In-hospital Resuscitation Research Articles

Initial Rhythm and Resuscitation Outcomes for Patients Developing Cardiac Arrest in Hospital

Health care resource allocation remains challenging in lower middle income countries such as Kenya with meager resources being allocated to resuscitation and critical care. The causes and outcomes for in-hospital cardiac arrest and resuscitation have not been studied. This study sought to determine the initial rhythm and the survival for patients developing in-hospital cardiac arrest. This was a prospective study for in-hospital cardiac arrest in 6 Kenyan hospitals from July 2014 to April 2016. Resuscitation teams were utilized to collect data during resuscitation using a standardized protocol. Patients with do-not-resuscitate orders, trauma, postsurgical, and pregnancy-related complications were excluded. The Modified Early Warning Score (MEWS)- systolic blood pressure, heart rate, respiration rate, temperature, and responsiveness-was determined based on worst parameters at least 4 hours prior to the arrest. A total of 353 patients with cardiac arrest were included over 19 months. The mean age was 61 years, 53.5% were male, and admission diagnoses included cardiovascular disease (15%), pneumonia 18.13%, and cancer 9%. The mean MEWS was 4.48 and low, intermediate, and high MEWS were found in 25.8%, 29.5%, and 44.8%, respectively. The mean time to cardiopulmonary resuscitation was 0.84 min. The initial rhythm was asystole in 47.6%, pulseless electrical activity in 38.2%, ventricular tachycardia/ventricular fibrillation in 5.4%, and unknown in 8.8%. Return of spontaneous circulation (ROSC) occurred in 29.2% of patients with the mean time to ROSC being 5.3 min. ROSC occurred in 17.3% of patients with asystole, 40.7% in pulseless electrical activity, 57.9% in ventricular tachycardia/ventricular fibrillation, and 25.8% in patients with an unknown rhythm. Of all patients, 16 (4.2%) were discharged alive. Nonshockable rhythms account for the majority of the cardiac arrests in hospitals in a lower middle income country and are associated with unfavorable outcomes. Future work should be directed to training health care personnel in recognizing early warning signs and implementing appropriate measures in a resource-scarce environment.

In-hospital major arrhythmias, arrhythmic death and resuscitation after successful primary percutaneous intervention for acute transmural infarction: a retrospective single-centre cohort study

BackgroundTransmural acute myocardial infarction (AMI) is associated with a high risk for ventricular arrhythmia before, during and after treatment. Consequently, it is recommended that patients diagnosed with transmural AMI be monitored in a cardiac care unit (CCU) so life-threatening arrhythmias can be treated promptly. We examined the incidence and timing of in-hospital malignant ventricular arrhythmias, sudden cardiac or arrhythmic death (SCD/AD) and resuscitation requirements in patients with transmural AMI recovering from percutaneous coronary intervention (PCI) undertaken within 12 h of symptom onset and without antecedent thrombolysis.MethodsThis was a retrospective cohort study using the Duisburg Heart Center (Germany) cardiac patient registry. In total, 975 patients met the inclusion criteria. The composite endpoint was post-PCI ventricular fibrillation or tachycardia, SCD/AD or requirement for resuscitation. We compared the demographic and clinical characteristics of patients who met the composite endpoint with those who did not, recorded the timing of endpoint episodes, and used multivariable logistic regression analysis to identify factors associated with the endpoint criteria.ResultsThere was no significant difference in the length of CCU or hospital stay between the groups. In-hospital mortality was 6.5%, and the composite endpoint was met in 7.4% of cases. Malignant ventricular tachyarrhythmia occurred in 2.8% of the patients, and SCD/AD occurred in 0.3% of the cases. There was a biphasic temporal distribution of endpoint events; specifically, 76.7% occurred < 96 h after symptom onset, and 12.6% occurred 240–360 h after symptom onset. Multivariable regression analysis identified positive associations between an endpoint episode and the following: age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01–1.05] per year); left ventricular ejection fraction (LVEF) < 30% (OR 3.66, 95% CI 1.91–6.99); peak serum creatine phosphokinase concentration (OR 1.01, 95% CI 1.00–1.02 per 100 U/dl); leucocytosis (OR 1.86, 95% CI 1.04–3.32), and coronary thrombus (OR 1.85, 95% CI 1.04–3.27).ConclusionsMost post-PCI malignant ventricular arrhythmias, SCD/AD and resuscitation episodes occurred within 96 h of transmural AMI (76.7%). A substantial minority (12.6%) of these events arose 240–360 h after symptom onset. Further study is needed to establish the influence of age, LVEF < 30%, peak serum creatine phosphokinase concentration, leucocytosis and coronary thrombus on post-PCI outcomes after transmural AMI.

