Initial Arrest Rhythm Research Articles

Prognostic Factors for Re-Arrest with Shockable Rhythm during Target Temperature Management in Out-Of-Hospital Shockable Cardiac Arrest Patients

Re-arrest during post-cardiac arrest care after the return of spontaneous circulation is not uncommon. However, little is known about the risk factors associated with re-arrest. A previous study failed to show a benefit of prophylactic antiarrhythmic drug infusion in all kinds of out-of-hospital cardiac arrest (OHCA) survivors. This study evaluated high-risk OHCA survivors who may have re-arrest with shockable rhythm during targeted temperature management (TTM). Medical records of consecutive OHCA survivors treated with TTM at four tertiary referral university hospitals in the Republic of Korea between January 2010 and December 2016 were retrospectively reviewed. Patients who did not have any shockable rhythm during cardiopulmonary resuscitation (CPR) or unknown initial rhythm were excluded. The primary outcome of interest was the recurrence of shockable cardiac arrest during TTM. There were 289 cases of initial shockable arrest rhythm and 132 cases of shockable rhythm during CPR. Of the 421 included patients, 11.4% of patients had a shockable re-arrest during TTM. Survival to discharge and good neurologic outcomes did not differ between non-shockable and shockable re-arrest patients (78.3% vs. 72.9%, p = 0.401; 53.1% vs. 54.2% p = 0.887). Initial serum magnesium level, ST segment depression or ventricular premature complex (VPC) in initial electrocardiography (ECG), prophylactic amiodarone infusion, and dopamine and norepinephrine infusion during TTM were significantly higher and more frequent in the shockable re-arrest group (all p values < 0.05). Normal ST and T wave in initial ECG was common in the non-shockable re-arrest group (p = 0.038). However, in multivariate logistic regression analysis, only VPC was an independent prognostic factor for shockable re-arrest (OR 2.806 (95% CI 1.276–6.171), p = 0.010). Initial VPC may be a prognostic risk factor for shockable re-arrest in OHCA survivors with shockable rhythm.

The effects of adrenaline in out of hospital cardiac arrest with shockable and non-shockable rhythms: Findings from the PACA and PARAMEDIC-2 randomised controlled trials

IntroductionPrevious research suggests there may be differences in the effects of adrenaline related to the initial cardiac arrest rhythm. The aim of this study was to assess the effect of adrenaline compared with placebo according to whether the initial cardiac arrest rhythm was shockable or non-shockable. MethodsReturn of spontaneous circulation (ROSC), survival and neurological outcomes according to the initial arrest rhythm were compared amongst patients enrolled in the PARAMEDIC-2 randomised, placebo controlled trial. The results of the PARAMEDIC-2 and PACA out of hospital cardiac arrest trials were combined and meta-analysed. ResultsThe initial rhythm was known for 3929 (98.2%) in the placebo arm and 3919 (97.6%) in the adrenaline arm. The effect on the rate of ROSC of adrenaline relative to placebo was greater in patients with non-shockable cardiac rhythms (1002/3003 (33.4%) versus 222/3005 (7.4%), adjusted OR: 6.5, (95% CI 5.6–7.6)) compared with shockable rhythms 349/716 (48.7%) versus (208/702 (29.6%), adjusted OR: 2.3, 95%CI: 1.9–2.9)). The adjusted odds ratio for survival at discharge for non-shockable rhythms was 2.5 (1.3, 4.8) and 1.3 (0.9, 1.8) for shockable rhythms (P value for interaction 0.065) and 1.8 (0.8–4.1) and 1.1 (0.8–1.6) respectively for neurological outcome at discharge (P value for interaction 0.295). Meta-analysis found similar results. ConclusionRelative to placebo, the effects of adrenaline ROSC are greater for patients with an initially non-shockable rhythm than those with a shockable rhythms. Similar patterns are observed for longer term survival outcomes and favourable neurological outcomes, although the differences in effects are less pronounced. ISRCTN73485024.

