Higher Return Of Spontaneous Circulation Rate Research Articles

Chest compressions for pediatric organized rhythms: A hemodynamic and outcomes analysis

AimPediatric cardiopulmonary resuscitation (CPR) guidelines recommend starting CPR for heart rates (HRs) less than 60 beats per minute (bpm) with poor perfusion. Objectives were to (1) compare HRs and arterial blood pressures (BPs) prior to CPR among patients with clinician-reported bradycardia with poor perfusion (“BRADY”) vs. pulseless electrical activity (PEA); and (2) determine if hemodynamics prior to CPR are associated with outcomes. Methods and ResultsProspective observational cohort study performed as a secondary analysis of the ICU-RESUScitation trial (NCT028374497). Comparisons occurred (1) during the 15 seconds “immediately” prior to CPR and (2) over the two minutes prior to CPR, stratified by age (≤1 year, >1 year). Poisson regression models assessed associations between hemodynamics and outcomes. Primary outcome was return of spontaneous circulation (ROSC). Pre-CPR HRs were lower in BRADY vs. PEA (≤1 year: 63.8 [46.5, 87.0] min−1 vs. 120 [93.2, 150.0], p < 0.001; >1 year: 67.4 [54.5, 87.0] min−1 vs. 100 [66.7, 120], p < 0.014). Pre-CPR pulse pressure was higher among BRADY vs. PEA (≤1 year (12.9 [9.0, 28.5] mmHg vs. 10.4 [6.1, 13.4] mmHg, p > 0.001). Pre-CPR pulse pressure ≥ 20 mmHg was associated with higher rates of ROSC among PEA (aRR 1.58 [CI95 1.07, 2.35], p = 0.022) and survival to hospital discharge with favorable neurologic outcome in both groups (BRADY: aRR 1.28 [CI95 1.01, 1.62], p = 0.040; PEA: aRR 1.94 [CI95 1.19, 3.16], p = 0.008). Pre-CPR HR ≥ 60 bpm was not associated with outcomes. ConclusionsPulse pressure and HR are used clinically to differentiate BRADY from PEA. A pre-CPR pulse pressure >20 mmHg was associated with improved patient outcomes.

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

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

Abstract 220: Association Between Initial Defibrillator Pad Position And Outcomes For Out-of-hospital Cardiac Arrest Patients Presenting With Shockable Rhythms

Background: Ventricular fibrillation (VF) or ventricular tachycardia (VT) are the most treatable causes of out-of-hospital cardiac arrest (OHCA). Yet, it remains unknown if defibrillator pad position, placement in the anterior-posterior (AP) or anterior-lateral (AL) positions, impacts patient outcomes in VF/VT OHCA. Aim: Evaluate the association between initial defibrillator pad placement (AP vs. AL) and OHCA outcomes for patients presenting with VF/VT. Methods: This was a prospective observational study of non-traumatic OHCA patients with initial VF/VT on EMS rhythm analysis treated by a single EMS agency in the Portland Cardiac Arrest Epidemiologic Registry (PDX Epistry) from July 1st, 2019 through October 15th, 2022. Our primary outcome was return of spontaneous circulation (ROSC) at any time and secondary outcomes were ROSC at emergency department (ED) arrival, survival to admission, survival to discharge, and functional survival (cerebral perfusion category score of ≤2). We performed t-tests, chi-squared tests, and multivariable logistic regressions adjusting for age, sex, witness status, bystander interventions, arrest location, 911 call to EMS arrival time, and year of arrest. Results: A total of 243 OHCA patients met inclusion criteria and 232 (95.5%) had initial pad positioning documented (133 AP and 99 AL). Patients with AP placement had higher rates of ROSC at any time (72.2% vs. 47.5%, p&lt;0.001), survival to admission (56.4% vs. 41.4%, p=0.024), survival to discharge (36.1% vs. 24.2%, p=0.050), and functional survival (36.1% vs. 21.2%, p=0.012) compared to AL, with no difference for ROSC at ED arrival (52.6% vs. 40.4%, p=0.065). AP versus AL placement showed higher adjusted odds (aOR [95% CI]) for ROSC at any time (2.76 [1.55-4.93]) and functional survival (2.06 [1.05-4.05]), but not ROSC at ED arrival (1.50, [0.85-2.64]), survival to admission (1.69 [0.96-2.96]) or survival to discharge (1.68 [0.86-3.27]). Among patients with ROSC at ED arrival, patients with AP placement, had shorter times from 911 call to sustained ROSC (21.0 vs. 28.4 min, p=0.013). Conclusions: Initial AP pad placement, compared to AL, was associated with higher ROSC, a reduction in time to sustained ROSC, and higher functional survival for patients with VF/VT OHCA.

