Initial Rhythm Of Ventricular Fibrillation Research Articles

Out-of-hospital cardiac arrest (OHCA) in Bosnia and Herzegovina in the period 2018 -2022: current trends, usage of automated external defibrillators (AED) and bystanders’ involvement

<p><strong>Aim</strong> To investigate out-of-hospital cardiac arrest (OHCA) trend, provided advanced life support (ALS) measures, automated external defibrillator (AEDs) utilization and by-standers involvement in cardiopulmonary resuscitation (CPR) during OHCA incidents.<br /><strong>Methods</strong> This cross-sectional study encompassed data pertaining to all OHCA incidents attended to by the Emergency Medical Service of Canton Sarajevo, Bosnia and Herzegovina, covering the period from January 2018 to December 2022.<br /><strong>Results</strong> Among a total of 1131 OHCA events, 236 (20.8 %) patients achieved return of spontaneous circulation (ROSC); there were 175 (74.1%) males and 61 (25.9%) females. The OHCA incidence was 54/100.000 inhabitants per year. After a 30-day period post-ROSC, 146 (61.9%) patients fully recovered, while 90 (38.1%) did not survive during this timeframe. Younger age (p<0.05), initial rhythm of ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) (p<0.05) and faster emergency medical team (EMT) response time (p<0.05) were significantly associated with obtaining ROSC. Only 38 (3.3%) OHCA events were assisted by bystanders, who were mostly medical professionals, 25 (65.7%), followed by close family members, 13 (34.3%). There was no report of AED usage.<br /><strong>Conclusion</strong> This follow-up study showed less ROSC achievement, similar bystanders’ involvement, similar factors associated with achieving ROSC (age, EMT response time) and a decline in OHCA events (especially in year 2021 and 2022) comparing to our previous study (2015-2019). There was an extremely low rate of bystander engagement and no AEDs usage. Governments and health organizations must swiftly improve public awareness, promote better practice (basic life support), and actively encourage bystander participation.</p>

Improving outcomes from paediatric cardiac arrest in low resource setting

Abstract Introduction Both out of (OHCA) and in hospital (IHCA) pediatric cardiac arrest has traditionally been considered a futile medical condition with dismal outcomes. This is further magnified by resuscitation protocols are typically articulated from the perspective of ideal resource environment without consideration of applicability in district hospitals or non-tertiary centres. Purpose To determine clinical outcomes from both paediatric OHCA and IHCA in low-resource setting and to identify shortcomings in relation to resuscitation in these areas, possible solutions and to suggest future research priorities. Methods This was a multicenter retrospective study in a middle sized city (estimated population 390000) served by a single Emergency Medical Services (EMS) system. All records of OHCA and IHCA under 16 years old were reviewed from the Cardiac Arrest Registry from 2017 to 2022. Data collected included demographic profiles, etiology of cardiac arrest, initial cardiac rhythm, time of initiation of cardiopulmonary resuscitation (CPR) and adrenaline administration by EMS team and duration of CPR. Outcomes of interest included return of spontaneous circulation (ROSC) and survival to hospital discharge (STHD). Results From the 5-year study period, 68 children (mean age of 5.8±1.2 yrs) were included in this study. 22 (32.4%) were infants (<1 year old) and 7 (10.3%) were neonates (<28 days old). Total mortality was observed at 63.2% (n=43). Return of spontaneous circulation (ROSC) was achieved in 40 (58.8%) patients and 33.8% (n=23) survived to hospital discharge. OHCA was witnessed in 52 (83.8%) children from total OHCA and bystander CPR was delivered only in 19 (30.6%) cases. All IHCA were witnessed. Asystole was the most common (n=39) initial rhythm. A delay in initiating cardiopulmonary resuscitation (CPR) and adrenaline administration was observed in 49 cases of OHCA and 1 in IHCA. The median time from emergency call to CPR and from CPR to first adrenaline administration was 20.9±1.2 min and 2.9±1.3 min for OHCA and 0.4±0.2 min and 1.5±0.7min for IHCA [Table 1]. Longer time to CPR and adrenaline administration was associated with lower chance of achieving ROSC and STHD. Using multivariate analyses, fewer adrenaline doses (p<0.05), witnessed cardiac arrest (p=0.001), initial rhythm of ventricular fibrillation (p<0.05) and shorter CPR duration (p=0.007) were good prognostic factors for ROSC and STHD. Conclusion Outcomes from OHCA and IHCA in low resource settings are poor. Unwitnessed arrest, delays in initiation of CPR and adrenaline administration were associated with poor survival. Recognition and identification of at-risk patients, early high-quality CPR and adrenaline administration are imperative to improve mortality. Early recognition and effective resuscitation protocols for children in the community and encouraging bystander CPR should be developed collaboratively with local experts and the EMS team.

