Impact Of Cardiopulmonary Resuscitation Research Articles

Fat embolism: a systematic review to facilitate the development of standardised procedures in pathology.

Fat embolism (FE) is a historically recognised but still actively researched topic in forensic pathology. Several aspects remain not fully elucidated, such as its aetiopathogenesis, its causal role in death determination, the impact of interfering factors (e.g. cardiopulmonary resuscitation or other medical procedures) and both qualitative and quantitative diagnostic methodologies in clinical and forensic contexts. These issues are further underscored by the potential involvement of FE in the causal determination of non-traumatic deaths, which often raises questions of professional liability. The present study aims to provide a comprehensive and up-to-date overview of the most recent scientific evidence relevant to forensic pathology. Our systematic research has included 58 articles from 1990 to the present on the topic of FE and fat embolism syndrome (FES). From these articles, we identified 45 case reports, from which the authors' descriptions were extracted to provide information on individual cases and the operational methods of forensic pathologists. Additionally, 21 experimental studies were identified, and their key findings have been summarised narratively. It has emerged that both traumatic and non-traumatic cases are frequently reported in the forensic context, with orthopaedic and cosmetic surgery being among the highest-risk specialities. Experimental studies have re-evaluated the role of a patent foramen ovale in the pathogenesis of FE, as well as the impact of cardiopulmonary resuscitation in causing FE severe enough to result in death. Additionally, there are new findings regarding diagnostic techniques, including radiological and immunohistological methods; however, they have not yet fully bridged the reliability gap compared to an accurate autopsy-histological evaluation. The major critical points that emerged include the lack of complete and detailed information on premortem clinical conditions, the underutilisation of grading systems and the methodological heterogeneity applied, resulting in considerable variability regarding the organs studied histologically and the diagnostic techniques used. Despite the limitations associated with the analysis of case reports and the heterogeneity of included experimental studies, we believe that this study can provide a comprehensive overview of the FE topic. It furnishes pathologists with an updated overview useful for clinical practice and guiding future research trends, as well as facilitating the development of standardised procedures.

Impact of Cardiopulmonary Resuscitation on Emergency Medical Staff-Romanian Perspective (IRESUS-EMS).

Background: Unnecessary resuscitation is defined as putting in a disproportionate amount of effort compared to the patients’ prognosis and chance of survival. The primary objective of this study was to determine the number of resuscitations perceived as unnecessary by emergency medical personnel and to correlate it with the characteristics of resuscitation team members, patient particularities and organizational factors related to the professional environment. Methods: This was a prospective cross-sectional study carried out in the emergency department of a university hospital, exploring the perception of the uselessness of cardiopulmonary resuscitation (CPR) through the completion of a questionnaire. Results: In total, 70.37% of respondents are often involved in CPR attempts in which the efforts made are disproportionate compared to the patients’ expected prognosis, in terms of survival or quality of life. The presence of a non-shockable rhythm increased, by two times, the chances of medical staff finding it unnecessary to initiate CPR. Conclusions: The current study was the first in Romania to investigate the perception of unnecessary CPR, based on the recollection of the last resuscitation performed by the emergency medical staff. The objective criteria related to the patient were the most important predictors for assessing the adequacy of the decision to initiate CPR.

Impact of cardiopulmonary resuscitation on outcome of kidney transplantations from braindead donors aged ≥65 years.

Patients with a history of cardiopulmonary resuscitation (CPR) and subsequent brain death are frequently evaluated for organ donation. Whether kidneys from ≥65-year-old braindead donors with a history of CPR can be transplanted with satisfactory outcomes is unknown. All kidney transplants (KTs) from ≥65-year-old donors performed at our center from 1999 to 2018 (n=185) were retrospectively analyzed and outcome was compared for KTs from donors with and without a history of CPR (n=27 and n=158, respectively). No significant differences in the incidence of delayed graft function (DGF) as well as 1- and 3-year graft function were observed between the CPR and the no-CPR group (DGF: 26.0%vs. 31.0%, p=.76; 1-year serum creatinine: 150.4μmol/L vs. 177.0μmol/L, p=.11; 3-year serum creatinine: 150.4μmol/L vs. 168.2μmol/L, p=.52, respectively). Death-censored graft survival was comparable after 1 and 5 years (CPR group: 81.5% and 76.7%vs. no-CPR group: 86.6% and 75.7%, p=.70). Likewise, patient survival was not significantly different. Multivariable Cox regression analysis also did not identify CPR as a significant risk factor for graft loss or death. Our study suggests that, following stringent donor selection, the outcome of KTs from ≥65-year-old braindead donors with and without a history of CPR is comparable.