A Motorcycle Paramedic Increases the Survival Rate of Patients after OHCA.

Background and Objectives: Despite advancements in modern medicine, the survival rate of patients after out-of-hospital cardiac arrest (OHCA) remains low. The proportion of OHCA patients who could be saved under ideal circumstances is unknown. A significant portion of patients experience cardiac arrest due to irreversible conditions. The survival of patients with reversible causes depends on the prompt initiation of basic life support (BLS) and early defibrillation. In order to increase the chances of survival, the motorcycle paramedic (MP) project was implemented in Ljubljana in 2003. The MP is equipped with an AED. In the case of OHCA with a shockable rhythm, he performs defibrillation before the arrival of the emergency medical team (EMT). The aim of this study was to evaluate whether the MP, by reducing response times to OHCA patients, increases the survival and outcome of these patients compared to the EMT. Materials and Methods: A retrospective analysis of OHCA cases within the area covered by Ljubljana Emergency Medical Service (EMS) was conducted for the period from January 2003 to December 2022. Instances where the MP arrived at the scene before the EMT were considered MP interventions and classified as the MP group; all other interventions were classified as the EMT group. Results: Between January 2003 and December 2022, the EMT performed resuscitation on 3352 patients. In 316 cases, the MP was simultaneously activated and arrived at the scene before the EMT. The response time in the MP group was shorter compared to the EMT group (7.7 ± 4.1 min vs. 9.9 ± 6.5 min, p < 0.001). In 16 patients, return of spontaneous circulation (ROSC) was achieved before the arrival of the EMT. The MP group had a higher ROSC rate, a larger proportion of patients were discharged from the hospital and there were more patients with a good neurological outcome compared to the EMT group (44.3% vs. 36.9%, p = 0.009; 18.7% vs. 13.0%, p = 0.005; 15.9% vs. 10.6%, p = 0.004, respectively). Conclusion: This study has demonstrated that the implementation of the MP into the EMS in Ljubljana has resulted in shorter response times, an increased survival rate and improved neurological outcome for OHCA patients.

Clinical practice of emergency department-initiated extracorporeal cardiopulmonary resuscitation for cardiac arrest in adults.

Clinical practice of emergency department-initiated extracorporeal cardiopulmonary resuscitation for cardiac arrest in adults.

Identifying cardiac activity using focused ultrasound in non-shockable arrests

Background: Each year, around 60 000 people in the UK experience an out-of-hospital cardiac arrest. The introduction of additional diagnostic tools such as focused cardiac ultrasound (FoCUS) aids assessment and management of patients at the point of care. The Resuscitation Council guidance recommends its use where possible. Method: A systematic literature search was undertaken of two databases, PubMed and Science Direct primarily to identify literature relevant to the use of ultrasound in medical cardiac arrests where the prevailing cardiac rhythm was non-shockable. Results: A total of 10 papers were included in the review out of 242 identified from the search. Across all papers, three themes were identified: prognostication, identification of reversible causes and true pulseless electrical activity (PEA) versus pseudo PEA. Conclusion: The evidence shows there is an association between cardiac activity identified with FoCUS and an increase in return of spontaneous circulation (ROSC) rates. The effect of FoCUS for improving survival is not statistically significant; however, there is a higher likelihood of survival because of its ability to aid decision making. Patients with cardiac motion identified by FoCUS had higher ROSC rates than those without. Although the data suggest that the presence of cardiac activity is highly associated with ROSC, there is little literature surrounding long-term outcomes of patients, so the ability of FoCUS to determine survival cannot be confirmed.