The Impact of Body Mass Index on In-Hospital Mortality in Post-Cardiac-Arrest Patients-Does Sex Matter?

A number of factors influence mortality in post-cardiac-arrest (CA) patients, nutritional status being one of them. The aim of this study was to assess whether there are sex differences in the prognostic impact of BMI, as calculated on admission to an intensive care unit, on in-hospital mortality in sudden cardiac arrest (SCA) survivors. We carried out a retrospective analysis of data of 129 post-cardiac-arrest patients with return of spontaneous circulation (ROSC) admitted to the Intensive Care Unit (ICU) of the University Teaching Hospital in Wrocław between 2017 and 2022. Female patients were significantly older than male patients (68.62 ± 14.77 vs. 62.7 ± 13.95). The results of univariable logistic regression analysis showed that BMI was not associated with the odds of in-hospital death in either male or female patients. In an age-adjusted model, age was an independent predictor of the odds of in-hospital death only in male patients (OR = 1.034). In our final multiple logistic regression model, adjusted for the remaining variables, none of the traits analysed were a significant independent predictor of the odds of in-hospital death in female patients, whereas an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) was an independent predictor of the odds of in-hospital death in male patients (OR = 0.247). BMI on admission to ICU is not a predictor of the odds of in-hospital death in either male or female SCA survivors.

Changes in Practice of Controlled Hypothermia After Cardiac Arrest in the Past 20 Years - A Critical Care Perspective.

For 20 years induced hypothermia and targeted temperature management (TTM) have been recommended to mitigate brain injury and increase survival after cardiac arrest. Based on animal research and small clinical trials the International Liaison Committee on Resuscitation strongly advocated hypothermia at 32-34°C for 12-24 hours for comatose out-of-hospital cardiac arrest patients with initial rhythm ventricular fibrillation or non-perfusing ventricular tachycardia. The intervention was implemented world-wide. The last decade hypothermia and TTM have been investigated in larger clinical randomized trials with focus on target temperature depth, target temperature duration, pre-hospital initiation versus in-hospital initiation, in non-shockable rhythms, and in in-hospital cardiac arrests. Systematic reviews suggest little or no effect of delivering the intervention based on the summary of evidence and ILCOR today recommends to only treat fever and keep temperatures below 37.5°C (weak recommendation, low certainty evidence). Here we describe the evolution of temperature management for cardiac arrest patients during the last 20 years and how the accrued evidence has influenced not only the recommendations but also the guideline process. We also discuss possible paths forward in this field, both bringing up whether fever management at all is beneficial for cardiac arrest patients, and which knowledge gaps future clinical trials in temperature management should address.

The Effect of Time to Treatment With Antiarrhythmic Drugs on Survival and Neurological Outcomes in Shock Refractory Out-of-Hospital Cardiac Arrest.

Examining the association of time to treatment (drug or placebo) with survival to hospital discharge and neurologic outcome. Post hoc analysis of the Resuscitation Outcomes Consortium Amiodarone, Lidocaine, Placebo randomized controlled trial. Emergency medical services enrolled patients with out-of-hospital cardiac arrest (OHCA) at multiple North American sites. Adults with nontraumatic OHCA and an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia refractory to at least one defibrillation attempt were included. None. We used logistic regression to examine the association of time to treatment with survival to hospital discharge and favorable neurologic status at discharge (modified Rankin Scale ≤ 3) for the three treatment groups including an interaction term between treatment and time to treatment to determine the effect of time on treatment effects. Time to treatment data were available for 2,994 out of 3,026 patients (99%). The proportion of patients who survived to hospital discharge decreased as time to drug administration increased, in amiodarone (odds ratio [OR], 0.91; 95% CI, 0.90-0.93 per min), lidocaine (OR, 0.93; 95% CI, 0.91-0.96), and placebo (OR, 0.91; 95% CI, 0.90-0.93). Comparing amiodarone to placebo, there was improved survival at all times of drug administration (OR, 1.32; 95% CI, 1.05-1.65). Comparing lidocaine to placebo, survival was not different with shorter times to drug administration (< 11 min), whereas survival was higher with lidocaine at longer times to drug administration with an interaction between treatment effect and time to treatment (p = 0.048). Survival with good neurologic outcome showed similar results for all analyses. Survival and favorable neurologic outcomes decreased with longer times to drug administration. Amiodarone improved survival at all time points whereas lidocaine improved survival only at later time points, compared with placebo.

