Initial Arrest Research Articles

1140: COOLING DEVICE USE AND FEVER AVOIDANCE IN POST-CARDIAC ARREST PATIENTS

Introduction: In the wake of TTM2 many clinicians have replaced therapeutic hypothermia using a cooling device with fever avoidance (sometimes without a cooling device) in post-cardiac arrest patients. Given this and the adverse effects of fever, we aimed to establish the incidence of post arrest fever (Tmax ≥38oC) when a cooling device was not used and impact on outcome. Methods: A retrospective chart review of adult cardiac arrest survivors admitted to the ICUs in the Mount Sinai Health System in 2021 was conducted. Patients who had traumatic arrests, extracorporeal cardiopulmonary resuscitation (ECPR), hypo- or hyperthermia prior to arrest, death within 72 hours, and those aged ≥90 years were excluded. Patients were stratified by cooling device vs no cooling device. Univariate and multivariable statistics were computed, and endpoints examined included Tmax of ≥38oC within 48h of admission and discharged alive (vs deceased). Results: 364 patients were screened, 170 excluded, and 194 analyzed. In univariate analysis, patients who were younger (median (IQR) 60 (53-67) vs 66 (56-75) years, p=0.014), status-post out-of-hospital arrest (77.1% vs 39.2%, p< 0.001), and with a longer ROSC time (16.5 (10-34.5) vs 8 (3-15) min, p< 0.0001) were more likely to receive a cooling device. Patients without a cooling device were more likely to reach Tmax ≥38oC (37.1% vs 13.5%, p< 0.001); however, those with a cooling device were less likely to be discharged alive (28.7% vs 55.3%, p< 0.001). In multivariable analyses controlling for variables such as age, arrest location, initial arrest rhythm, and ROSC time, lack of cooling device was consistently an independent predictor of Tmax ≥38oC. Further, lower peak temperature at 48h emerged in some multivariable models as an independent predictor of being discharged alive. At the same time, however, lack of cooling device was a consistent independent predictor of being discharged alive. Lower ROSC time and greater GCS were associated with being discharged alive in some models. Conclusions: Cooling devices appeared to be associated with fever prevention but used in patients who ultimately did poorly. Moreso than use of a cooling device, achieving fever avoidance (however that may be obtained) may be more important for prognosis.

The Syrian regime’s apparatus for systemic torture: A qualitative narrative study of testimonies from survivors

BackgroundDespite broad interest of the Syrian refugee plight in the academic and media circles, there are still limited studies analyzing the lived experiences of torture survivors under the Syrian regime. This qualitative study interviewed torture survivors to examine the form and function of the Syrian regime’s security apparatus, and the personal aftermath of survivors.MethodsThirteen in-depth interviews were conducted in Arabic with Syrian refugees who endured torture. Study participants were at least 19 years of age, resided as refugees in Jordan, and voluntarily agreed to participate in the study. Participation was anonymous and no incentives were provided. Only oral consent was required. Audio-recorded interviews were transcribed and translated to English, and then analyzed for repetitive themes utilizing the narrative approach.ResultsMajor themes were observed across three experience-phases: pre-captivity, during captivity, and post-captivity. The pre-captivity phase included two sub-themes: the Syrian regime’s initial detection and arrest system, and the intelligence system. The captivity phase was also divided into two sub-themes: environmental conditions in detention facilities, and torture methods including physical and psychological torture. Some of the environmental conditions in detention facilities included lack of sanitation, crowding, starvation, and withholding of medical care. Torture methods encompassed beatings, electric shocks, nail-pulling, hanging, drowning, suffocation, rape, and the witnessing of killing, sexual assault, or torture of others. The post-captivity phase included their release from captivity, escaping Syria, and post-displacement conditions and activism.ConclusionsThe Syrian regime employs a vast security apparatus to track, detain, interrogate, torture, and subjugate its civilian population. A systematic mechanism commences even before captivity and continues for years after release, with negative implications on the well-being of survivors, their families, and the Syrian people as a collective community. The Syrian war saw a shift toward mass detention, torture as a form of social punishment, subjugation, and indeterminate imprisonment. Intervention agencies, host countries, and policymakers must be informed of survivors’ experiences to better address their needs. Moreover, the international community must advocate for a firm stance against torture, demand justice, and prosecute all parties engaged in perpetuating such extreme forms of suffering and trauma.