Pediatric Out-of-Hospital Cardiac Arrests: An Epidemiological Study

Objective To identify the epidemiological patterns of pediatric out-of-hospital cardiac arrests (OHCA) in Queensland, Australia and to investigate associations between patient variables and prehospital outcome. Methods Included were pediatric (>4 days–18 years) OHCA patients attended by paramedics in the state of Queensland (Australia) between January 2009 and December 2019. Patient and arrest characteristics were described. Factors associated with return of spontaneous circulation (ROSC) on hospital arrival were investigated. Results A total of 1,612 pediatric patients were included; 611 were deceased prior to paramedic arrival and 1,001 received resuscitation attempts by paramedics. Approximately one quarter (26.8%) of resuscitation-attempted patients achieved ROSC on hospital arrival. Most arrests (49.7%) were due to medical causes. Arrests due to trauma had the lowest rate of ROSC on hospital arrival (9.6%), whereas those due to drug overdose had the highest rate (40%). Patients in rural areas had a lower rate of ROSC on hospital arrival than those in metropolitan areas (20.7% vs 32.5%, p < 0.001). The median response interval to all OHCA patients was 8 minutes. Trauma was considerably more prevalent in rural areas than in metropolitan areas, while all other etiologies were comparable. Older pediatric age groups had higher rates of ROSC on hospital arrival than infants, particularly early adolescents (39.4% vs. 14.9%, p = 0.001). Etiology, age, bystander witness, shockable initial rhythm, and geographic locality factors were independently associated with ROSC on hospital arrival. Conclusions Approximately a quarter of pediatric prehospital OHCA achieved ROSC on hospital arrival. Prehospital outcome differs according to patient cohort and is associated with diverse patient demographic variables.

Whole Blood Selective Aortic Arch Perfusion for Exsanguination Cardiac Arrest: Assessing Myocardial Tolerance to the Duration of Cardiac Arrest.

Selective aortic arch perfusion (SAAP) is an endovascular technique that consists of aortic occlusion with perfusion of the coronary and cerebral circulation. It been shown to facilitate return of spontaneous circulation (ROSC) after exanguination cardiac arrest (ECA), but it is not known how long arrest may last before the myocardium can no longer be durably recovered. The aim of this study is to assess the myocardial tolerance to exsanguination cardiac arrest before successful ROSC with SAAP. Male adult swine (n = 24) were anesthetized, instrumented, and hemorrhaged to arrest. Animals were randomized into three groups: 5, 10, and 15 min of cardiac arrest before resuscitation with SAAP. Following ROSC, animals were observed for 60 min in a critical care environment. Primary outcomes were ROSC, and survival at 1-h post-ROSC. Shorter cardiac arrest time was associated with higher ROSC rate and better 1-h survival. ROSC was obtained for 100% (8/8) of the 5-min ECA group, 75% (6/8) of the 10-min group, 43% (3/7) of the 15-min group (P = 0.04). One-hour post-ROSC survival was 75%, 50%, and 14% in 5-, 10-, and 15-min groups, respectively (P = 0.02). One-hour survivors in the 5-min group required less norepinephrine (1.31 mg ± 0.83 mg) compared with 10-SAAP (0.76 mg ± 0.24 mg), P = 0.008. Whole blood SAAP can accomplish ROSC at high rates even after 10 min of unsupported cardiac arrest secondary to hemorrhage, with some viability beyond to 15 min. This is promising as a tool for ECA, but requires additional optimization and clinical trials.Animal Use Protocol, IACUC: 0919015.

Near-infrared spectroscopy during cardiopulmonary resuscitation for pediatric cardiac arrest: A prospective, observational study

AimCerebral oxygenation (rSO2) is not routinely measured during pediatric cardiopulmonary resuscitation (CPR). We aimed to determine whether higher intra-arrest rSO2 was associated with return of spontaneous circulation (ROSC) and survival to hospital discharge. MethodsProspective, single-center observational study of cerebral oximetry using near-infrared spectroscopy (NIRS) during pediatric cardiac arrest from 2016 to 2020. Eligible patients had ≥30 s of rSO2 data recorded during CPR. We compared median rSO2 and percentage of rSO2 measurements above a priori thresholds for the entire event and the final five minutes of the CPR event between patients with and without ROSC and survival to discharge. ResultsTwenty-one patients with 23 CPR events were analyzed. ROSC was achieved in 17/23 (73.9%) events and five/21 (23.8%) patients survived to discharge. The median rSO2 was higher for events with ROSC vs. no ROSC for the overall event (62% [56%, 70%] vs. 45% [35%, 51%], p = 0.025) and for the final 5 minutes of the event (66% [55%, 72%] vs. 43% [35%, 44%], p = 0.01). Patients with ROSC had a higher percentage of measurements above 50% during the final five minutes of CPR (100% [100%, 100%] vs. 0% [0%, 29%], p = 0.01). There was no association between rSO2 and survival to discharge. ConclusionsHigher cerebral rSO2 during CPR for pediatric cardiac arrest was associated with higher rates of ROSC but not with survival to discharge.