Elderly Man With Out-of-hospital Cardiac Arrest

An 88-year-old man experienced a cardiac arrest at home, with an initial rhythm of ventricular fibrillation. Paramedics achieved return of circulation after 2 defibrillations and 1 dose of epinephrine; they intubated the patient in the field. In the emergency department, physicians performed transesophageal echocardiography to identify the potential causes (Figure 1, Figure 2, Video).

Insights From the Ventricular Fibrillation Waveform Into the Mechanism of Survival Benefit From Bystander Cardiopulmonary Resuscitation.

BackgroundThe mechanism by which bystander cardiopulmonary resuscitation (CPR) improves survival following out‐of‐hospital cardiac arrest is unclear. We hypothesized that ventricular fibrillation (VF) waveform measures, as surrogates of myocardial physiology, mediate the relationship between bystander CPR and survival.Methods and ResultsWe performed a retrospective cohort study of adult, bystander‐witnessed patients with out‐of‐hospital cardiac arrest with an initial rhythm of VF who were treated by a metropolitan emergency medical services system from 2005 to 2018. Patient, resuscitation, and outcome variables were extracted from emergency medical services and hospital records. A total of 3 VF waveform measures (amplitude spectrum area, peak frequency, and median peak amplitude) were computed from a 3‐second ECG segment before the initial shock. Multivariable logistic regression estimated the association between bystander CPR and survival to hospital discharge adjusted for Utstein elements. Causal mediation analysis quantified the proportion of survival benefit that was mediated by each VF waveform measure. Of 1069 patients, survival to hospital discharge was significantly higher among the 814 patients who received bystander CPR than those who did not (0.52 versus 0.43, respectively; P<0.01). The multivariable‐adjusted odds ratio for bystander CPR and survival was 1.6 (95% CI, 1.2, 2.1), and each VF waveform measure attenuated this association. Depending on the specific waveform measure, the proportion of mediation varied: 53% for amplitude spectrum area, 31% for peak frequency, and 29% for median peak amplitude.ConclusionsBystander CPR correlated with more robust initial VF waveform measures, which in turn mediated up to one‐half of the survival benefit associated with bystander CPR. These results provide insight into the biological mechanism of bystander CPR in VF out‐of‐hospital cardiac arrest.

Young Child With Seizure

An 8-year-old boy, previously with a diagnosis of epilepsy, arrived by ambulance to the emergency department (ED) after becoming unresponsive after a “seizure-like” episode. Despite a normal electroencephalogram (EEG) result, he received daily levetiracetam and experienced seizures only when fearful or anxious. After being scolded, the patient experienced a myoclonic episode that was typical for him. However, he then became unresponsive, prompting his parents to call 911. Ambulance records described a pulseless patient with initial rhythm of ventricular fibrillation.

Multidisciplinary shock team is associated with improved outcomes in patients undergoing ECPR

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) has been increasingly used in cardiopulmonary resuscitation (ECPR) in select patients. Few centers have published their experience or outcomes with ECPR. The aim of our study was to evaluate outcomes of adult patients in cardiac arrest placed on VA ECMO in the catheterization laboratory. We performed a retrospective analysis of adult patients in refractory cardiac arrest who underwent ECPR at the Minneapolis Heart Institute (MHI) at Abbott Northwestern Hospital from January 2012 to December 2017. Relevant data were obtained from electronic medical records, including arrest to ECMO flow time, total ECMO support time, and outcomes. Twenty-six adult patients underwent ECPR at the study site during the defined time period. Seven patients (27%) sustained cardiac arrest out of hospital, 19 patients arrested in-hospital with eight of those occurring in the catheterization laboratory. Seventeen (65%) patients had initial rhythm of ventricular fibrillation or tachycardia (VF/VT). All patients underwent mechanical CPR with LUCAS device. Overall 30 day and 6 month survival was 69%. Median time from arrest to ECMO flow was 46 mins (21,68) vs 61 mins (36,71) in survivors and non-survivors, respectively. Sixteen of 18 survivors discharged with a CPC score of 1 or 2. We demonstrate that adult patients in cardiac arrest initiated on VA ECMO in the cardiac catheterization laboratory and cared for by a multidisciplinary shock team in the critical care unit have superior long-term survival and functionally favorable neurologic recovery when compared to current literature.