The impact of a high-performance cardiopulmonary resuscitation protocol on survival from out-of-hospital cardiac arrests witnessed by paramedics

AimIn this study, we examine the effect of a high-performance cardiopulmonary resuscitation (HP-CPR) protocol on patient outcomes following out-of-hospital cardiac arrests (OHCA) witnessed by emergency medical services (EMS) personnel. MethodsWe performed a retrospective cohort study of adult, EMS witnessed OHCA patients of medical aetiology in Victoria, Australia. Patients treated after the introduction of a HP-CPR protocol and training programme between February 2019 and January 2020 were compared to historical controls between January 2015 and January 2019. The effect of a HP-CPR protocol on survival to hospital discharge was examined using logistic regression models adjusted for arrest factors. ResultsA total of 1,561 and 420 EMS witnessed OHCA patients were treated in the control and intervention periods, respectively. Baseline characteristics were mostly balanced across study periods, except for an initial arrest rhythm of asystole which was more frequent during the intervention period (20.2% vs 15.9%; p-value = 0.04). Unadjusted survival to hospital discharge was similar across control and intervention periods for the overall population (32.1% vs 29.4%, p-value = 0.27), but significantly higher during the intervention period for initial shockable arrests (76.9% vs 66.6%; p-value = 0.03). After adjustment for confounders, cases in the intervention period were associated with an improvement in the adjusted odds of survival to hospital discharge for overall arrests (adjusted odds ratio [AOR] 1.37, 95% CI: 1.00–1.88) and initial shockable arrests (AOR 1.70, 95% CI: 1.03–2.82). ConclusionThe implementation of a HP-CPR protocol was associated with a significant improvement in survival from EMS witnessed OHCA. Efforts to improve CPR performance could yield further improvements in patient outcomes.

NIMG-71. REAL-WORLD ASSESSMENT OF IDH1 INHIBITOR IVOSIDENIB IN IDH MUTANT LOWER GRADE GLIOMAS – THE JOHNS HOPKINS EXPERIENCE

Abstract BACKGROUND As clinical trials are ongoing to establish the role of IDH inhibitors in the treatment of lower-grade gliomas, long-term data is not yet available. Hence, here we share our real-world experience with off-label ivosidenib. METHODS In this single-institution retrospective analysis, we included chemo/radiotherapy-naïve, gadolinium non-enhancing WHO Grade 2/3 IDH1-mutated astrocytomas (AS) and oligodendrogliomas (OG) that were treated with off-label ivosidenib for ≥ 5 months for active tumor growth. We performed semi-automated volumetric analyses on T2/FLAIR images in 3D Slicer v4.11. Annualized growth-rates before and on ivosidenib were calculated, and time to initial response (reduction in growth-rate), growth arrest (growth-rate ≤ 0cc/yr) and shrinkage in patients with confirmatory data available (≥ 1 confirmatory follow-up scan). Progression-free survival (PFS), at 6 and 12 months were assessed (progression defined as ≥ 40% volume increase per RANO 3D). RESULTS We studied 12 patients (2F, median age 46yrs [range 26-60], 8/4 AS/OG; 4 grade 3) with an average of 17.2 months (5-33) follow-up on ivosidenib. Eleven (92%) patients had confirmatory data. Response rate was 82% (9/11) with median time of 4.9 (3.5-6.3) months to initial response and 11.1 (4.1-21.4) months to growth arrest. Growth arrest occurred 3-folds faster in OG than in AS (4.2±0.8 vs.12.5±4.2 months, p=0.014). Mean best response was 11.4±12.8% volume reduction, after a median of 12.1±9.3 months on ivosidenib. Mean PFS was 24.4 months (CI95%18.8-29.9). PFS-6 and PFS-12 were 91%, and 88% (7/8), respectively. No major toxicity was noted. There were 3 discontinuations, two for radiographic progression, one for increased seizure frequency. CONCLUSIONS In this small cohort, ivosidenib was well-tolerated with a high response rate; however, responses took up to a year to become evident and seemingly faster in oligodendrogliomas. These data suggest that ivosidenib might require more than 5 months of commitment and volumetrics may help the detection of early response.