Prehospital predictors for return of spontaneous circulation in traumatic cardiac arrest.

Traumatic cardiac arrests (TCAs) are associated with high mortality and the majority of deaths occur at the prehospital scene. The aim of the present study was to assess, in a prehospital physician-led emergency medical system, the factors associated with sustained return of spontaneous circulation (ROSC) in TCA, including advanced life procedures. The secondary objectives were to assess factors associated with 30-day survival in TCA, evaluate neurological recovery in survivors, and describe the frequency of organ donation among patients experiencing a TCA. We conducted a retrospective study of all TCA patients included in the French nationwide cardiac arrest registry from July 2011 to November 2020. Multivariable logistic regression analysis was used to identify factors independently associated with ROSC. A total of 120,045 out-of-hospital cardiac arrests were included in the registry, among which 4,922 TCA were eligible for analysis. Return of spontaneous circulation was sustained on-scene in 21.1% (n = 1,037) patients. Factors significantly associated with sustained ROSC were not-asystolic initial rhythms (pulseless electric activity (odds ratio [OR], 1.81; 95% confidence interval [CI], 1.40-2.35; p < 0.001), shockable rhythm (OR, 1.83; 95% CI, 1.12-2.98; p = 0.016), spontaneous activity (OR, 3.66; 95% CI, 2.70-4.96; p < 0.001), and gasping at the mobile medical team (MMT) arrival (OR, 1.40; 95% CI, 1.02-1.94; p = 0.042). The MMT interventions significantly associated with ROSC were as follows: intravenous fluid resuscitation (OR, 3.19; 95% CI, 2.69-3.78; p < 0.001), packed red cells transfusion (OR, 2.54; 95% CI, 1.84-3.51; p < 0.001), and external hemorrhage control (OR, 1.74; 95% CI, 1.31-2.30; p < 0.001). Among patients who survived (n = 67), neurological outcome at Day 30 was favorable (cerebral performance categories 1-2) in 72.2% cases (n = 39/54) and 1.4% (n = 67/4,855) of deceased patients donated one or more organ. Sustained ROSC was frequently achieved in patients not in asystole at MMT arrival, and higher ROSC rates were achieved in patients benefiting from specific advanced life support interventions. Organ donation was somewhat possible in TCA patients undergoing on-scene resuscitation. Prognostic and epidemiologic, Level III.

PREDICTIVE VALUE OF CLINICAL MEASURES FOR RSO2 DURING IN-HOSPITAL CARDIAC ARREST

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: Cerebral oximetry is a non-invasive method of monitoring regional cerebral oxygenation (rSO2). rSO2 has been proposed as an alternative to end-tidal CO2 (ETCO2) as a predictor of return of spontaneous circulation (ROSC) and end-organ perfusion. Previously, we demonstrated that higher rSO2 is associated with higher rates of ROSC and improved neurologic recovery in in-hospital cardiac arrest (IHCA) patients. However, there are currently no studies examining patient-specific, peri-cardiac arrest variables that correlate with higher rSO2. Identifying modifiable variables can help tailor patient-specific interventions in addition to ACLS to optimize rSO2 and improve survival and neurologic recovery from IHCA. The aim of this study was to identify which clinical variables, particularly modifiable ones, are predictive of a higher rSO2. METHODS: We performed an ancillary cohort analysis of data collected as part of an ongoing multicenter prospective study of adult IHCA in 15 hospitals across the US and UK. rSO2 values were collected in real-time using a portable near-infrared spectroscopy device (SedLine, Nonin). Demographics, vitals, and labs were collected via chart review. Among 323 adult IHCA patients, under a multivariable regression model, we investigated the predictive value of age, hemoglobin (hgb), partial pressure of oxygen (PaO2), epinephrine dose, and APACHE II score for mean rSO2. Using two-sample t-tests, we also investigated the difference in mean rSO2 in relation to sex, shockable versus non-shockable rhythm, and manual versus mechanical CPR. RESULTS: We demonstrated a small, statistically significant, negative correlation for hgb (coefficient = -0.17, p = 0.03). Due to the unexpected negative correlation, an individual linear regression was performed, demonstrating no statistically significant correlation (coefficient = -0.14, p = 0.07). We did not find any statistically significant correlation with the other variables. We also did not find a statistically significant difference in mean rSO2 in relation to sex, initial rhythm, and type of CPR. CONCLUSIONS: Our study demonstrates no statistically significant correlation between PaO2, hgb, epinephrine dose, APACHE II scores, and rSO2. The lack of correlation for hgb is particularly interesting, as hgb has been demonstrated to positively correlate with rSO2 in healthy individuals. However, there are limitations to this study. Intra-cardiac paO2 and hgb were generally high in our sample size (92 mmHg and 14.0 g/dL, respectively), which may explain the lack of statistical significance. In addition, rSO2 data from each individual patient across the duration of CPR is variable, and utilizing mean rSO2 may be an oversimplification. CLINICAL IMPLICATIONS: The current standard of care is to apply a single ACLS protocol to an inherently heterogeneous group of patients undergoing cardiac arrest. As a result, there is ongoing interest in identifying modifiable variables to optimize survival and neurologic recovery. Our study demonstrates that clinical measures we expect to correlate with ROSC and neurologic recovery may not actually have a very large impact on clinical outcome. However, given the limitations of this study, further studies need to be conducted to identify and tailor patient-specific approaches to enhance resuscitative care. DISCLOSURES: No relevant relationships by Hon Chau, source=Web Response No relevant relationships by Elise Huppert, source=Web Response No relevant relationships by Sam Parnia, source=Web Response No relevant relationships by Thaddeus Tarpey, source=Web Response No relevant relationships by Jing Xu, source=Web Response