Abstract 158: Pediatric In-Hospital Cardiac Arrest Associated With Pulmonary Hypertension: A Common Pathophysiology

Introduction: In laboratory studies, pulmonary hypertension (PH) during CPR worsens outcomes but can be ameliorated with inhaled nitric oxide (iNO). The prevalence of pre-arrest PH among children with IHCA and its impact on outcomes are not well described. Hypothesis: We hypothesized that among children with IHCA, pre-arrest PH would be common and associated with worse survival to discharge. Methods: Retrospective single-center cohort study of consecutive pediatric ICU patients (1/1/2006 - 12/31/2017) with an echocardiogram in the 48 hours preceding IHCA, excluding those with cyanotic congenital heart disease. Echocardiograms were analyzed by a cardiologist blinded to other patient data. PH was defined as abnormal septal position and/or peak tricuspid regurgitant velocity &gt; 2.8 m/sec. Patient and arrest characteristics and treatments were compared between subjects with and without PH using non-parametric tests. Logistic regression evaluated the association between PH and outcome, adjusting a priori for age and initial arrest rhythm, as well as for candidate variables associated with survival (p&lt;0.10). Results: Of 284 IHCA subjects, 57 (20%) had an evaluable echocardiogram. PH was present in 20/57 (35%); 9/20 (45%) had no prior clinical history of PH. Children with PH had worse RV systolic function as measured by median fractional area change (32% vs. 45%; p=0.005), RV global longitudinal strain (-15% vs. -21.1%; p=0.046), and tricuspid annular plane systolic excursion z-score (-4.50 vs. -3.53; p=0.17). Children with PH had more RV dilation (median RV:LV end-diastolic area ratio 0.90 vs. 0.52; p=0.005) and similar rates of qualitative LV dysfunction (45% vs. 59%, p=0.40). Children with PH were more likely to receive iNO [16/20 (80%) vs. 12/37 (32%); p&lt;0.001] and isoproterenol [9/20 (45%) vs. 1/37 (3%); p&lt;0.001] during CPR. There were no differences in other IHCA characteristics. On multivariable analysis, PH was not associated with ROSC [14/20 (70%) vs. 24/37 (65%); adjOR 1.30 (0.25 - 6.69); p=0.77] or survival to hospital discharge [8/20 (40%) vs. 10/37 (27%); adjOR 1.17 (0.22 - 6.44); p=0.85]. Conclusions: PH was present in 35% of children with IHCA. In a cohort with a high frequency of treatment with iNO during CPR, PH was not associated with survival.

Impact of Emergency Medical Service arrival time and initial arrest rhythm on return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest: The experience of the province of Lecce, Italy

Introduction: Out-of-hospital cardiac arrest (OHCA) is a major cause of death and disability worldwide. In 2013, the Territorial Emergency Medical Service (EMS) of Lecce, a public service operating in an Italian province of 814,495 inhabitants, developed an OHCA registry. The present study aims to evaluate the relationship between EMS arrival time, shockable rhythms and return of spontaneous circulation (ROSC).

Validation of the Cardiac Arrest Survival Postresuscitation In-hospital (CASPRI) score in an East Asian population

BackgroundThe Cardiac Arrest Survival Postresuscitation In-hospital (CASPRI) score is a useful tool for predicting neurological outcome following in-hospital cardiac arrest (IHCA), and was derived from a cohort selected from the Get With The Guidelines-Resuscitation registry between 2000 and 2009 in the United States. In an East Asian population, we aimed to identify the factors associated with outcomes of resuscitated IHCA patients and assess the validity of the CASPRI score.MethodsA retrospective study was conducted in a single centre in Taiwan. Patients with IHCA between 2006 and 2014 were screened.ResultsAmong the 796 included patients, 94 (11.8%) patients achieved neurologically intact survival. Multivariable logistic regression analyses identified factors significantly associated with neurological outcome. Six of these factors were also components of the CASPRI score, including duration of resuscitation, neurological status before IHCA, malignant disease, initial arrest rhythms, renal insufficiency and age. In univariate logistic regression analysis, the CASPRI score was significantly associated with neurological outcome (odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.80–0.87); the area under the receiver operating characteristics curve was 0.79 (95% CI: 0.74–0.84).ConclusionIn this retrospective study conducted in a single centre at Taiwan, we identified the common prognosticators of IHCA shared by both East Asian and Western societies. As a composite prognosticator, CASPRI score predicts outcomes with excellent accuracy among successfully resuscitated IHCA patients in an East Asian population. This tool allows accurate IHCA prognostication in an East Asian population.