Abstract 12: Identifying Emergency Medical Service Agencies In Black And Hispanic Communities With High Cardiac Arrest Survival Rates

Background: Black and Hispanic individuals have lower survival rates for out-of-hospital cardiac arrest (OHCA). Whether there are Emergency Medical Service (EMS) agencies in Black and Hispanic communities with high survival rates for OHCA is unknown but critical to identifying strategies to reduce racial and ethnic disparities in OHCA survival. Methods: Within the Cardiac Arrest Registry to Enhance Survival, we identified adults with non-traumatic OHCA during 2015-2019. EMS agencies were categorized as working in Black/Hispanic communities if &gt;50% of residents in their catchment area were Black or Hispanic. Using hierarchical logistic regression, we calculated risk-standardized survival rates (RSSR) to hospital admission for OHCA in each EMS agency, adjusted for patients’ age, sex, witnessed arrest status, presumed arrest etiology, initial cardiac arrest rhythm, and arrest location. We then examined the distribution of EMS agencies that work in Black/Hispanic communities across quartiles of OHCA survival. Results: Among 764 EMS agencies (258,342 OHCAs), the median RSSR was 27.4% with an absolute difference of &gt;10% across quartiles (median 22.4% in the lowest vs. 32.9% in the highest quartile; 191 EMS agencies in each quartile). There were 82 EMS agencies working in Black/Hispanic communities overall, with 26 (31.7%) in the lowest RSSR quartile and 15 (18.3%) in the highest. After further adjustment for agency-level rates of bystander CPR, EMS response time and termination of resuscitation practices, there remained 29 (35.4%) EMS agencies in the lowest RSSR quartile and 16 (19.5%) in the highest. Conclusion: EMS agencies working in Black and Hispanic communities have lower prehospital survival for OHCA, although high-performing agencies exist. Identifying best practices at EMS agencies with the highest prehospital survival rates, particularly among agencies serving Black and Hispanic communities, has the potential to improve overall OHCA survival and reduce existing survival disparities.

Abstract 210: Norepinephrine Versus Epinephrine For Post-Cardiac Arrest Shock In The Prehospital Setting: A Retrospective Analysis

Introduction: Shock after out-of-hospital cardiac arrest (OHCA) is common and often treated with vasopressors. Compared with norepinephrine (NOR), infusion of epinephrine (EPI) is associated with higher mortality and morbidity among hospitalized patients; but the optimal prehospital approach is unknown. We sought to examine whether infusion of EPI versus NOR is associated with neurologically-intact survival among OHCA patients. Methods: This retrospective cohort study included transported OHCA cases in Seattle, WA from 2014-2021 who received advanced life support. Our primary exposure was infusion of EPI or NOR. Our primary outcome was neurologically-favorable survival (Cerebral Performance Category score of 1 or 2) to hospital discharge. Key secondary outcomes were prehospital rearrest, survival to hospital admission, and hospital mortality. We conducted multivariable logistic regression adjusting for baseline patient and OHCA characteristics. Results: Of 1784 OHCA patients, 263 (15%) received NOR and 201 (11%) received EPI infusions, 18 received both, and 1298 received neither. Those who received EPI were older (median 65 [IQR 52-78] vs 62 [IQR 47-75] years), but otherwise had similar baseline characteristics, including initial arrest rhythm (Table 1). Patients who received EPI were over twice as likely to have rearrested in the prehospital setting (53% vs 24%). After adjustment, there was no difference in neurologically-favorable survival (OR 0.91, 95% CI 0.47-1.78). We found no difference in survival to hospital admission or discharge. Conclusion: Neurologically-favorable survival was similar among patients who received NOR or EPI infusions for post-OHCA shock, though patients who received EPI had prehospital rearrests more often. Future trials should examine the optimal approach to hemodynamic management for post-OHCA shock.