MP32: Paramedics using near-infrared spectroscopy in out-of-hospital cardiac arrest: a feasibility study

Introduction: Long-term outcomes following out-of-hospital cardiac arrest (OHCA) remain poor. Two-thirds of OHCA patients surviving to hospital admission die from neurological injuries, and of those discharged, one-third have irreversible cognitive disabilities due to cerebral ischemia. Near-infrared spectroscopy (NIRS) is a non-invasive imaging technique which is able to continuously detect regional cerebral oxygenation (rSO2). NIRS monitoring has been used to measure rSO2 during in-hospital cardiac arrest resuscitation. Our study is the first feasibility study of paramedics applying NIRS monitoring during OHCA resuscitation. Methods: One NIRS monitor (Equanox 7600; Nonin, Plymouth, MI, USA) was placed on an Emergency Response Unit (ERU) with York Region Paramedic Services. ERU paramedics were trained to apply the device to patients foreheads during OHCA resuscitation and record rSO2 until arrival at hospital or termination of resuscitation. Paramedics did not alter any aspect of patient care by using the NIRS monitor. They were instructed to press an action marker on the device during ACLS interventions (e.g. defibrillation, intubation, medications, etc). rSO2 data was later downloaded for analysis. Our feasibility criteria was to obtain &gt;70% of data files with rSO2 data and &gt;70% of data files with event markers. Results: Data was collected from 24 OHCA patients over a period of 10 months. 19 cases (79%) files contained rSO2 data and 17 cases (71%) had event markers. The rSO2 data present in each file varied widely from complete recording for the entire call duration to sporadic brief readings. Event markers varied from 1 to 10 markers spaced throughout the cases. Conclusion: This is the first study to demonstrate that the use of NIRS by paramedics as part of OHCA resuscitation is feasible. Future studies are required to determine how rSO2 monitoring can be used to guide OHCA resuscitation. The results of this study will help inform protocols for future studies evaluating the use of NIRS in the out-of-hospital setting.

Public-Access Defibrillation in Sudden Cardiac Arrest (Short Review)

A public-access defibrillation is one of key techniques for improvement of the pre-hospital and in-hospital resuscitation success and survival rates of resuscitated patients in the case of a sudden cardiac arrest caused by ventricular fibrillation and ventricular tachycardia. The short review discusses the relation between the type of a sudden cardiac arrest and the survival rate, the 'chain of survival' concept and the role of early defibrillation, as well as the function of public-access defibrillation programs and the contribution of automated external defibrillators in prehospital and in-hospital resuscitation. In conclusion, the perspectives of introduction of the public-access defibrillation in Russia are discussed.

Predictive value of continuous monitoring end-tidal carbon dioxide partial pressure on in-hospital resuscitation outcome: secondary analysis of the data from a multicenter observational study