Impact of cardiopulmonary resuscitation on organ donation in Switzerland.

The lack of suitable donor organs limits the number of solid organ transplants. Patients who underwent cardiopulmonary resuscitation (CPR) after cardiac arrest may represent a sizeable subgroup of deceased organ donors, as they often progress to brain death or have life-sustaining therapy withdrawn. We aimed to quantify deceased organ donation after CPR in Switzerland for the first time by analysing the characteristics of potential and utilised organ donors after CPR. Data on deceased adult and paediatric patients who were reported to and approved by Swisstransplant for organ donation were analysed, including both donation after brain death (DBD) and donation after controlled cardiocirculatory death (cDCD) from 2016 to 2018. We analysed baseline characteristics of potential donors who underwent CPR in the context of their hospitalisation, as compared with donors without prior CPR. Considering the varying characteristics between these two donor groups, we assessed the effect of CPR on different allocation outcomes (donor and organ utilisation, organ yield per utilised donor) using multivariable regression. Additionally, we present selected CPR circumstances and compared different subgroups of CPR donors according to duration of CPR and duration of no-flow time. Of the 461 deceased potential organ donors included in the analysis, 173 (37.5%) underwent CPR. CPR donors were, on average, younger (median age 53 vs 62, p <0.001), had different causes of death (p <0.001), and were more often of the cDCD type (30.1% vs 18.4%, p = 0.004) as compared with non-CPR donors. Of the 173 CPR donors, 152 (87.9%) could be utilised (minimum one organ transplanted), and in the multivariable analysis, utilisation rate was higher in the CPR donor group than in the non-CPR donor group (odds ratio 3.3, 95% confidence interval 1.1–11.5; p = 0.046). Organ specific utilisation of heart, liver, and kidney, and total organ yield per donor, did not differ significantly between CPR and non-CPR donors. Our study reveals that a substantial proprotion of deceased organ donors in Switzerland underwent CPR in context of their hospitalisation. CPR donors are different from non-CPR donors with respect to age, cause of death and donation type. However, when carefully selected according to their haemodynamic condition, CPR donors are comparable to non-CPR donors in terms of donor and organ utilisation, as well as the average organ yield. Thus, all patients who are resuscitated from cardiac arrest but who subsequently progress to death should be evaluated for organ donation. How CPR donors compare with non-CPR donors regarding transplant outcomes should be studied further.

The impact of cardiopulmonary resuscitation (CPR) training on schoolchildren and their CPR knowledge, attitudes toward CPR, and willingness to help others and to perform CPR: mixed methods research design

BackgroundThe benefits of cardiopulmonary resuscitation training for schoolchildren are well known, but the appropriate age for introducing training is still being discussed. This is a very important issue, since out-of-hospital cardiac arrest is a major public health concern. The objective of this study was to investigate the effects of implemented cardiopulmonary resuscitation training on the knowledge of schoolchildren in the last three grades of Slovenian elementary schools and theirs willingness, attitudes, and intentions toward helping others and performing cardiopulmonary resuscitation. The experience of training instructors was also explored.MethodsA mixed methods research design was employed, using a Separate Pre-Post Samples Design and focus groups. Research was conducted in 15 Slovenian public elementary schools offering cardiopulmonary resuscitation training. Focus groups included training instructors and developers. Data was collected with a structured questionnaire from April to June 2018 and analyzed using univariate and bivariate analyses. The three focus groups were convened in September and October 2018. Content analysis of the discussion transcriptions was conducted. The sample included 764 schoolchildren aged 12.5–14.5 years before cardiopulmonary resuscitation training and 566 schoolchildren after training. Three non-homogeneous focus groups included eight cardiopulmonary resuscitation instructors.ResultsSignificant progress in cardiopulmonary resuscitation knowledge was noted after training implementation, with the greatest progress seen in the youngest age group (mean age 12.5). The greatest increase after training was seen for the variables Attitude toward helping others (p = 0.001) and Self-confidence (p = 0.001). Analysis of the focus groups yielded two themes: (a) the effects of cardiopulmonary resuscitation training on schoolchildren, and (b) the systemic responsibility of the school system and professional bodies.ConclusionsSignificant progress in schoolchildren’s cardiopulmonary resuscitation knowledge after training was established. Early introduction of training is recommended. Cardiopulmonary resuscitation knowledge raises awareness of the responsibility to help others and increases self-confidence to provide bystander cardiopulmonary resuscitation. It can be concluded that early cardiopulmonary resuscitation training for children is crucial. It should be a mandatory part of school curricula in those countries where cardiopulmonary resuscitation is not yet mandatory.