Immediate intravenous epinephrine versus early intravenous epinephrine for in-hospital cardiopulmonary arrest

BackgroundIntravenous epinephrine has been a key treatment in cardiopulmonary arrest since the early 1960s. The ideal timing for the first dose of epinephrinee is uncertain. We aimed to investigate the association of immediate epinephrine administration (within 1-min of recognition of cardiac arrest) with return of spontaneous circulation (ROSC) up to 24-h.MethodsThis was a multicenter retrospective analysis of patients who underwent cardiopulmonary resuscitation. We included the following patients: 1) ≥18 years-old, 2) non-shockable rhythms, 3) received intravenous epinephrine during cardiopulmonary resuscitation, 4) witnessed in-hospital arrest and 5) first resuscitation attempt (for patients requiring more than one resuscitation attempt). We excluded patients who suffered from traumatic arrest, were pregnant, had shockable rhythms, arrested in the operating room, with Do-Not-Resuscitate (DNR) order, and patient aged 17 years-old or less.ResultsA total of 360 patients were included in the analysis. Median age was 62 years old and median epinephrine administration time was two minutes. We found that immediate epinephrine administration (within 1-min) is associated with higher rates of ROSC up to 24-h (OR = 1.25, 95% CI; [1.01–1.56]), compared with early epinephrine (≥2-min) administration. After adjusting for confounding covariates, earlier administration of epinephrine predicted higher rates of ROSC sustained for up to 24-h (OR 1.33 95%CI [1.13–1.55]).ConclusionsImmediate administration of epinephrine in conjunction with high-quality CPR is associated with higher rates of ROSC.

Abstract 132: Cardiopulmonary Resuscitation with Chest Compressions During Sustained Inflations in a Pediatric Porcine Model - A Randomized Control Animal Trial

Background: Pediatric resuscitation guidelines recommend continuous chest compressions (CC) with asynchronized ventilation (CCaV) during cardiopulmonary resuscitation (CPR) once an airway has been secured. However, the optimal CC technique remains unknown. Aim: To determine if CCs during sustained inflations (SI) improves return of spontaneous circulation (ROSC) of asphyxiated pediatric piglets compared to CCaV. Intervention and measurements: Piglets (age 20-23 days) were anesthetized, intubated, instrumented, and asphyxiated. Protocolized resuscitation was initiated when mean arterial blood pressure was &lt;25mmHg with bradycardia. Piglets (n=12/group) were randomized to receive CCaV resuscitation (CCaV group) according to the current resuscitation guidelines, or CC during SI (CC+SI group). The CC+SI group received a SI with a peak inflating pressure of 25 cmH 2 O for 30sec, CCs were provided at a rate of 100/min, and SI was interrupted after 30 sec for one second before a further 30sec SI was provided. CC and SI were continued until ROSC. Respiratory parameters, carotid blood flow, systemic artery pressures, and cerebral oxygenation were measured. Main results: Median (IQR) time to ROSC was significantly decreased in the CC+SI group compared to CCaV with 248 (41-346)sec vs. 720 (167-720)sec (p=0.049), respectively. CC+SI had a 100% higher rate of ROSC compared to CCaV with 10(83%) vs. 5(42%) (p=0.089), respectively. Piglets in the CC+SI group received a median (IQR) 3.5 (0-5.8) intravenous epinephrine boluses compared to 8.0 (1.8-11) in the CCaV group (p=0.123). Conclusions: Combining CC and SI significantly improved time to ROSC and survival in asphyxiated pediatric piglets when compared to the current standard of CCs with CCaV during pediatric CPR.