To approach the predictive value of continuous monitoring end-tidal carbon dioxide partial pressure (PETCO2) on the outcome of in-hospital cardiopulmonary resuscitation (CPR), and explored the indicators of termination of resuscitation. A secondary analysis of a multicenter observational study data was conducted. The screening aim was adult non-traumatic in-hospital CPR patients whose PETCO2 were recorded within 30 minutes of CPR. Clinical information was reviewed. The mean PETCO2 in restoration of spontaneous circulation (ROSC) and non-ROSC patients was recorded. The outcome of CPR was continuously assessed by PETCO2 ≤ 10 mmHg (1 mmHg = 0.133 kPa) for 1, 3, 5, 8, 10 minutes. Receiver operating characteristic (ROC) curve was plotted, and the predictive value of PETCO2 ≤ 10 mmHg for different duration on the outcome of CPR was evaluated. A total of 467 recovery patients, including 419 patients with complete recovery were screened. Patients who were out-of-hospital resuscitation, non-adults, traumatic injury, had no PETCO2 value, PETCO2 value failed to explained the clinical conditions, or patients had not monitored PETCO2 within 30 minutes of resuscitation were excluded, and finally 120 adult patients with non-traumatic in-hospital resuscitation were enrolled in the analysis. The mean PETCO2 in 50 patients with ROSC was significantly higher than that of 70 non-ROSC patients [mmHg: 17 (11, 27) vs. 9 (6, 16), P < 0.01]. ROC curve analysis showed that the area under ROC curve (AUC) of PETCO2 during the resuscitation for predicting recovery outcome was 0.712 [95% confidence interval (95%CI) = 0.689-0.735]; when the cut-off was 10.5 mmHg, the sensitivity was 57.8%, and the specificity was 78.0%, the positive predictive value (PPV) was 84.6%, and negative predictive value (NPV) was 46.9%. The duration of PETCO2 ≤ 10 mmHg was used for further analysis, which showed that with PETCO2 ≤10 mmHg in duration, the prediction of the sensitivity of the patients failed to recover decreased from 58.2% to 28.2%, but specificity increased from 39.4% to 100%; PPV increased from 40% to 100%, and NPV decreased from 57.5% to 34.2%. For adult non-traumatic in-hospital CPR patients, continuous 10 minutes PETCO2 ≤10 mmHg may be an indicate of termination of CPR.

Family Support During Resuscitation: A Quality Improvement Initiative.

Despite increasing support for family presence during cardiopulmonary resuscitation, a review of the literature revealed no published protocols or training curricula to guide hospitals in implementing a family support provider role. To develop a curriculum and train dedicated resuscitation team members whose role is to provide family support during in-hospital resuscitation events. An interdisciplinary team developed a 4-hour training session for the family support staff. The session included an introduction to the evidence for family presence during resuscitation and local data on resuscitations. The training was composed of 4 sections: (1) clinical aspects of resuscitation, (2) integration into the resuscitation team and steps for providing family support during resuscitation, (3) responding to families in distress, and (4) self-care practices. Before and after the training session, the participants completed surveys of self-rated knowledge and attitudes toward family presence during resuscitation. Fifty-nine social workers and 8 spiritual care providers were trained in 2015. There was a significant increase in all rated aspects of knowledge of the family support role and self-care strategies. Through the creation of an interdisciplinary curriculum, an institution can effectively train health care providers in a new resuscitation team role: the family support provider.

Automated external defibrillators in the hospital: A case of medical reversal

Automated external defibrillators (AEDs) emerged in the 1980s as an important innovation in pre-hospital emergency cardiac care (ECC). In the years since, the American Heart Association (AHA) and the International Liaison Committee for Resuscitation (ILCOR) have promoted AED technology for use in hospitals as well, resulting in the widespread purchase and use of AED-capable defibrillators. In-hospital use of AEDs now appears to have decreased survival from cardiac arrests. This article will look at the use of AEDs in hospitals as a case of “medical reversal.” Medical reversal occurs when an accepted, widely used treatment is found to be ineffective or even harmful. This article will discuss the issue of AEDs in the hospital using a conceptual framework provided by recent work on medical reversal. It will go on to consider the implications of the reversal for in-hospital resuscitation programs and emergency medicine more generally.

Prehospital Supraglottic Airway Was Associated With Good Neurologic Outcome in Cardiac Arrest Victims Especially Those Who Received Prolonged Cardiopulmonary Resuscitation.

We performed this study to investigate the association of prehospital supraglottic airway (SGA) on neurologic outcome in cardiac arrest victims with adjustment of postresuscitation variables as well as prehospital and resuscitation variables. This study was a retrospective study based on a multicenter prospective cohort registry from December 2013 to April 2016. According to the 28-day cerebral performance categories (CPCs) scale, patients were divided into the good-outcome group (CPC1-2) and the poor-outcome group (CPC3-5). We compared the two groups with respect to demographic variables, prehospital and in-hospital resuscitation variables, and postresuscitation variables. A total of 869 cardiac arrest victims who received in-progress cardiopulmonary resuscitation (CPR) were delivered to the emergency department of three hospitals, and 310 patients were admitted to the intensive care unit. The use of a prehospital SGA was independently associated with 28-day good neurologic outcome (odds ratio [OR]= 7.88; 95% confidence interval [CI]= 1.33-46.53; p=0.023] when postresuscitation variables were adjusted, although there were no significant association with the acquisition of sustained return of spontaneous circulation (OR= 0.992; 95% CI= 0.591-1.666; p=0.976). Furthermore, a prehospital SGA was significantly associated with good neurologic outcome, especially in patients who received prolonged CPR (low flow time>15 minutes; OR= 3.41; 95% CI= 1.23-9.45; p=0.018) rather than in patients with nonprolonged CPR (OR= 4.50; 95% CI= 0.75-27.13; p=0.101). When postresuscitation variables were adjusted, the prehospital SGA was independently associated with 28-day good neurologic outcome in cardiac arrest victims.