Impact of cardiopulmonary resuscitation on a cannot intubate, cannot oxygenate condition: a randomised crossover simulation research study of the interaction between two algorithms

ObjectivesDuring a ‘cannot intubate, cannot oxygenate’ situation, asphyxia can lead to cardiac arrest. In this stressful situation, two complex algorithms facilitate decision-making to save a patient’s life: difficult airway management...

116.5: Assessment of impact of cardiopulmonary resuscitation on short and midterm results of cardiac transplantation.

116.5: Assessment of impact of cardiopulmonary resuscitation on short and midterm results of cardiac transplantation.

Impact of Cardiopulmonary Resuscitation on Cardiac Transplantation outcome

Introduction: Donor heart shortage limits heart transplantations programs while the number of patients waiting for cardiac transplant continues to increase. Optimizing the use of all available donor hearts is a vital key to reduce waiting list mortality. Among different extended criteria, prolong cardiopulmonary resuscitation (CPR), i.e. more than 20 min, has been considered under doubt to be a selection criterion in donor selection. The aim of this study was to compare the outcomes of heart transplantation from cardiopulmonary-resuscitated donors to those who received hearts from donors who did not require cardiopulmonary resuscitation.Methods: This study was a retrospective analysis of adult heart transplantation program in Masih Daneshvari Hospital in Tehran, Iran from 2010 to 2019. Donors and recipients’ demographics, cause of end-stage heart disease and brain death, duration of hospitalization for both donors and recipients and also the duration of cardiopulmonary resuscitation and other factors related to it were investigated. Qualitative variables were compared using Chi-square test. Quantitative variables were compared using T-test. Patient and graft survival rates were calculated using the actuarial method and compared using Wilcoxon's test.Results: Among 92 recipients, 39 were transplanted with cardiac grafts from CPR-suffering donors. There were no significant differences regarding sex, age, donor and recipient hospitalization periods, early rejection and 1-year-survival rate considering CPR and non-CPR grafts. However, we detected a strong negative correlation between the duration of CPR and 3-year-survival rate (P = 0.02 and R-value = -0.62) and also its association with post-transplant arrhythmias (P = 0.04).Conclusion: There is a negative possible influence of long-lasting CPRs (especially more than 20 minutes) in midterm survival and post-transplant complications.

Impact of cardiopulmonary resuscitation (CPR) on the survival of patients with cancer: DNR before or after cardiac arrest?

71 Background: Cardiopulmonary resuscitation (CPR) after cardiac arrest in cancer patients is associated with lower survival rates when compared to non-cancer patients. The quality of life of those who survive after CPR to be discharged is often diminished. Among these patients there is a high likelihood of changing their code status to DNR. Methods: Our study determines the overall survival rate, the survival to discharge rate, and the DNR change rate postcode among cancer patients who underwent CPR in our cancer center. Data was analyzed retrospectively from electronic records of cancer patients who had cardiac arrest and underwent CPR between April 2017 and March 2018 at a tertiary cancer center. The end points included the overall survival immediately after CPR, the survival rate at 24h, the survival to discharge rate, and the DNR change rate postcode. Results: Between 2017 and 2018, a total of 396 codes were registered in cancer patients in our center, out of which 53% had cardiopulmonary arrest as trigger event. In more than 90% of the patients, average chest compression rate, average compression rate, average compression depth, and overall compression in the targeted zone were obtained, meeting all the required criteria to deliver high-quality CPR. Overall survival rate in cancer patients was 79% after CPR efforts. The survival rate at 24h was 48%, while the rate of survival to discharge was 17%. 64% of the patients changed their code status to DNR in critical care settings. Conclusions: The prognosis remains poor for cancer patients undergoing CPR. A significant proportion of patients who survive CPR will become DNR postcode. Physicians should effectively and honestly engage in discussing end of life matters with their cancer patients.