Paediatric in-hospital cardiac arrest: Factors associated with survival and neurobehavioural outcome one year later

ObjectiveTo investigate clinical characteristics associated with 12-month survival and neurobehavioural function among children recruited to the Therapeutic Hypothermia after Paediatric Cardiac Arrest In-Hospital trial. MethodsChildren (n = 329) with in-hospital cardiac arrest who received chest compressions for ≥2 min, were comatose, and required mechanical ventilation after return of circulation were included. Neurobehavioural function was assessed using the Vineland Adaptive Behaviour Scales, second edition (VABS-II) at baseline (reflecting pre-arrest status) and 12 months post-arrest. Norms for VABS-II are 100 (mean) ±15 (SD). Higher scores indicate better functioning. Outcomes included 12-month survival, 12-month survival with VABS-II decreased by ≤15 points from baseline, and 12-month survival with VABS-II ≥70. ResultsAsystole as the initial arrest rhythm, administration of >4 adrenaline doses, and higher post-arrest blood lactate concentration were independently associated with lower 12-month survival; an adrenaline dosing interval of 3–<5 min and open chest compressions were independently associated with greater 12-month survival. Use of extracorporeal membrane oxygenation (ECMO) and higher blood lactate were independently associated with lower 12-month survival with VABS-II decreased by ≤15 points from baseline; open chest compressions was independently associated with greater 12-month survival with VABS-II decreased by ≤15 points. Asystole as the initial rhythm, use of ECMO, and higher blood lactate were independently associated with lower 12-month survival with VABS-II ≥70; open chest compressions was independently associated with greater 12-month survival with VABS-II ≥70. ConclusionsCardiac arrest and resuscitation factors are associated with long-term survival and neurobehavioural function among children who are comatose after in-hospital arrest.

Do not attempt resuscitation orders at the emergency department of a teaching hospital.

ABSTRACTObjectiveTo identify factors associated with not attempting resuscitation.MethodsA cross-sectional study conducted at the emergency department of a teaching hospital. The sample consisted of 285 patients; in that, 216 were submitted to cardiopulmonary resuscitation and 69 were not. The data were collected by means of the in-hospital Utstein Style. To compare resuscitation attempts with variables of interest we used the χ2 test, likelihood ratio, Fisher exact test, and analysis of variance (p<0.05).ResultsNo cardiopulmonary resuscitation was considered unjustifiable in 56.5% of cases; in that, 37.7% did not want resuscitation and 5.8% were found dead. Of all patients, 22.4% had suffered a previous cardiac arrest, 49.1% were independent for Activities of Daily Living, 89.8% had positive past medical/surgical history; 63.8% were conscious, 69.8% were breathing and 74.4% had a pulse upon admission. Most events (76.4%) happened at the hospital, the presumed cause was respiratory failure in 28.7% and, in 48.4%, electric activity without pulse was the initial rhythm. The most frequent cause of death was infection. The factors that influenced non-resuscitation were advanced age, history of neoplasm and the initial arrest rhythm was asystole.ConclusionAdvanced age, past history of neoplasia and asystole as initial rhythm were factors that significantly influenced the non-performance of resuscitation. Greater clarity when making the decision to resuscitate patients can positively affect the quality of life of survivors.

GW28-e0609 Out-of-hospital cardiac arrest: who were more likely to have shock-able initial rhythms?

Victims with shock-able initial arrest rhythms (ventricular fibrillation or pulse-less ventricular tachycardia, VF/VT) have much better outcomes from out-of-hospital cardiac arrest (OHCA) than those with non-shock-able initial rhythms (pulse-less electrical activities, PEA or asystole). Prompt

DOES ST DEPRESSION HELP PREDICT CORONARY ARTERY DISEASE AFTER AN OUT-OF-HOSPITAL CARDIAC ARREST?