P 96 Patients’ beliefs and resuscitation statistics – Mere coincidence or a causal link?

Introduction Imagine being a physician in the Emergency Department (ED) on Christmas. Suddenly, one of your patients approaches you and tells you that the conincidence of full moon and Christmas will cause unusual things. Having received a rational education in university, you of course do not take this patient seriously. Suddenly, however, you experience more resuscitations of initially stable patients than expected from available statistics. The success rate of these resuscitations also turns out higher than expected. Objective In 2015, a full moon dawned on Christmas. We aimed to analyze whether this rare event was associated with an increase of cardiac arrests in the Emergency Department (ED) as compared to the number of events on other Christmas and non-Christmas days and further to assess respective outcomes of resuscitation. Design Retrospective, cohort study. Setting The ED of a Swiss academic tertiary medical care centre. Participants All patients admitted to the emergency department excluding minor injuries (which were treated in a separate unit) during the full moon on Christmas eve and Christmas day 2015 were compared to control cases on other Christmas and non-Christmas days. For comparisons regarding successful resuscitation, published data as collected by the American Heart Association during 2015 served as a reference. Main outcome measure Number of resuscitations per total number of admissions and proportion of successful resuscitations. Results On Christmas 2015, three out of 24 patients (12.5%) required in-hospital resuscitation, whereas none of the 95 control-patients had to be resuscitated (Odds ratio = 31.1, 95% CI = 1.55–624.5, p = 0.02). All three resuscitations were successful, which differed significantly from success rates of in-hospital resuscitation statistics for the year 2015, Odds ratio 20.4, 95% CI = 1.06–395.9, p = 0.046 ( American Heart Association, 2015 ). Conclusions The coincidence of full moon and Christmas was associated with significantly more cardiac arrests in the emergency department than on other days and resuscitations were significantly more successful than expected. How can these seemingly bizarre findings be explained? It seems unreasonable that patients” beliefs can have effects this strong. On the other hand, evidence-based medicine cannot be applied because the coincidence of full moon and Christmas (in the years 1977, 2015) only happens every couple of decades and has not been studied before. Full moon alone does not seem to have an effect on resuscitations ( Alves et al., 2003 ). whereas Christmas is related to a higher number of deaths ( Phillips et al., 2004 ). The retrospective nature limits the validity of our results and calls for prospective, multicentre trials in 2034, when the next full moon is expected to dawn on Christmas.

Epinephrine in Out-of-hospital Cardiac Arrest: Helpful or Harmful?

Objective:Epinephrine is the primary drug administered during cardiopulmonary resuscitation (CPR) to reverse cardiac arrest. The evidence for the use of adrenaline in out-of-hospital cardiac arrest (OHCA) and in-hospital resuscitation is inconclusive. We conducted a systematic review on the clinical efficacy of adrenaline in adult OHCA patients to evaluate whether epinephrine provides any overall benefit for patients.Data Sources:The EMBASE and PubMed databases were searched with the key words “epinephrine,” “cardiac arrest,” and variations of these terms.Study Selection:Data from clinical randomized trials, meta-analyses, guidelines, and recent reviews were selected for review.Results:Sudden cardiac arrest causes 544,000 deaths in China each year, with survival occurring in <1% of cases (compared with 12% in the United States). The American Heart Association recommends the use of epinephrine in patients with cardiac arrest, as part of advanced cardiac life support. There is a clear evidence of an association between epinephrine and increased return of spontaneous circulation (ROSC). However, there are conflicting results regarding long-term survival and functional recovery, particularly neurological outcome, after CPR. There is currently insufficient evidence to support or reject epinephrine administration during resuscitation. We believe that epinephrine may have a role in resuscitation, as administration of epinephrine during CPR increases the probability of restoring cardiac activity with pulses, which is an essential intermediate step toward long-term survival.Conclusions:The administration of adrenaline was associated with improved short-term survival (ROSC). However, it appears that the use of adrenaline is associated with no benefit on survival to hospital discharge or survival with favorable neurological outcome after OHCA, and it may have a harmful effect. Larger placebo-controlled, double-blind, randomized control trials are required to definitively establish the effect of epinephrine.