The landscape of paediatric in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit

AimTo report the patient characteristics and clinical outcome of paediatric in-hospital cardiac arrest in the United Kingdom (UK) National Cardiac Arrest Audit (NCAA) database. MethodsAnalysis of all recorded paediatric cardiac arrests in the NCAA dataset over a seven-year period ending on 31 December 2018, within acute children’s hospitals (including standalone paediatric hospitals and hospitals with tertiary paediatric services) and acute general hospitals participating in NCAA. In this period 1456 patients (with 1580 events), 1 month to 16 years of age, received chest compressions and/or defibrillation and were attended by a hospital-based resuscitation team in response to an emergency call. The main outcome measure was survival to discharge. ResultsFor this cohort of paediatric in-hospital cardiac arrest patients the overall rates of sustained return of spontaneous circulation (ROSC) were 69.1% with unadjusted survival to hospital discharge of 54.2%. The presenting rhythm was shockable in 4.3% of events and non-shockable in 82.1% (remainder undetermined); rates of survival to hospital discharge associated with these rhythms were 63.9% and 51.7%. A difference in outcomes was observed between Children’s hospitals and acute general hospitals with ROSC rates of 79.1% and 55.5% respectively and survival to hospital discharge rates of 57.7% and 49.3% respectively. ConclusionsThese first results from the NCAA database describing the outcome of paediatric in-hospital cardiac arrest in UK hospitals will serve as a benchmark from which to assess the future impact of changes in service delivery, organisation and treatment for in-hospital cardiac arrest in young people. Outcomes for specialist paediatric centres should be studied further as higher rates of ROSC and survival to hospital discharge were observed.

An outcome study of adult in-hospital cardiac arrests in non-monitored areas with resuscitation attempted using AED.

To investigate the outcomes of patients with in-hospital cardiac arrest (IHCA) who underwent cardiopulmonary resuscitation (CPR) using an automated external defibrillator (AED) in non-monitored areas. Additionally, to detect correlated factors associated with rate of return of spontaneous circulation (ROSC) and survival rate, among collected data. This study included 109 patients. After investigating patient characteristics and resuscitation-related factors, the correlated factors associated with ROSC rates and survival rate were analyzed using univariate and multivariate analyses. The rate of survival to hospital discharge was 21.1%. CPR with AED performed since 2013 was associated with a higher ROSC rate (adjusted odds ratio [AOR] 3.24, 95% confidence interval [CI]: 1.21 to 9.52, p<0.05), but not with the survival rate after ROSC. Tracheal intubation was significantly associated with a higher ROSC rate (AOR 3.62, 95% CI: 1.27 to 11.7, p<0.05) and a lower survival rate after ROSC (hazard ratio 6.6, 95% CI: 1.2 to 43.3, p<0.05). Dysrhythmia as the cause of cardiac arrest and intensive care unit (ICU) admission after ROSC were associated with higher survival rates (hazard ratio 0.056, 95% CI: 0.004 to 0.759, p<0.05, and hazard ratio 0.072, 95% CI: 0.017 to 0.264, p<0.0001, respectively). The factors associated with ROSC rate and those associated with the survival rate after ROSC were different. Although initial shockable rhythms on AED were not associated with the survival rate, dysrhythmia as the etiology of cardiac arrest, and ICU admission were significantly associated with higher survival rates after ROSC.