Following an out-of-hospital cardiac arrest (OHCA), guidelines support immediate coronary angiography (CA) for patients with acute ST-elevation (STE), although no such recommendations exist for ST-depression (STD). To examine the relationship between the documented arrest rhythm and immediate post-arrest ECG on CA findings in a large cohort of OHCA patients. We performed a retrospective analysis of consecutive patients with OHCA in the Metro Vancouver region from 2009-2015, using the Resuscitation Outcomes Consortium Cardiac Arrest Registry. Patients that did not survive to admission, or with known non-cardiac cause for OHCA were excluded. ST-segment change of >0.1mV in 2 contiguous leads was considered significant. Coronary artery disease was defined as stenosis (any artery ≥70% or left main ≥50%) or occlusion (any artery 99-100%). A total of n=604 OHCA met all inclusion criteria. The median age was 64-y (range 20-101 y) with 75% males. Most cardiac arrests were witnessed (67%) with 60% receiving bystander CPR. The documented arrest rhythm was ventricular tachycardia/fibrillation (VT/VF; 50%), pulseless electrical activity (18%), asystole (19%), and unspecified (12%). After exclusion of LBBB (n=22) and uninterpretable ECGs (n=36), the immediate post-arrest ECG demonstrated STE (35%), STD (30%), and no ST abnormality (35%). The overall rate of CA was 45% with most undergoing CA within 0-1 days of admission (median 0 days, IQR 0-1 days). On CA, 22% had stenosis and 54% had occlusion. Percutaneous intervention was attempted in 53%, and bypass surgery recommended in 16%. The median LVEF was 42% (IQR 35-55%). Table 1 shows the odds ratios for coronary stenosis or occlusion stratified by the arrest rhythm for those with and without STE. In non-STE patients (n=116), STD correlated weakly with coronary occlusion (ROC C-statistic 0.61, 96% specificity when STD > 3mm). In OHCA patients without STE, VT/VF as the initial arrest rhythm was a better harbinger of underlying ischemia when compared to marked STD. Reliance on STD alone may underestimate the number of patients in whom reversing ischemia could improve outcomes after OHCA.

Prognostic indicators of survival and survival prediction model following extracorporeal cardiopulmonary resuscitation in patients with sudden refractory cardiac arrest

BackgroundExtracorporeal cardiopulmonary resuscitation (ECPR) has been considered in selected candidates with potentially reversible causes during a limited period. Candidate selection and the identification of predictable conditions are important factors in determining outcomes during CPR in the emergency department (ED). The objective of this study was to determine the key indicators and develop a prediction model for survival to hospital discharge in patients with sudden cardiac arrest who received ECPR.MethodsThis retrospective analysis was based on a prospective cohort, which included data on CPR with ECPR-related variables. Patients with sudden cardiac arrest who received ECPR at the ED from May 2006 to June 2016 were included. The primary outcome was survival to discharge. Prognostic indicators and the prediction model were analyzed using logistic regression.ResultsOut of 111 ECPR patients, there were 18.9% survivors. Survivors showed younger age, shorter CPR duration (p < 0.05) and had tendencies of higher rate of initial shockable rhythm (p = 0.055) and higher rate of any ROSC event before ECPR (p = 0.066) than non-survivors. Eighty-one percent of survivors showed favorable neurologic outcome at discharge. In univariate analysis, the following factors were associated with survival: no preexisting comorbidities, initial serum hemoglobin level ≥14 g/dL, and mean arterial pressure ≥60 mmHg after ECPR. Based on multivariate logistic regression, predictors for survival in ECPR were as follows: age ≤56 years, no asystole as the initial arrest rhythm, CPR duration of ≤55 min, and any return of spontaneous circulation (ROSC) event before ECPR. The prediction scoring model for survival had a c-statistic of 0.875.ConclusionsWith careful consideration of differences in the inclusion criteria, the prognostic indicators and prediction scoring model for survival in our study may be helpful in the rapid decision-making process for ECPR implementation during CPR in the ED.

Association of body mass index with clinical outcomes for in-hospital cardiac arrest adult patients following extracorporeal cardiopulmonary resuscitation.