Self-teaching to improve patient confidence in resuscitation skills: A quality improvement project.

Sudden cardiac death occurs predominantly at home where cardiopulmonary resuscitation (CPR) is often not provided. We tested the hypothesis that a self-teaching kit distributed to patients would effectively increase self-confidence in CPR. Patients seen by an advanced registered nurse practitioner in a general cardiology clinic were offered a self-teaching kit to learn CPR. Four-point scale survey questions were assessed at distribution and via phone call at 30 days. Kits were distributed to 21 patients; of whom, 17 (81%) patients used the kit. Patients reported greater self-confidence of performing CPR (2.6 before versus 3.2 after, p < .05) and greater comfort if someone needed CPR (2.4 before versus 3.1 after, p < .05). Self-teaching CPR kits were used by the substantial majority of patients and were effective at increasing both self-confidence and willingness to perform CPR. Similar nurse-run programs could increase awareness and impact of CPR in communities.

Impact of cardiopulmonary resuscitation training in 1st year of MBBS

Background: The present medical education system fails to inculcate appropriate skills and competence to the students to serve the community. As the world is moving toward the system of “need-based education,” the training of the undergraduates should be oriented toward acquiring practical skills to prepare them to confidently deal with emergency situations in future. Objectives: The objective of this study is to estimate the impact of cardiopulmonary resuscitation (CPR) training in the 1st year of MBBS. Materials and Methods: The study included 150 MBBS 1st year students. The students were given formal training of CPR which included the lecture followed by a hands-on training of CPR on mannequins. The pre-and post-training assessment of the students was done using questionnaire. Assessment of the skill was done by direct observation of the procedure on a mannequin by a checklist. Results: The average pre-training score was 6.39 ± 2.11 and post-training score was 16.56 ± 1.89. The post-training scores of the student were remarkably better than the pre-training score (P < 0.001). According to the results of the assessment of skill by direct observation, students scored better initially in the first part, i.e., knowledge section and the score in the second part, i.e., skill demonstration improved gradually with practice. Conclusion: Training the MBBS students about CPR in 1st year itself is very useful and productive. Training the future health care provider in younger age and preparing them for the emergencies will lead to major reform in the health education system.

Advanced life support and mechanical ventilation

Artificial ventilation is one of the best known resuscitation procedures. It is generally accepted that there must be oxygen delivery to vital organs during cardiac arrest and resuscitation in order to prevent irreversible damage, but there is an increasing number of ventilation concepts for resuscitation. Traditional and alternative methods of ventilation are reviewed. The need for positive-pressure ventilation during resuscitation as an essential gold standard might be overestimated at least in the first minutes of cardiopulmonary resuscitation (CPR). The co-founders of the concept of cardiocerebral resuscitation could show positive effects of a sole passive oxygenation at the beginning of advanced life support (ALS). Research was published on continuous positive airway pressure (CPAP) ventilation as well as on CPAP plus pressure support ventilation. In addition to positive-pressure ventilation, the use of an impedance threshold device, partly in addition with active compression-decompression CPR, was investigated in both experimental and clinical settings. None of these methods alone could be proven to improve the outcome of cardiac arrest. The role of high oxygen concentration during CPR also remains unclear. Positive-pressure ventilation with pure oxygen remains, in clinical practice, the gold standard in ALS. Further research should focus on the role of passive oxygenation during early ALS. The concentration of oxygen needed during resuscitation has to be defined and alternative ventilation patterns, regarding the impact of CPR, should be investigated.

Potential Impact of a Targeted Cardiopulmonary Resuscitation Program for Older Adults on Survival from Private-residence Cardiac Arrest