Time to change the times? Time of recurrence of ventricular fibrillation during OHCA

Aim of the studyFor out-of-hospital-cardiac-arrest (OHCA) due to ventricular fibrillation (VF) guidelines recommend early defibrillation followed by chest compressions for two minutes before analyzing shock success. If rhythm analysis reveals VF again, it is obscure whether VF persisted or reoccurred within the two-minutes-cycle of chest compressions after successful defibrillation. We investigated the time of VF-recurrence in OHCA. MethodsWe examined all cases of OHCA presenting with initial VF rhythm at arrival of ALS-ambulance (Marburg-Biedenkopf-County, 246.648 inhabitants) from January 2014 to March 2018. Three independent investigators analyzed corpuls3® ECG-recordings. We included ECG-data from CPR-beginning until four minutes after the third shock. VF termination was defined as the absence of a VF-waveform within 5 s of shock delivery. VF recurrence was defined as the presence of a VF-waveform in the interval 5 s post shock delivery. ResultsWe included 185 shocks in 82 patients. 74.1% (n = 137) of all shocks terminated VF, but VF recurred in 81% (n = 111). The median (IQR) time of VF-recurrences was 27 s (13.5 s/80.5 s) after shock. 51.4% (n = 57) of VF-recurrence occurred 5–30 s after shock, 13.5% (n = 15) VF-recurrence occurred 31−60 s after shock, 21.6% (n = 24) of VF-recurrence occurred 61–120 s after shock, 13.5% (n = 15) of VF-recurrence occurred 121–240 s after shock. ConclusionsAlthough VF was terminated by defibrillation in 74.1%, VF recurred in 81% subsequent to the chest compression interval. Thus, VF reappears frequently and early. It is unclear to which extend chest compressions influence VF-relapse. Further studies need to re-evaluate the algorithm, timing of antiarrhythmic therapy or novel defibrillation strategies to minimize refibrillation during shockable OHCA.

Prognostic value of transient conduction disturbance in out-of-hospital cardiac arrest.

A retrospective observational study to verify the impact of electrocardiograms (ECGs) following out-of-hospital cardiac arrest (OHCA) on mortality. We retrospectively studied 101 OHCA patients who achieved a return of spontaneous circulation (ROSC) and survived for ≥3h. Among them, 50 patients (66±17years; 22 male) were evaluated using 12-lead ECGs repeatedly and were included in the final analysis: immediately after ROSC (initial ECG) and after the initial evaluation in the emergency department (second ECG). Transient conduction disturbance (transient CD) was defined as a narrowing in QRS duration from the initial to second ECG of ≥18ms. Multivariate Cox regression analyses were carried out to predict 90-day mortality following OHCA. Among 50 OHCA patients, 30 patients survived for 90days. Thirty patients had initial ventricular fibrillation rhythm. Median emergency medical services response time and low-flow duration were 8 and 21min, respectively. Multivariate analysis showed that the transient CD and low-flow duration were significant predictors of all-cause mortality (hazard ratio 16.55, 1.06; P=0.001, 0.022, respectively). Transient CD is a powerful predictor of 90-day mortality in patients who survived 3h after ROSC from OHCA.

Abstract 228: Epidemiology and Outcome of Out-Of-Hospital Cardiac Arrests in Kunming, Yunnan, China

Objective: The purpose of this study was to better understand the epidemiological features and outcomes of emergency medical service(EMS)-assessed out-of-hospital cardiac arrests(OHCAs) in Kunming,Yunnan,China. Methods: In this prospective study,datas were collected according to the Utstein style on all cases of OHCAs from January 2010 to December 2014 in urban areas covered by Kunming EMS system.The outcomes were analysed at four time points of survival: no return of spontaneous circulation (no-ROSC),return of spontaneous circulation (ROSC),survival to hospital admission, and survival to hospital discharge.The adjusted odds ratios(ORs) and 95% confidence intervals(CIs) for survival were calculated and adjusted for potential risk factors using stratified multivariable logistic regression analysis. Results: There were 3387 EMS-assessed OHCAs with cardiac aetiology from 2010 to 2014. The incidence of EMS-assessed OHCA with cardiac aetiology was 20.7 per 100,000 inhabitants per year. Of the 3387 EMS-assessed OHCAs with cardiac aetiology,the rates of ROSC,survival to admission and survival to discharge were 12.4%,3.5% and 0.9% respectively. There were only 73(2.2%)patients with initial rhythm of ventricular fibrillation(VF) or pulseless ventricular tachycardia(VT) observed in the EMS-assessed OHCAs with cardiac aetiology.There was no statistical difference among the five years in outcomes of OHCAs with cardiac aetiology.Younger age, bystander CPR,witnessed by EMS, OHCA with initial rhythm of VF/pulseless VT,shorter medication interval,and shorter response interval were associated with a higher rate of survival to discharge respectively. Conclusion: In the urban areas of Kunming covered by EMS system, survival outcome of OHCA was unsatisfactory.Improvements are required in every link of the chain of survival.