BackgroundObesity might be associated with disturbance of cannulation in situation of extracorporeal cardiopulmonary resuscitation (ECPR). However, limited data are available on obesity in the setting of ECPR. Therefore, we investigated the association between body mass index (BMI) and clinical outcome in patients underwent ECPR.MethodsFrom January 2004 to December 2013, in-hospital cardiac arrest patients who had ECPR were enrolled from a single-center registry. We divided patients into four group according to BMI defined with the WHO classification (underweight, BMI < 18.5, n = 14; normal weight, BMI = 18.5–24.9, n = 118; overweight, BMI = 25.0–29.9, n = 53; obese, BMI ≥ 30, n = 15). The primary outcome was survival to hospital discharge.ResultsAnalysis was carried out for a total of 200 adult patients (39.5% females). Their median BMI was 23.20 (interquartile range, 20.93–25.80). The rate of survival to hospital discharge was 31.0%. There was no significant difference in survival to hospital discharge among the four groups (underweight, 35.7%; normal, 31.4%; overweight, 30.2%; obese, 26.7%, p = 0.958). Neurologic outcomes (p = 0.85) and procedural complications (p = 0.40) were not significantly different among the four groups either. SOFA score, initial arrest rhythm, and CPR to extracorporeal membrane oxygenation (ECMO) pump on time were significant predictors for survival to discharge, but not BMI.ConclusionBMI was not associated with in-hospital mortality who underwent ECPR. Neurologic outcomes at discharge or procedural complications following ECPR were not related with BMI either.

Abstract 12440: Impact of Changes in the Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care on Neurologically Intact Survival

Introduction: The AHA and International Liaison Committee on Resuscitation (ILCOR) published the Guidelines 2000 for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC). Since 2000, the ILCOR has reported the International Consensus on CPR and ECC Science with Treatment Recommendations (CoSTR) in 5-year cycles. However, few nationwide studies have investigated the efficacy of changes in the CPR guidelines. Methods: A total of 1,136,283 adult patients who received CPR after out-of-hospital cardiac arrest (OHCA) between 2005 and 2014 were included from the All-Japan Utstein Registry, a prospective, nationwide, population-based registry. We divided the study patients into 3 groups according to each guideline era (the G2000 era was cases in 2005, the CoSTR2005 era from 2006 to 2010 and the CoSTR2010 era from 2011 to 2014). The primary endpoint was favorable 30-day neurological outcome after OHCA. Multiple logistic regression analysis for primary endpoint was performed to adjust for possible confounders due to imbalances in baseline characteristics. Results: Of the 1,136,283 patients, 100,509 (8.8%) were in the G2000 era, 549,147 (48.3%) in the CoSTR2005 era and 486,627 (42.8%) in the CoSTR2010 era. Baseline characteristics exhibited significant differences among the three groups, including age, sex, time interval from call receipt to paramedic arrival at patient’s side, arrest witnessed, bystander CPR, initial arrest rhythm, advanced CPR, cause of OHCA, etc. After adjustment for resuscitation, the CoSTR2005 and the CoSTR2010 (reference, the G2000) were independent predictor of favorable 30-day neurological outcome (the CoSTR2005: adjusted OR, 1.588; 95% CI: 1.488-1.696, and the CoSTR2010: adjusted OR, 2.100; 95% CI: 1.966-2.242, respectively) and the subgroups of patients with even unwitnessed OHCA (the CoSTR2005: adjusted OR, 1.210; 95% CI: 1.057-1.386, and the CoSTR2010: adjusted OR, 1.484; 95% CI: 1.296-1.700, respectively). Conclusions: In a nationwide study for all adult patients with OHCA, the CoSTR2005 had favorable neurological outcome 1.6 times as high as the G2000, and also the CoSTR2010 had it 2.2 times. The neurologically intact survival increased each time the CPR guidelines were changed.

Pediatric Out-of-Hospital Cardiac Arrest Characteristics and Their Association With Survival and Neurobehavioral Outcome.