Manual chest compressions versus LUCAS 2© – A comparative study of End-tidal carbon dioxide levels during in-hospital resuscitation

Purpose: In-hospital resuscitation poses many challenges, not least the ability to deliver high quality chest compressions during Cardiopulmonary Resuscitation (CPR). The purpose of our study was to compare in-hospital chest compressions performed manually and compare with those performed by a recently purchased LUCAS2© mechanical chest compression system.

Is there an elephant in the room?! A study to assess the chest compression ability of staff at a London acute hospital trust

Purpose: In-Hospital resuscitation presents varying challenges. Exposure to cardiac arrests can vary, therefore experience at skilled delivery can differ. There is an expectation that all staff should be able to achieve “High Quality Chest compressions” (Resuscitation Council UK 2015).

Temporal trends and hospital-level variation of inhospital cardiac arrest incidence and outcomes in the Veterans Health Administration

Despite significant attention to resuscitation care by hospitals, national data on trends in the incidence and survival of patients with inhospital cardiac arrest (IHCA) are limited. To determine trends and hospital-level variation in the incidence and outcomes associated with IHCA. In exploratory analyses, we evaluated the relationship between hospital-level IHCA incidence and outcomes with general hospital-wide quality improvement activities. Retrospective cohort study of 2,205,123 hospitalizations at 101 Veterans Health Administration (VHA) hospitals between 2008 and 2012. Risk- and reliability-adjusted hospital-level IHCA incidence and survival to hospital discharge. A total of 8821 (0.40%) IHCA occurred between 2008 and 2012, with no significant change in risk-adjusted incidence over this time (P = .77). Hospital-level IHCA incidence varied substantially across facilities, with a median hospital incidence of 4.0 per 1000 hospitalizations and a range from 1.4 to 11.8 per 1000 hospitalizations. Overall, survival to discharge after IHCA was 31.2%. Risk-adjusted odds of survival increased over the study period (2012 vs 2008, OR: 1.49, 95% CI: 1.27, 1.75) but survival varied substantially across facilities from 20.3% to 45.4%. General hospital quality improvement activities were inconsistently associated with IHCA incidence and survival. Within the VHA, the incidence and outcomes of IHCA showed important trends over time but varied substantially across hospitals with no consistent link to general hospital quality improvement activities. Identification of specific resuscitation practices at hospitals with low incidence and high survival of IHCA may guide further improvements for inhospital resuscitation.

Two cases of low birth weight infant survival by prehospital emergency hysterotomy

BackgroundDuring maternal cardiac arrest, emergency hysterotomy (EH) is recommended after four minutes of resuscitation, if no signs of spontaneous circulation are detected. This extreme procedure is believed to be potentially beneficial for both the mother and the infant. Both maternal and neonatal survivals seem to be associated to the time delay between the cardiac arrest and the delivery and in-hospital resuscitation location. In addition to this, gestational age is an important determinant to neonatal outcome.Case presentationWe report two emergency hysterotomies executed in an out-of-hospital location. The infants delivered by EH were low birth weight infants and born 20–23 min after maternal cardiac arrest. Both infants survived and had normal physical and neurological growth at the age of two years. Unfortunately, mothers in these both cases died in the field.ConclusionContrary to earlier beliefs, it is possible to perform a successful EH also in out-of-hospital setting, even with incomplete surgical skills. However, training and preparation are extremely important for achieving the highest possible readiness to treat maternal cardiac arrest situations also prehospitally.