Abstract 29: Comparison of Amiodarone versus Lidocaine for Treatment of In-Hospital Cardiac Arrest

Introduction: Over 200,000 patients are treated annually in the United States for in-hospital cardiac arrest (IHCA). Patients with an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) have a survival rate of less than 50%. The current American Heart Association (AHA) Advanced Cardiovascular Life Support guidelines suggest amiodarone or lidocaine as first-line agents for shock-refractory VF/pVT based on randomized clinical trials in adults with out-of-hospital cardiac arrest. Based on these results, we hypothesized that amiodarone and lidocaine have equivalent efficacy in treating hospitalized patients with VF/pVT. Methods: This is a retrospective risk-adjusted cohort study using the AHA Get with the Guidelines-Resuscitation® (GWTG-R) registry. The study included adult patients between January 1, 2000 to December 31, 2014 with IHCA due to VF/pVT that received either amiodarone or lidocaine. The primary outcome was return of spontaneous circulation (ROSC). Secondary outcomes were 24-hour survival, survival to hospital discharge, and survival with favorable neurologic outcome based on Cerebral Performance Category (CPC) 1 or 2. Results: A total of 14,630 events were included in the analysis. Among patients who met inclusion criteria, 68.7% (n=10,058) were treated with amiodarone and 31.3% (n=4,572) were treated with lidocaine. Results from multivariable logistic regression analysis showed that, controlling for 19 covariates, ROSC rates were not statistically different with lidocaine treatment vs. amiodarone (AOR = 1.02, 95% CI 0.94, 1.11). However, lidocaine treatment was associated with higher odds of a) 24-hour survival, AOR = 1.14, 95% CI 1.06, 1.23; b) survival to discharge, AOR = 1.15, 95% CI 1.06, 1.24; and c) favorable neurologic outcome at hospital discharge, AOR = 1.21, 95% CI 1.11, 1.31. Conclusion: In adult IHCA patients with VF/pVT, treatment with lidocaine compared to amiodarone was not associated with higher ROSC rates, but was associated with higher rates of survival and favorable neurological outcomes. Additional research is needed to determine the optimal antiarrhythmic therapy for VF/pVT in IHCA.

Effects of Endotracheal Administration of Epinephrine in Cardiac Arrest of Adult and Pediatric Swine

BACKGROUND: Few studies have investigated the effects of hypovolemia on area under the curve (AUC) and the return of spontaneous circulation (ROSC) comparing adults and children in cardiac arrest.AIMS: To compare the epinephrine endotracheal (ET) administration relative to AUC, rate, time to, and odds of achieving ROSC between hypovolemic adult and pediatric cardiac arrest models.METHODS: This was an experimental study using male Adult ET and Pediatric ET swine. Pediatric ET pigs (N=7) weighed 20-30 kg representing the average weight for a child between 5 and 6 years of age. Adult ET pigs (N=7) weighed 60 to 80 kg. All were exsanguinated 35% of their blood volume. Swine were put into arrest for 2 minutes. Cardiopulmonary resuscitation (CPR) was initiated for 2 minutes; epinephrine was then administered. Blood samples were collected over 5 minutes. RESULTS: No significant difference occurred in AUC between the groups (p &gt; 0.05). The Pediatric ET group had higher rates of ROSC and a shorter time to ROSC (p &lt; 0.05). Pediatric ET group had a 15 times greater odds of achieving ROSC compared to the Adult ET group. CONCLUSION: Based on the results of this study, we recommend epinephrine administration via ET within the pediatric arrest model, but not for the adult.