To investigate relationships between cardiac arrest characteristics and survival and neurobehavioral outcome among children recruited to the Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital trial. Secondary analysis of Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital trial data. Thirty-six PICUs in the United States and Canada. All children (n = 295) had chest compressions for greater than or equal to 2 minutes, were comatose, and required mechanical ventilation after return of circulation. Neurobehavioral function was assessed using the Vineland Adaptive Behavior Scales, Second Edition at baseline (reflecting prearrest status) and 12 months postarrest. U.S. norms for Vineland Adaptive Behavior Scales, Second Edition scores are 100 (mean) ± 15 (SD). Higher scores indicate better functioning. Outcomes included 12-month survival and 12-month survival with Vineland Adaptive Behavior Scales, Second Edition greater than or equal to 70. Cardiac etiology of arrest, initial arrest rhythm of ventricular fibrillation/tachycardia, shorter duration of chest compressions, compressions not required at hospital arrival, fewer epinephrine doses, and witnessed arrest were associated with greater 12-month survival and 12-month survival with Vineland Adaptive Behavior Scales, Second Edition greater than or equal to 70. Weekend arrest was associated with lower 12-month survival. Body habitus was associated with 12-month survival with Vineland Adaptive Behavior Scales, Second Edition greater than or equal to 70; underweight children had better outcomes, and obese children had worse outcomes. On multivariate analysis, acute life threatening event/sudden unexpected infant death, chest compressions more than 30 minutes, and weekend arrest were associated with lower 12-month survival; witnessed arrest was associated with greater 12-month survival. Acute life threatening event/sudden unexpected infant death, other respiratory causes of arrest except drowning, other/unknown causes of arrest, and compressions more than 30 minutes were associated with lower 12-month survival with Vineland Adaptive Behavior Scales, Second Edition greater than or equal to 70. Many factors are associated with survival and neurobehavioral outcome among children who are comatose and require mechanical ventilation after out-of-hospital cardiac arrest. These factors may be useful for identifying children at risk for poor outcomes, and for improving prevention and resuscitation strategies.

Mayo registry for telemetry efficacy in arrest study: An evaluation of the feasibility of the do not intubate code status

Introduction: Guidelines recommend discussing code status with patients on hospital admission. No study has evaluated the feasibility of a full code with do not intubate (DNI) status. Methods: A retrospective analysis of patients who experienced a cardiopulmonary arrest was performed between May 1, 2008 and June 20, 2014. A descriptive analysis was created based on whether patients required mechanical ventilatory support during the hospitalization and comparisons were made between both patient subsets. Results: A total of 239 patients were included. Almost all (n=218, 91.2%) required intubation during the hospitalization. Over half (n=117, 53.7%) were intubated on the same day as the cardiopulmonary arrest and 91 patients (41.7%) were intubated at the time of arrest. Comparisons between intubated and non-intubated patients showed little differences in clinical characteristics, except for a higher proportion of medical cardiac etiology for admission in patients who did not require intubation (n=10, 47.6% versus n=55, 25.2%; p=0.18) and initial arrest rhythm of ventricular tachycardia/fibrillation (n=8, 38.1% versus n=50, 22.9%; p=0.37). No differences in 24-hour and posthospital survivals were present. Conclusion: Mechanical ventilatory support is commonly utilized in patients who experience a cardiopulmonary arrest. The DNI status may not be a feasible code status option for most patients.

Associations between gender and cardiac arrest outcomes in Pan-Asian out-of-hospital cardiac arrest patients

BackgroundThe incidence of out-of-hospital cardiac arrest (OHCA) in women is thought to be lower than that of men, with better outcomes in some Western studies. ObjectivesThis study aimed to investigate the effect of gender on OHCA outcomes in the Pan-Asian population. MethodologyThis was a retrospective, secondary analysis of the Pan Asian Resuscitation Outcomes Study (PAROS) data between 2009 and 2012. We included OHCA cases which were presumed cardiac etiology, aged 18 years and above and resuscitation attempted by emergency medical services (EMS) systems. We used multi-level mixed-effects logistic regression models to account for the clustering effect of individuals within the country. Primary outcome was survival to hospital discharge. ResultsWe included a total of 40,159 OHCA cases, 40% of which were women. We found that women were more likely to be older and have an initial non-shockable arrest rhythm; they were more likely to receive bystander cardio-pulmonary resuscitation (CPR). The univariate analysis showed that women were significantly less likely to have return of spontaneous circulation (ROSC) at scene or in the emergency department (ED), and had lower rates of survival-to-admission and discharge, and poorer overall and cerebral performance outcomes. There was however, no significant gender difference on outcomes after adjustment of other confounders. Women in the reproductive age group (age 18–44 years) were significantly more likely to have ROSC at scene or in the ED, higher rates of survival-to-admission and discharge, and have better overall and cerebral performance outcomes after adjustment for differences in baseline and pre-hospital factors. Menopausal women (age 55 years and above) were less likely to survive to admission after adjusting for other pre-hospital characteristics but not after age adjustment. ConclusionDifferences in survival outcomes between reproductive and menopausal women highlight a need for further investigations into the plausible social, pathologic or hormonal basis.