Abstract 13: Myocardial Metabolic And Electrolyte Derangements Linked To PEA Rearrest

Background: Cardiac rearrest after return of spontaneous circulation (ROSC) is a significant barrier to successful resuscitation, making it a high priority for emergency care research. Regardless of initial arrest rhythm, rearrest is commonly due to pulseless electrical activity (PEA). However, mechanisms underlying PEA rearrest are poorly understood. Previously, myocardial contractile function during ischemia-reperfusion has been tied to alterations in extracellular sodium (Na+) and calcium (Ca2+) concentrations. Objective: To determine physiological predictors and explore potential mechanisms underlying susceptibility to PEA rearrest. Methods: Acute myocardial infarction (AMI) induced by left anterior descending artery (LAD) occlusion was followed by 8 min of VF, then pigs were resuscitated (defibrillation, CPR, epinephrine) to ROSC and the LAD was reperfused. Pigs were instrumented to measure metabolic variables from arterial and coronary sinus venous blood gases, electrolytes, and hemodynamics. Subjects that had PEA rearrest (n=7) were compared to those that did not rearrest (n=4). Results: Hemodynamic and primary arrest characteristics were similar between PEA and no rearrest groups, including ischemia duration, time to ROSC, CPR events, and epinephrine administration. At ROSC, hemodynamic and metabolic variables including pH, myocardial lactate consumption, myocardial arterial/venous oxygen difference were also similar between groups. Importantly, post-ROSC myocardial lactate consumption was significantly increased in the PEA group (3.9 vs. 0.5 mmol, p&lt;0.03) as was coronary sinus Na+ (147 vs. 135 mEq/L, p&lt;.03); however, coronary sinus Ca2+ was significantly reduced (1.9 vs. 2.3 mEq/L, p&lt;.01 ). Taken together, these data suggest that metabolic substrate depletion may promote local electrolyte shifts contributing to mechanical dysfunction underlying PEA. Conclusion: PEA rearrest was associated with increased myocardial lactate consumption and derangements in cardiac Na+ and Ca2+ in a translational model with well controlled arrest characteristics. Improved understanding of mechanisms underlying post-ROSC electrolyte shifts may identify novel mechanisms and therapeutic approaches to prevent and treat PEA.

The Polo kinase Cdc5 is regulated at multiple levels in the adaptation response to telomere dysfunction.

Telomere dysfunction activates the DNA damage checkpoint to induce a cell cycle arrest. After an extended period of time, however, cells can bypass the arrest and undergo cell division despite the persistence of the initial damage, a process called adaptation to DNA damage. The Polo kinase Cdc5 in Saccharomyces cerevisiae is essential for adaptation and for many other cell cycle processes. How the regulation of Cdc5 in response to telomere dysfunction relates to adaptation is not clear. Here, we report that Cdc5 protein level decreases after telomere dysfunction in a Mec1-, Rad53- and Ndd1-dependent manner. This regulation of Cdc5 is important to maintain long-term cell cycle arrest but not for the initial checkpoint arrest. We find that both Cdc5 and the adaptation-deficient mutant protein Cdc5-ad are heavily phosphorylated and several phosphorylation sites modulate adaptation efficiency. The PP2A phosphatases are involved in Cdc5-ad phosphorylation status and contribute to adaptation mechanisms. We finally propose that Cdc5 orchestrates multiple cell cycle pathways to promote adaptation.