Improving quality in measuring time to initiation of CPR during in-hospital resuscitation

ObjectiveTime from the onset of “low or no flow” indicators of cardiac failure to initiation of cardiopulmonary resuscitation is an important quality metric thought to improve the likelihood of survival and preservation of end organ function. We hypothesized that delays in initiation of chest compressions were under recognized during in-hospital resuscitation and aimed to develop a system which identifies the actual time of deterioration during cardiac events. MethodsRetrospective review on prospectively identified resuscitation records and monitor data were compared. Return of spontaneous circulation, survival, and changes in functional status of patients pre- and post-events with chest compressions were collected as outcome measures. ResultsBetween October 2012 and April 2015, 59 events which met eligibility criteria occurred in either our pediatric cardiac or general pediatric intensive care units. The median time from event onset to initiation of chest compressions was 47s(s) (interquartile range (IQR) 28–80s) as assessed using monitor data, while the resuscitation record reported a median time of 0s (IQR 0–60s), reflecting the time from recognition to initiation of chest compressions. According to the resuscitation record, 81% vs. 63% of events achieved the quality standard of less than one minute depending on which review method was used (p=0.04). ConclusionsThere is a significant difference between time of deterioration to initiation of chest compressions and the time of recognition to initiation of chest compressions. Resuscitation records should be modified to include more information about the actual timing of patient deterioration.

Risk stratification of survival in injured patients with cardiopulmonary resuscitation within the first hour of arrival to trauma centre: retrospective analysis from the national trauma data bank

BackgroundThe purpose of this study was to evaluate overall survival and associated survival factors for patients with trauma who had cardiopulmonary resuscitation (CPR) within 1 hour after arrival to a...

Clinical experience and skills of physicians in hospital cardiac arrest teams in Denmark: a nationwide study.

BackgroundThe quality of in-hospital resuscitation is poor and may be affected by the clinical experience and cardiopulmonary resuscitation (CPR) training. This study aimed to investigate the clinical experience, self-perceived skills, CPR training and knowledge of the guidelines on when to abandon resuscitation among physicians of cardiac arrest teams.MethodsWe performed a nationwide cross-sectional study in Denmark. Telephone interviews were conducted with physicians in the cardiac arrest teams in public somatic hospitals using a structured questionnaire.ResultsIn total, 93 physicians (53% male) from 45 hospitals participated in the study. Median age was 34 (interquartile range: 30–39) years. Respondents were medical students working as locum physicians (5%), physicians in training (79%) and consultants (16%), and the median postgraduate clinical experience was 48 (19–87) months. Most respondents (92%) felt confident in treating a cardiac arrest, while fewer respondents felt confident in performing intubation (41%) and focused cardiac ultrasound (39%) during cardiac arrest. Median time since last CPR training was 4 (2–10) months, and 48% had attended a European Resuscitation Council (ERC) Advanced Life Support course. The majority (84%) felt confident in terminating resuscitation; however, only 9% were able to state the ERC guidelines on when to abandon resuscitation.ConclusionPhysicians of Danish cardiac arrest teams are often inexperienced and do not feel competent performing important clinical skills during resuscitation. Less than half have attended an ERC Advanced Life Support course, and only very few physicians know the ERC guidelines on when to abandon resuscitation.

In-hospital resuscitation.

What was the nature of the CPD activity, practice-related feedback and/or event and/or experience in your practice? This CPD article explored the Resuscitation Council UK guidelines for in-hospital resuscitation and considered their application to practice.

In-hospital resuscitation.

What was the nature of the CPD activity, practice-related feedback and/or event and/or experience in your practice? The CPD article outlined the response sequence required for cardiac arrest in an in-hospital environment and discussed effective cardiopulmonary resuscitation (CPR) and defibrillation.

The “train as you fight” concept: Applicable for in-hospital resuscitation training?

Background: Motivating caregivers for CPR and recognition of the potentially threatened patient provider and refresher courses, especially if they have a low potential exposure rate, is difficult. Solutions run from mass training to individual, computer-guided schemes. Historically, the grouping technique has primarily been on level of training (BLS, ALS) to be given. But, particularly under in-hospital conditions, ad hoc ‘teams’ (i.e. secretaries, nurses and doctors) will work together until a resuscitation team arrives when a patient collapses. We instituted a combined multi-level, on-site training scheme to evaluate if such in-company team training (“train as you fight”) would be beneficial to teaching results.