Epidemiology of traumatic cardiac arrest in patients presenting to emergency department at a level 1 trauma center.

Introduction:There is a paucity of literature on prehospital care and epidemiology of traumatic cardiac arrest (TCA) in India. This study highlights the profile and characteristics of TCA.Methods:A retrospective cohort study was conducted to study epidemiological profile of TCA patients ≥1 year presenting to a level 1 trauma center of India.Results:One thousand sixty-one patients were recruited in the study. The median age (interquartile range) was 32 (23–45) years (male:female ratio of 5.9:1). Asystole (253), pulseless electrical activity (11), ventricular fibrillation (six), and ventricular tachycardia (five) were initial arrest rhythm. Road traffic crash (RTC) (57.16%), fall from height (18.52%), and assault (10.51%) were modes of injury. Prehospital care was provided by police (36.59%), ambulance (10.54%), relatives (45.40%), and bystanders (7.47% cases). Return of spontaneous circulation was seen in 69 patients, of which only three survived to hospital discharge.Conclusion:RTC in young males was a major cause of TCA. Asystole was the most common arrest rhythm. Police personnel were major prehospital service provider. Prehospital care needs improvement including the development of robust TCA registry.

The Utility of Therapeutic Hypothermia for Post-Cardiac Arrest Syndrome Patients With an Initial Nonshockable Rhythm.

Therapeutic hypothermia (TH) attenuates reperfusion injury in comatose survivors of cardiac arrest. The utility of TH in patients with nonshockable initial rhythms has not been widely accepted. We sought to determine whether TH improved neurological outcome and survival in postarrest patients with nonshockable rhythms. We identified 519 patients after in- and out-of-hospital cardiac arrest with nonshockable initial rhythms from the Penn Alliance for Therapeutic Hypothermia (PATH) registry between 2000 and 2013. Propensity score matching was used. Patient and arrest characteristics used to estimate the propensity to receive TH were age, sex, location of arrest, witnessed arrest, and duration of arrest. To determine the association between TH and outcomes, we created 2 multivariable logistic models controlling for confounders. Of 201 propensity score-matched pairs, mean age was 63 ± 17 years, 51% were male, and 60% had an initial rhythm of pulseless electric activity. Survival to hospital discharge was greater in patients who received TH (17.6% versus 28.9%; P < 0.01), as was a discharge Cerebral Performance Category of 1 to 2 (13.7% versus 21.4%; P = 0.04). In adjusted analyses, patients who received TH were more likely to survive (odds ratio, 2.8; 95% confidence interval, 1.6-4.7) and to have better neurological outcome (odds ratio, 3.5; 95% confidence interval, 1.8-6.6) than those that did not receive TH. Using propensity score matching, we found that patients with nonshockable initial rhythms treated with TH had better survival and neurological outcome at hospital discharge than those who did not receive TH. Our findings further support the use of TH in patients with initial nonshockable arrest rhythms.

Cardiac arrest with initial arrest rhythm of pulseless electrical activity: do rhythm characteristics correlate with outcome?