Variation in coronary angiography use in Out-of-Hospital cardiac arrest

IntroductionMultiple studies have examined the association of early coronary angiography (CAG) among out-of-hospital cardiac arrest (OHCA) patients with conflicting results. However, patterns of use of CAG among OHCA patients in real-world settings are not well-described. MethodsUtilizing data from the Resuscitation Outcomes Consortium’s Continuous Chest Compressions trial for our analysis, we stratified patients based on initial arrest rhythm and ST-elevation on initial post-resuscitation electrocardiogram (ECG) and examined the rates of CAG in resuscitated patients. We also examined the rates of CAG across different trial clusters in the overall study population as well as in pre-specified patient subgroups ResultsOf 26,148 patients in the CCC trial, 5,608 survived to hospital admission and were enrolled in the study. Among them, 26 % underwent CAG. Patients with ST-elevation underwent CAG at a significantly higher rate than patients presenting without ST-elevation (70 % vs 31 %, p < 0.001). Similarly, patients presenting with shockable rhythms underwent CAG more frequently compared with patients with non-shockable rhythms (28 % vs 5 %, p < 0.001). There was marked variation in CAG frequency across different trial clusters with the proportion of patients within a trial cluster receiving CAG ranging from 4 % − 41 %. The proportion varied more among patients with ST-elevation (16 % − 82 %) or initial shockable rhythm (11 % − 75 %) compared with no ST-elevation (2 % − 28 %) or initial non-shockable rhythm (0 % − 19 %). ConclusionAmong a national cohort of OHCA patients, large variation in the use of CAG exists, highlighting the existing uncertainty regarding perceived benefit from early CAG in OHCA.

Breast cancer liver metastasis: Pathogenesis and clinical implications.

Breast cancer is the most common malignant disease in female patients worldwide and can spread to almost every place in the human body, most frequently metastasizing to lymph nodes, bones, lungs, liver and brain. The liver is a common metastatic location for solid cancers as a whole, and it is also the third most common metastatic site for breast cancer. Breast cancer liver metastasis (BCLM) is a complex process. Although the hepatic microenvironment and liver sinusoidal structure are crucial factors for the initial arrest of breast cancer and progression within the liver, the biological basis of BCLM remains to be elucidated. Importantly, further understanding of the interaction between breast cancer cells and hepatic microenvironment in the liver metastasis of breast cancer will suggest ways for the development of effective therapy and prevention strategies for BCLM. In this review, we provide an overview of the recent advances in the understanding of the molecular mechanisms of the hepatic microenvironment in BCLM formation and discuss current systemic therapies for treating patients with BCLM as well as potential therapeutic development based on the liver microenvironment-associated signaling proteins governing BCLM.

Protected carotid artery stenting in patients with severe stenosis.

Intraplaque hemorrhage (IPH) and ulcers are the major findings of unstable plaques. In addition, initial symptoms are associated with postprocedural complications after carotid artery stenting (CAS). The aim of this study was to determine the safety of CAS using an embolic protection device in symptomatic patients with severe carotid artery stenosis and unstable plaques such as IPH and ulcers.This retrospective study included 140 consecutive patients with severe carotid stenosis. These patients underwent preprocedural carotid vessel wall imaging to evaluate the plaque status. We analyzed the incidence of initial clinical symptoms, such as headache, nausea, and vomiting, after CAS. The primary outcomes analyzed were the incidence of stroke, myocardial infarction, and death within 30 days of CAS.Sixty-seven patients (47.9%) had IPH, and 53 (38.9%) had ulcers on carotid wall imaging/angiography. Sixty-three patients (45.0%) had acute neurological symptoms with positive diffusion-weighted image findings. Intraluminal thrombi on initial angiography and flow arrest during CAS were significantly higher in patients with IPH and symptomatic patients. Symptoms were significantly higher in patients with IPH than in those without (63.5% vs 35.1%, P < .001). There were no significant differences in clinical symptoms after stenting or in primary outcomes, regardless of IPH, ulcer, or initial symptoms.IPH and plaque ulceration are risk factors in symptomatic carotid stenosis. However, IPH and plaque ulceration were not a significant risk factors for cerebral embolism during protected carotid artery stent placement in patients with carotid stenosis. Protected CAS might be feasible and safe despite the presence of unstable plaques.