Abstracts for the 2019 NAEMSP Scientific Assembly

The approach to managing out-of-hospital cardiac arrest (OOHCA) has generally involved either minimal on-scene resuscitation to reduce time to arrival at hospital or extended care at the scene to increase the chance of return of spontaneous circulation (ROSC) before transport. This study compared patient outcomes across EMS agencies with respect to the duration of on-scene time. We hypothesized that EMS agencies with greater average time on-scene would have more favorable outcomes. The Cardiac Arrest Registry to Enhance Survival (CARES) was used to identify OOHCA cases, including characteristics and outcomes. EMS agencies were included if they submitted at least 80 OOHCAs from 2013 to 2017. To study outcomes based upon culture of OOHCA management, outcomes were studied by EMS agency rather than by individual patient cases. Agencies in the top and bottom quartiles of on-scene time duration were categorized as high (HOSTAs) and low on-scene time agencies (LOSTAs), respectively. Generalized estimating equation models compared HOSTAs and LOSTAs. We classified 89 agencies as HOSTAs (24,114 patients, average ≥25 minutes on scene) and 89 agencies as LOSTAs (37,297 patients, average <18.9 minutes on-scene). Among patients transported, HOSTAs were more likely to have a shockable rhythm (28.4% vs. 22.2%, OR = 1.4, 95%CI 1.2 to 1.5), a witnessed arrest (65.1% vs. 53.6%, OR = 1.7, 95% CI 1.5 to 1.9), and receive bystander CPR (41.9% vs. 37.0%, OR = 1.3, 95% CI 1.1 to 1.5) than LOSTAs, all p < 0.001. When controlling for these and other patient characteristics, including mechanical CPR device use, HOSTAs had a higher proportion of ROSC on emergency department arrival (66.7% vs. 31.1%, OR = 4.6, 95%CI 3.5 to 6.0, p < 0.001), survival to discharge for transported patients (22.3% vs. 11.2%, OR = 2.6, 95%CI 2.0 to 3.4, p < 0.001), and good neurologic outcome among survivors (84.9% vs. 78.6%, OR = 1.3, 95%CI = 1.0 to 1.7, p = 0.04) than LOSTAs. This study suggests that HOSTAs have more favorable patient outcomes compared to LOSTAs. RESULTS indicate that spending more time on-scene performing resuscitation is associated with higher rates of ROSC, survival and survival with good neurologic function.

Gender Disparities in Out-of-hospital Cardiac Arrests.

BackgroundDespite advances in resuscitation science and public health, out-of-hospital cardiac arrest (OOHCA) has an average survival rate of only 12% nationwide, compared to 24.8% of patients who suffer from cardiac arrest while in hospital. Additionally, gender is an important element of human health, and there is a clear pattern for gender-specific survivability in cardiac arrest. This study examined differences in presentations, treatment, management, and outcomes.AimThe primary focus of this study was to shed light on differences in presentations, treatments, and outcomes between men and women suffering from an out-of-hospital cardiac arrest and the accompanying contributing factors.MethodsAll emergency medical services-related data, including age, date, initial rhythm, chemical interventions (i.e., epinephrine, dextrose), blood glucose levels, defibrillations, endotracheal tube (ETT) attempts, final airway management, achievement of return of spontaneous circulation (ROSC), and the conclusion of the case up to the emergency department, were recorded using a standardized emergency medical services (EMS) charting record by the highest-ranking EMS provider on the ambulance. The reports were retrospectively collected and analyzed.ConclusionThe study examined demographics, treatments rendered, and outcomes in OOHCA cases that occurred in a major United States (US) city in 2016. Several significant differences in care were noted between men and women. In general, women received less respiratory, chemical, and electrical interventions than men; however, statistically significant differences were only observed in the number of attempts of endotracheal intubations, number of doses of epinephrine per encounter, and number of defibrillations per encounter. In spite of generally receiving less care, women appeared to respond more favorably to cardiac arrest interventions, as demonstrated by higher rates of ROSC. Despite this, women were also found to be eight years older at the time of arrest. Future studies are needed to determine causality in discrepancies between the genders in addition to investigating differences in treatment in other areas of the United States.

Impact of cardiopulmonary resuscitation time on the effectiveness of emergency department thoracotomy after blunt trauma.

Debate remains about the threshold cardiopulmonary resuscitation (CPR) duration associated with futile emergency department thoracotomy (EDT). To validate the CPR duration associated with favorable outcomes, we investigated the relationship between CPR duration and return of spontaneous circulation (ROSC) after EDT in blunt trauma. A retrospective observational study was conducted at three tertiary centers over the last 7years. We included bluntly injured adults who were pulseless and required EDT at presentation, but excluded those with devastating head injuries. After multivariate logistic regression identified the CRP duration as an independent predictor of ROSC, receiver operating characteristic curves were used to determine the threshold CPR duration. Patient data were divided into short- and long-duration CPR groups based on this threshold, and we developed a propensity score to estimate assignment to the short-duration CPR group. The ROSC rates were compared between groups after matching. Forty patients were eligible for this study and ROSC was obtained in 12. The CPR duration was independently associated with the achievement of ROSC [odds ratio 1.18; 95% confidence interval (CI) 1.01-1.37, P = 0.04], and the threshold CPR duration was 17min. Among the 14 patients with a short CPR duration, 13 matched with the patients with a long CPR duration, and a short CPR duration was significantly associated with higher rates of ROSC (odds ratio 8.80; 95% CI 1.35-57.43, P = 0.02). A CPR duration < 17min is independently associated with higher ROSC rates in patients suffering blunt trauma.