Traditional cardiopulmonary resuscitation (CPR) training programs do not target older adults who are most likely to witness private-residence cardiac arrests and do not reliably result in a bystander who is likely to perform CPR in the event of an arrest. This study was performed to compare targeted CPR training programs for older adults (older than 50 years) that 1) increase numbers of CPR-trained bystanders of private-residence cardiac arrest or 2) increase the percentage of trained bystanders of private-residence cardiac arrest who perform CPR. A simultaneous outcome was to estimate the minimal significant survival benefit associated with each of the training programs. A probabilistic simulation model was developed in Fortran95 that incorporated key out-of-hospital cardiac arrest elements, including witnessed arrests, CPR-trained witness, CPR provision, and impact of CPR on ventricular fibrillation. Input data were derived from published or publicly available data, including a large prospective cohort study of outcomes in Oakland County, MI. Monte Carlo simulation (n = 10,000) and sensitivity analyses (n = 40) were used to assess median and the empiric 95% confidence intervals [CIs] for incremental survival with either intervention. The baseline model, calibrated to the characteristics of the input-data community, established that, for private-residence cardiac arrests, 40.8% of cardiac arrest bystanders were trained in CPR; however, only 25.7% performed CPR. This yielded 4.81% survival (95% CI = 4.72 to 4.89). Modeling the impact on the baseline training level with increased CPR performance among trainees indicated that 75% of private-residence trained bystanders would need to perform CPR in order to reach a minimally significant improvement in survival (5.02%; 95% CI = 4.94 to 5.15). Similarly, targeted CPR training that would result in a significant survival benefit (to 5.01%; 95% CI = 4.93 to 5.09) would require that 70.8% of bystanders be trained. CPR training programs that focus on yielding 75% of trainees who perform CPR in the event of witnessing an arrest would have equivalent results to mass CPR training programs that result in 70% of bystanders being trained in CPR. However, the minimal survival benefit associated with these programs (around 0.2%) may prove either method costly with minimal effect.

Potential Impact of a Targeted Cardiopulmonary Resuscitation Program for Older Adults on Survival from Private-residence Cardiac Arrest

Objective: Traditional cardiopulmonary resuscitation (CPR) training programs do not target older adults who are most likely to witness private-residence cardiac arrests and do not reliably result in a bystander who is likely to perform CPR in the event of an arrest. This study was performed to compare targeted CPR training programs for older adults (older than 50 years) that 1) increase numbers of CPR-trained bystanders of private-residence cardiac arrest or 2) increase the percentage of trained bystanders of private-residence cardiac arrest who perform CPR. A simultaneous outcome was to estimate the minimal significant survival benefit associated with each of the training programs. Methods: A probabilistic simulation model was developed in Fortran95 that incorporated key out-of-hospital cardiac arrest elements, including witnessed arrests, CPR-trained witness, CPR provision, and impact of CPR on ventricular fibrillation. Input data were derived from published or publicly available data, including a large prospective cohort study of outcomes in Oakland County, MI. Monte Carlo simulation (n= 10,000) and sensitivity analyses (n= 40) were used to assess median and the empiric 95% confidence intervals [CIs] for incremental survival with either intervention. Results: The baseline model, calibrated to the characteristics of the input-data community, established that, for private-residence cardiac arrests, 40.8% of cardiac arrest bystanders were trained in CPR; however, only 25.7% performed CPR. This yielded 4.81% survival (95% CI = 4.72 to 4.89). Modeling the impact on the baseline training level with increased CPR performance among trainees indicated that 75% of private-residence trained bystanders would need to perform CPR in order to reach a minimally significant improvement in survival (5.02%; 95% CI = 4.94 to 5.15). Similarly, targeted CPR training that would result in a significant survival benefit (to 5.01%; 95% CI = 4.93 to 5.09) would require that 70.8% of bystanders be trained. Conclusions: CPR training programs that focus on yielding 75% of trainees who perform CPR in the event of witnessing an arrest would have equivalent results to mass CPR training programs that result in 70% of bystanders being trained in CPR. However, the minimal survival benefit associated with these programs (around 0.2%) may prove either method costly with minimal effect.

Potential impact of a targeted cardiopulmonary resuscitation program for older adults on survival from private residence cardiac arrest