Early risk stratification for progression to death by neurological criteria following out-of-hospital cardiac arrest

BackgroundSome patients resuscitated from out-of-hospital cardiac arrest (OHCA) progress to death by neurological criteria (DNC). We hypothesized that initial brain imaging, electroencephalography (EEG), and arrest characteristics predict progression to DNC. MethodsWe identified comatose OHCA patients from January 2010 to February 2020 treated at a single quaternary care facility in Western Pennsylvania. We abstracted demographics and arrest characteristics; Pittsburgh Cardiac Arrest Category, initial motor exam and pupillary light reflex; initial brain computed tomography (CT) grey-to-white ratio (GWR), sulcal or basal cistern effacement; initial EEG background and suppression ratio. We used two modeling approaches: fast and frugal tree (FFT) analysis to create an interpretable clinical risk stratification tool and ridge regression for comparison. We used bootstrapping to randomly partition cases into 80% training and 20% test sets and evaluated test set sensitivity and specificity. ResultsWe included 1,569 patients, of whom 147 (9%) had diagnosed DNC. Across bootstrap samples, >99% of FFTs included three predictors: sulcal effacement, and in cases without sulcal effacement, the combination of EEG background suppression and GWR ≤ 1.23. This tree had mean sensitivity and specificity of 87% and 81%. Ridge regression with all available predictors had mean sensitivity 91 % and mean specificity 83%. Subjects falsely predicted as likely to progress to DNC generally died of rearrest or withdrawal of life sustaining therapies due to poor neurological prognosis. Two of these cases awakened from coma during the index hospitalization. ConclusionsSulcal effacement on presenting brain CT or EEG suppression with GWR ≤ 1.23 predict progression to DNC after OHCA.

Prehospital ABC (Age, Bystander and Cardiogram) scoring system to predict neurological outcomes of cardiopulmonary arrest on arrival: post hoc analysis of a multicentre prospective observational study

BackgroundThere is currently limited evidence to guide prehospital identification of patients with cardiopulmonary arrest on arrival (CPAOA) to hospital who have potentially favourable neurological function. This study aimed to develop...

Cellular Senescence in Aging Lungs and Diseases.

Cellular senescence represents a state of irreversible cell cycle arrest occurring naturally or in response to exogenous stressors. Following the initial arrest, progressive phenotypic changes define conditions of cellular senescence. Understanding molecular mechanisms that drive senescence can help to recognize the importance of such pathways in lung health and disease. There is increasing interest in the role of cellular senescence in conditions such as chronic obstructive pulmonary disease (COPD) and idiopathic pulmonary fibrosis (IPF) in the context of understanding pathophysiology and identification of novel therapies. Herein, we discuss the current knowledge of molecular mechanisms and mitochondrial dysfunction regulating different aspects of cellular senescence-related to chronic lung diseases to develop rational strategies for modulating the senescent cell phenotype in the lung for therapeutic benefit.

Outcomes of cardiopulmonary resuscitation in patients with pulmonary arterial hypertension.

Over the past 20 years, despite significant advancements in pulmonary arterial hypertension (PAH) medical therapy, many patients require admission to the hospital and are at risk for in‐hospital cardiac arrest (IHCA). Prior data found poor survival in PAH patients after cardiac arrest. The purpose of this study was to explore post‐IHCA outcomes in PAH patients receiving advanced medical therapies. This is a single‐center retrospective study of PAH patients who underwent cardiopulmonary resuscitation for IHCA between July 2005 and May 2021. Patients were identified through an internal cardiac arrest database. Twenty six patients were included. Half of the cohort had idiopathic PAH, with 54% of patients on combination therapy, 27% on monotherapy, and 19% of patients on no therapy. Mean right atrial pressure, mean pulmonary artery pressure, cardiac index, and pulmonary vascular resistance were 13 ± 6 mmHg, 57 ± 13 mmHg, 2.0 ± 0.7 L/min/m2, and 14.5 ± 7.6 Wood units, respectively. Most common etiology of cardiac arrest was circulatory collapse. Initial arrest rhythm in all but one patient was pulseless electrical activity. Six patients (23%) achieved return of spontaneous circulation (ROSC) and one patient (4%) survived to hospital discharge. Rates of ROSC and survival to discharge after IHCA are poor in patients with PAH. Even patients with mild hemodynamics had low likelihood of survival. In patients who are lung transplant candidates, there should be early consideration of extracorporeal support before cardiac arrest.

