommended.

Mechanical versus manual chest compressions for cardiac arrest

This is the first update of the Cochrane review on mechanical chest compression devices published in 2011 (Brooks 2011). Mechanical chest compression devices have been proposed to improve the effectiveness of cardiopulmonary resuscitation (CPR). To assess the effectiveness of mechanical chest compressions versus standard manual chest compressions with respect to neurologically intact survival in patients who suffer cardiac arrest. We searched the Cochrane Central Register of Controlled Studies (CENTRAL; 2013, Issue 12), MEDLINE Ovid (1946 to 2013 January Week 1), EMBASE (1980 to 2013 January Week 2), Science Citation abstracts (1960 to 18 November 2009), Science Citation Index-Expanded (SCI-EXPANDED) (1970 to 11 January 2013) on Thomson Reuters Web of Science, biotechnology and bioengineering abstracts (1982 to 18 November 2009), conference proceedings Citation Index-Science (CPCI-S) (1990 to 11 January 2013) and clinicaltrials.gov (2 August 2013). We applied no language restrictions. Experts in the field of mechanical chest compression devices and manufacturers were contacted. We included randomised controlled trials (RCTs), cluster RCTs and quasi-randomised studies comparing mechanical chest compressions versus manual chest compressions during CPR for patients with atraumatic cardiac arrest. Two review authors abstracted data independently; disagreement between review authors was resolved by consensus and by a third review author if consensus could not be reached. The methodologies of selected studies were evaluated by a single author for risk of bias. The primary outcome was survival to hospital discharge with good neurological outcome. We planned to use RevMan 5 (Version 5.2. The Nordic Cochrane Centre) and the DerSimonian & Laird method (random-effects model) to provide a pooled estimate for risk ratio (RR) with 95% confidence intervals (95% CIs), if data allowed. Two new studies were included in this update. Six trials in total, including data from 1166 participants, were included in the review. The overall quality of included studies was poor, and significant clinical heterogeneity was observed. Only one study (N = 767) reported survival to hospital discharge with good neurological function (defined as a Cerebral Performance Category score of one or two), demonstrating reduced survival with mechanical chest compressions when compared with manual chest compressions (RR 0.41, 95% CI 0.21 to 0.79). Data from four studies demonstrated increased return of spontaneous circulation, and data from two studies demonstrated increased survival to hospital admission with mechanical chest compressions as compared with manual chest compressions, but none of the individual estimates reached statistical significance. Marked clinical heterogeneity between studies precluded any pooled estimates of effect. Evidence from RCTs in humans is insufficient to conclude that mechanical chest compressions during cardiopulmonary resuscitation for cardiac arrest are associated with benefit or harm. Widespread use of mechanical devices for chest compressions during cardiac events is not supported by this review. More RCTs that measure and account for the CPR process in both arms are needed to clarify the potential benefit to be derived from this intervention.

Association between initial prescribed minute ventilation and post-resuscitation partial pressure of arterial carbon dioxide in patients with post-cardiac arrest syndrome

BackgroundPost-cardiac arrest hypocapnia/hypercapnia have been associated with poor neurological outcome. However, the impact of arterial carbon dioxide (CO2) derangements during the immediate post-resuscitation period following cardiac arrest remains uncertain. We sought to test the correlation between prescribed minute ventilation and post-resuscitation partial pressure of CO2 (PaCO2), and to test the association between early PaCO2 and neurological outcome.MethodsWe retrospectively analyzed a prospectively compiled single-center cardiac arrest registry. We included adult (age ≥ 18 years) patients who experienced a non-traumatic cardiac arrest and required mechanical ventilation. We analyzed initial post-resuscitation ventilator settings and initial arterial blood gas analysis (ABG) after initiation of post-resuscitation ventilator settings. We calculated prescribed minute ventilation:MVmL/kg/min=tidalvolumeTV/idealbodyweightIBWxrespiratoryrateRRfor each patient. We then used Pearson’s correlation to test the correlations between prescribed MV and PaCO2. We also determined whether patients had normocapnia (PaCO2 between 30 and 50 mmHg) on initial ABG and tested the association between normocapnia and good neurological function (Cerebral Performance Category 1 or 2) at hospital discharge using logistic regression analyses.ResultsSeventy-five patients were included. The majority of patients were in-hospital arrests (85%). Pulseless electrical activity/asystole was the initial rhythm in 75% of patients. The median (IQR) TV, RR, and MV were 7 (7 to 8) mL/kg, 14 (14 to 16) breaths/minute, and 106 (91 to 125) mL/kg/min, respectively. Hypocapnia, normocapnia, and hypercapnia were found in 15%, 62%, and 23% of patients, respectively. Good neurological function occurred in 32% of all patients, and 18%, 43%, and 12% of patients with hypocapnia, normocapnia, and hypercapnia respectively. We found prescribed MV had only a weak correlation with initial PaCO2, R = -0.40 (P < 0.001). Normocapnia was associated with good neurological function, odds ratio 4.44 (95% CI 1.33 to 14.85).ConclusionsWe found initial prescribed MV had only a weak correlation with subsequent PaCO2 and that early Normocapnia was associated with good neurological outcome. These data provide rationale for future research to determine the impact of PaCO2 management during mechanical ventilation in post-cardiac arrest patients.

Prediction of Survival to Discharge Following Cardiopulmonary Resuscitation Using Classification and Regression Trees*

To predict the likelihood that an inpatient who experiences cardiopulmonary arrest and undergoes cardiopulmonary resuscitation survives to discharge with good neurologic function or with mild deficits (Cerebral Performance Category score = 1). Classification and Regression Trees were used to develop branching algorithms that optimize the ability of a series of tests to correctly classify patients into two or more groups. Data from 2007 to 2008 (n = 38,092) were used to develop candidate Classification and Regression Trees models to predict the outcome of inpatient cardiopulmonary resuscitation episodes and data from 2009 (n = 14,435) to evaluate the accuracy of the models and judge the degree of over fitting. Both supervised and unsupervised approaches to model development were used. 366 hospitals participating in the Get With the Guidelines-Resuscitation registry. Adult inpatients experiencing an index episode of cardiopulmonary arrest and undergoing cardiopulmonary resuscitation in the hospital. The five candidate models had between 8 and 21 nodes and an area under the receiver operating characteristic curve from 0.718 to 0.766 in the derivation group and from 0.683 to 0.746 in the validation group. One of the supervised models had 14 nodes and classified 27.9% of patients as very unlikely to survive neurologically intact or with mild deficits (< 3%); the best unsupervised model had 11 nodes and classified 21.7% as very unlikely to survive. We have developed and validated Classification and Regression Tree models that predict survival to discharge with good neurologic function or with mild deficits following in-hospital cardiopulmonary arrest. Models like this can assist physicians and patients who are considering do-not-resuscitate orders.