Study objectives: Traditional cardiopulmonary resuscitation (CPR) training programs do not target older adults who are most likely to witness private-residence cardiac arrests nor reliably train a bystander who is likely to perform CPR in the event of an arrest. The objective of this study is to compare targeted CPR training programs for older adults (>50 years) that (1) increase numbers of CPR-trained bystanders; or (2) increase the percentage of trained bystanders who perform CPR. A simultaneous outcome is to estimate the minimal significant survival benefit associated with each of the training programs. Methods: A probabilistic simulation model was developed in Fortran95 that incorporated key out-of-hospital cardiac arrest elements, including witnessed arrests, CPR-trained witness, CPR provision, and impact of CPR on ventricular fibrillation. Input data were derived from published or publicly available data, including a large prospective cohort study of outcomes in Oakland County, MI. Monte Carlo simulation (n=10,000) and sensitivity analyses (n=40) were used to assess median and 95% confidence intervals (CIs) for incremental survival with either intervention. Results: The baseline model, calibrated to the input-data community's characteristics, established that 40.8% of cardiac arrest bystanders were trained in CPR; however, only 25.7% performed CPR, which yielded 4.81% survival (95% CI 4.72% to 4.89%). Modeling the impact on the baseline training level with increased CPR performance among trainees indicated that 75% of trained bystanders would need to perform CPR to reach a minimally significant improvement in survival (5.02%; 95% CI 4.94% to 5.15%). Similarly, targeted CPR training that would result in a significant survival benefit (to 5.01%; 95% CI 4.93% to 5.09%) would require that 70.8% of bystanders be trained. Conclusion: CPR training programs that focus on yielding 75% of trainees who perform CPR in the event of witnessing an arrest would have equivalent results to mass CPR training programs that result in 70% of arrest bystanders being trained in CPR. However, the minimal survival benefit associated with these programs (∼0.2%) may prove neither method cost-ineffective.

Catheter Aided Repositioning of a Displaced Permanent Pacemaker Lead

A 91-year-old woman, who had a pacemaker implanted in 1977, underwent replacement of a pulse generator and lead in 1995 because of recurrent syncope. The new lead dislodged the next day and migrated to the pulmonary artery. Because of her dependence on continued pacing, repeated resuscitation was required. Considering her advanced age and the impact of cardiopulmonary resuscitation on her general condition, we attempted catheter aided repositioning of the pacemaker lead. The procedure was technically successful; lead position was stable and optimal pacing parameters were attained. She was discharged in good condition.

The eyes, the brain, and cardiac resuscitation

The mechanisms and neurological pathways governing pupil size and reactivity are complex and still not fully understood in brain damage and disease [l]. Until very recently ‘widely dilated fixed pupils’ were generally accepted as a reliable sign of irreversible brain damage and a strong justilication for abandoning unsuccessful cardiopulmonary resuscitation (CPR), despite the wide variation in pupil size in this context and their longrecognised unreliability as a guide to cerebral oxygenation and integrity, including brain death [2-41. Whilst a reduction in pupil size is one of the most valuable signs of effective CPR, and often more forceful chest compression can delay pupil enlargement in protracted resuscitation, so far as I know there has been no clinical study on the relationship between pupil size and cerebral blood flow in this situation. A change which is surely long overdue is the final abandonment of still widely used terms (even in the literature) to describe pupil size, such as ‘small’, ‘moderately constricted’, ‘widely dilated’ and so on in favour of accurate assessment in millimetres [4], as has long been standard practice with the Glasgow Coma Score [5]. As to ‘widely dilated’ (2 8 mm diameter) pupils being ‘fixed’, do we ever see pupils of this size in this situation react to light, since the reflex seems to be abolished by severe cerebral ischemia, and reappears only as the pupils return to normal size (~6 mm) and then not invariably in CPR? My personal experience suggests that as in general anaesthesia a positive eyelash reflex during CPR signifies that consciousness is only slightly depressed. It also suggests the brain is intact and the patient will swiftly regain consciousness once satisfactory heart action returns [4]. However, it generally disappears when CPR lasts for more than several minutes. The light reflex is a valuable sign in trauma patients [l] but how useful and how reliable a guide to brain status is it in CPR, and how does it compare with monitoring the eyelash reflex and pupil size? The concept of a protective penumbra during brain ischemia, between 10 and 30% of normal cerebral blood flow (CBF), structural integrity with functional silence [6], offers valuable insights into the possible impact of CPR on the brain [7]. It is likely that each part of the brain has its own critical flow value, highest in selectively vulnerable areas, in particular the cerebral cortex, its filter the reticular formation of the thalamus and the hippocampus [8-lo]. It is also likely the ischemic penumbra is, at least initially, flow time-dependant [l 11, its value rising as CPR continues (Fig. 1). One large study [ 121 has shown that provided CPR starts within about 5-6 min of cardiac arrest and