A retrospective multi-centre cohort study: Pre-hospital survival factors of out-of-hospital cardiac arrest (OHCA) patients in Thailand

ObjectiveThis study aimed to explore significant pre-hospital factors affecting the survivability of Out-of-Hospital Cardiac Arrest (OHCA) patients in countries with developing EMS systems. MethodA retrospective cohort study was conducted examining data from January 1, 2017 to December 31, 2020 from Utstein Registry databases in Thailand, collected through Pan-Asian Resuscitation Outcomes Study (PAROS). Data were collected from three centres, including regional, suburban-capital, and urban-capital hospitals. The primary endpoint of this study was 30-day survival or discharged alive after an OHCA event. The multivariable risk regression was done by modified Poisson regression with robust error variance to explore the association between 30-day survival and pre-hospital factors with potential confounders adjustments. FindingsOf 1,240 OHCA cases transferred by Emergency Medical Services (EMS), 42 patients (3.4%) were discharged alive after 30 days, including 22 (8.6%), 8 (3.0%), and 12 (1.7%) from regional, suburban-capital, and urban-capital centres, respectively. The initial arrest rhythm was 89.7% unshockable, with no significant variations across the three centres. Overall, bystander Cardiopulmonary Resuscitation (CPR) was 40.4%. However, bystander CPR with Automated External Defibrillator (AED) application was 0.8%. Bystander CPR significantly increased 30-day survival probability (aRR 1.88, 95% CI 1.01 to 3.51; p 0.049). Additionally, reducing the EMS response time by one minute significantly increased OHCA survivability (aRR 1.12, 95% CI 1.04 to 1.20; p 0.001). ConclusionsResponse time and bystander CPR are the factors that improve the 30-day survival outcomes of OHCA patients. In contrast, scene time, transport time, and pre-hospital advanced airway management didn’t improve 30-day OHCA survival.

Factors Associated with Pediatric In-Hospital Recurrent Cardiac Arrest

AbstractThe objective of this article was to identify demographic and clinical factors associated with early recurrent arrest (RA; &lt;48 hours) and late RA (≥48 hours) among pediatric inpatients following an initial in-hospital cardiac arrest. A retrospective cohort study of inpatients was performed in a free-standing academic quaternary care children's hospital. All inpatients were &lt;18 years old with a cardiac arrest event requiring ≥1 minute of cardiopulmonary resuscitation with the return of spontaneous circulation sustained for ≥20 minutes at Seattle Children's Hospital from February 1, 2012, to September 18, 2019. Of the 237 included patients, 20 (8%) patients had an early RA and 30 (13%) had a late RA. Older age and severe prearrest acidosis were associated with a higher risk of early RA, odds ratios (OR) = 1.2 (95% confidence interval [CI]: 1.1–1.3) per additional year and 4.6 (95% CI: 1.2–18.1), respectively. Prearrest organ dysfunction was also associated with a higher risk of early RA with an OR of 3.3 (95% CI: 1.1–9.4) for respiratory dysfunction, OR = 1.4 (95% CI: 1.1–1.9) for each additional dysfunctional organ system, and OR = 1.1 (95% CI: 1–1.2) for every one-point increase in PELOD2 score. The neonatal illness category was associated with a lower risk of late RA, OR 0.3 (95% CI: 0.1–0.97), and severe postarrest acidosis was associated with a higher risk of late RA, OR = 4.2 (95% CI: 1.1–15). Several demographic and clinical factors offer some ability to identify children who sustain a recurrent cardiac arrest, offering a potential opportunity for intervention to prevent early recurrent arrest.