ObjectivesCardiac arrest is a leading cause of death in the United States, with pulseless electrical activity (PEA) as a common initial arrest rhythm. We sought to determine if rate of electrical activity and QRS width correlate with survival in patients who present with PEA out-of-hospital cardiac arrest. Methods and resultsThis is a retrospective review of patients with PEA out-of-hospital cardiac arrest with first documented cardiac rhythm of PEA from January 2010 to September 2013. Demographic, arrest and initial rhythm characteristics, and patient outcome were abstracted via systematic chart review. The initial 20 seconds of each rhythm strip were used to ascertain electrical rate and QRS width. Primary outcome was survival to hospital discharge. Four hundred fourteen patients were eligible for the study. One hundred fifty-two patients did not have sufficient data for analysis. Two hundred sixty-two patients were included in the final analysis with mean age, 66 years. There were 23 (8.8%) survivors and 17 (6.5%) neurologically intact survivors. Mean heart rate was 58 (confidence interval, 54-63) beats per minute, and mean QRS interval was 100 (confidence interval, 95-106) milliseconds. Twenty-nine point seven percent of patients had wide QRS complexes, and 70.3% were narrow. There was no difference in survival in patients based on heart rate (13.1% vs 7.4%, P = .16) or QRS interval (8.7% vs 7.7%, P = .79). ConclusionsIn this single emergency medical services agency study, neither PEA electrical rate nor QRS width correlated with survival or neurologic outcome.

STEMI AND OUT OF HOSPITAL CARDIAC ARREST (START) REGISTRY: ANGIOGRAPHIC FINDINGS IN PATIENTS WITH AND WITHOUT SHOCKABLE INITIAL ARREST RHYTHMS

Survival following out-of-hospital cardiac arrest plus ST-segment elevation myocardial infarction (OOHCA+STEMI) is worse in the absence of an initial shockable arrest rhythm (ventricular tachycardia or fibrillation). This study seeks to detail angiographic differences between those with and without

The Association of Health Status and Providing Consent to Continued Participation in an Out‐of‐hospital Cardiac Arrest Trial Performed Under Exception From Informed Consent

Emergency medical research performed under federal regulation 21 § CFR 50.24 provides a means to protect human subjects and investigate novel time-sensitive treatments. Although prospective individual consent is not required for studies conducted under this regulation, consent from a legally authorized representative (LAR) or the patient at the earliest feasible opportunity is required to obtain short- and long-term outcome data. The objective of this study was to determine which demographic, cardiac arrest, and patient outcome characteristics predicted the likelihood of obtaining informed consent following enrollment under exception from informed consent in a multicenter cardiac arrest study. This investigation was an analysis of data collected during a multisite, randomized, controlled, out-of-hospital cardiac arrest clinical trial performed under 21 § CFR 50.24. Research personnel attempted to obtain informed consent from LARs and subjects for medical records review of primary outcome data, as well as consent for neurologic outcome assessments up to 1 year post-cardiac arrest. Hospital discharge and neurologic status were obtained from public records and/or medical records up until the time consent was formally denied, in accordance with federal regulations and guidance. Local institutional review boards also allowed medical records review for cases where consent was neither obtained nor declined despite multiple consent attempts. Patient demographic, cardiac arrest, and clinical outcome characteristics were analyzed in univariate multinomial regression models, with consent status (obtained, denied, neither obtained nor denied) as the dependent variable. A multivariate multinomial logistic regression was then performed. An exploratory secondary analysis following the same process was performed after assigning patients who neither consented nor declined to the declined consent group. Among a total study population of 1,655 cardiac arrest subjects, 457 were transported and had consent attempted (27.6%). The survival status and neurologic function at the time of hospital discharge were known in 440 of 457 (96%) subjects. In the multivariate analysis, initial rhythm of ventricular fibrillation/ventricular tachycardia (VF/VT) and survival with good neurologic outcome were strong predictors of obtaining consent (odds ratio [OR] = 3.15, 95% confidence interval [CI] = 1.73 to 5.75; OR = 7.64, 95% CI = 2.28 to 25.63, respectively). The exploratory secondary analysis also showed initial rhythm of VF/VT and survival with good neurologic outcome as strong predictors of obtaining consent (OR = 1.86, 95% CI = 1.17 to 2.95; OR = 4.52, 95% CI = 2.21 to 9.26, respectively). Initial arrest rhythm and survival with good neurologic outcome were highly predictive of obtaining consent in this cardiac arrest trial. This phenomenon could result in underrepresentation of outcome data in the study arm with the worse outcome and represents a significant potential confounder in studies performed under 21 § CFR 50.24. Future revisions to the exception from informed consent regulations should allow access to critical survival data recorded as part of standard documentation, regardless of patient consent status.