Performance of an automated ultrasound device in identifying and tracing the heart in porcine cardiac arrest

BackgroundWhile intra-arrest echocardiography can be used to guide and monitor chest compression quality, it is not currently feasible on the scene of out-of-hospital cardiac arrests. Rapid and automated sonographic localization of the heart may provide first-responders guidance to an optimal area of compression without requiring them to interpret ultrasound images. In this proof-of-concept porcine study, we sought to describe the performance of an automated ultrasound device in correctly identifying and tracing the borders of the heart in three distinct states: pre-arrest, arrest, and late arrest.MethodsAn automated ultrasound device (bladder scanner) was placed on the chests of 7 swine, along the left sternal border (4th–8th intercostal spaces). Scanner-generated images were recorded for each space during pre-arrest, arrest, and finally late arrest. 828 images of the LV and LV outflow tract were randomized and 150 (50/state) selected for analysis. Scanner tracings of the heart were then digitally obscured to facilitate tracing by expert reviewers who were blinded to the physiologic state. Reviewer tracings were compared to bladder scanner tracings; with concordance between these images determined via Sørensen–Dice index (SDI).ResultsWhen compared to human reviewers, the bladder scanner was able to identify and trace the borders during cardiac arrest. The bladder scanner performed best at the time of arrest (SDI 0.900 ± 0.059). As resuscitation efforts continued and time from initial arrest increased, the scanner’s performance decreased dramatically (SDI 0.597 ± 0.241 in late arrest).ConclusionAn automated ultrasound device (bladder scanner) reliably traced porcine hearts during cardiac arrest. It is possible a device could be developed to indicate where compressions should be performed without requiring the operator to interpret ultrasound images. Further investigation into rapid, automated, sonographic localization of the heart to identify the area of compression in out-of-hospital cardiac arrest is warranted.

Individualized management objectives for hypoxic-ischemic brain injury after cardiac arrest

Hypoxic-ischemic brain injury after cardiac arrest is the main cause of death and neurologic dysfunction in patients after the return of spontaneous circulation. The mechanisms of ischemic and hypoxic brain injury include hypoxia of brain tissue caused by the cessation of cerebral blood flow during the initial cardiac arrest and cerebrovascular dysfunction and reperfusion injury after the recovery of circulation. Cerebral circulatory perfusion, cerebral autoregulation, and cerebral edema can be monitored and controlled as therapeutic targets. In this study, from the aspects of body temperature, mean arterial pressure, oxygen concentration, partial pressure of carbon dioxide in the artery, and cerebral edema, monitoring methods such as measurement of cerebral oxygen saturation, assessment of cerebral blood flow, imaging of the brain, and measurement of intracranial pressure were introduced to explore individual management objectives for hypoxic-ischemic brain injury.

Long term control of corrosion of steel reinforcement by a two-stage cathodic protection method

It has been shown experimentally that corrosion of steel reinforcement can be arrested if sufficient cathodic charge at a current density higher than 20 mA/m2 is applied over a period of weeks. Once corrosion is arrested, a cathodic prevention current density, which requires a current density an order of magnitude lower than for conventional cathodic protection, can be applied for long-term prevention of re-initiation of corrosion. Self-contained products were developed in the laboratory according to the Two-Stage principle, each single product containing a battery-operated ICCP element which produces a high initial current output of between 20 mA/m2 and 50 mA/m2 of steel area during an initial polarisation corrosion arrest phase and a galvanic anode component which delivers the lower cathodic prevention current long-term. Diodes ensure that the current from the battery is delivered to the steel reinforcement and not dumped onto the galvanic anode and allow the galvanic current to flow only when the ICCP element becomes inoperable. This paper describes the principles of the technique, illustrates products developed and presents medium-term field studies to demonstrate the success of the Two-Stage CP technique.