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

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

Ethnic and Neighborhood Socioeconomic Differences In Incidence and Survival From Out-Of-Hospital Cardiac Arrest In Singapore

Objective: We aimed to examine the association of ethnicity and socioeconomic status (SES) with Out-of-Hospital Cardiac Arrest (OHCA) incidence and 30-day survival in Singapore. Methods: We analyzed the Singapore cohort of Pan-Asia Resuscitation Outcome Study (PAROS), a multi-center, prospective OHCA registry between 2010 and 2015. The Singapore Socioeconomic Disadvantage Index (SEDI) score, obtained according to zip code, was used as surrogate for neighborhood SES. Age-adjusted OHCA incidence and Utstein survival were calculated by ethnicity and SES. Utstein survival was defined as the number of cardiac OHCA cases with initial rhythm of ventricular fibrillation witnessed by a bystander who survived 30-days or until hospital discharge. Logistic regression was used to investigate association of ethnicity with 30-day and Utstein survivals. Results: Our study population comprised 8,900 patients: 6,453 Chinese, 1,472 Malays, and 975 Indians. The overall age-adjusted incidence ratios (95% CI) for Malay/Chinese and Indian/Chinese were 1.93 (1.83–2.04) and 1.95 (1.83–2.08), respectively. The overall age-adjusted incidence ratios (95% CI) for average/low and high/low SEDI group were 1.12 (0.95–1.33) and 1.29 (1.08–1.53), respectively. Malay showed lesser Utstein survival of 8.1% compared to Chinese (14.6%) and Indian (20.4%) [p = 0.018]. Ethnicity did not reach statistical significance (p = 0.072) in forward selection model of Utstein survival, while SEDI score and category were not significant (p > 0.2 and p = 0.349). Conclusions: We found Malay and Indian communities to be at higher risks of OHCA compared to Chinese, and additionally, the Malay community is at higher risk of subsequent mortality than the Chinese and Indian communities. These disparities were not explained by neighborhood SES.

Maternal out-of-hospital cardiac arrest: A retrospective observational study

AimOut-of-hospital cardiac arrests (OHCAs) in pregnant women are rare events. In this study, we aimed to describe a cohort of pregnant women who experienced OHCAs in a large urban area, and received treatment by the prehospital teams in a two-tiered emergency response system. MethodsThis retrospective study included pregnant women over 18 years of age who experienced OHCAs. The analysed variables included maternal age, gestational age, variables specific to the rescue system, number of shocks delivered by an automatic external defibrillator, and rates of maternal and neonatal survival. ResultsOver the 5-year study period, 19,515 OHCAs occurred, 16 of which were in pregnant women. These 16 patients had a median age of 31 years [interquartile range (IQR): 28–35] and a median gestational age of 20 weeks [IQR: 10–33]. Three patients (18.8%) had an initial rhythm of ventricular fibrillation. Only one patient underwent thrombolysis. Of the 16 patients, 6 (38%) died after resuscitation on the scene. The remaining 10 were transported to the hospital, of whom 5 achieved circulation through a mechanical CPR device. Only 2 patients were alive 30days after OHCA. ConclusionsOver half of the pregnant women who experienced OHCA were at least 20 weeks pregnant. Analysis of the prehospital medical data suggests that the current recommendations are difficult to apply in an out-of-hospital environment. Specific recommendations for this situation must be developed.

Early initiation of extracorporeal life support in refractory out-of-hospital cardiac arrest: Design and rationale of the INCEPTION trial

We hypothesize that early initiation of ECPR in refractory out-of-hospital cardiac arrest (OHCA) improves the survival rate with favorable neurological status. The INCEPTION trial is an investigator-initiated, prospective, multicenter trial that will randomly allocate 110 patients to either continued CPR or ECPR in a 1:1 ratio. Patients eligible for inclusion are adults (≤ 70 years) with witnessed OHCA presenting with an initial rhythm of ventricular fibrillation (VF) or ventricular tachycardia (VT), who received bystander basic life support and who fail to achieve sustained return of spontaneous circulation within 15 minutes of cardiopulmonary resuscitation by emergency medical services. The primary endpoint of the study is 30-day survival rate with favorable neurological status, defined as 1 or 2 on the Cerebral Performance Category score. The secondary endpoints include 3, 6 and 12-month survival rate with favorable neurological status and the cost-effectiveness of ECPR compared to CCPR. The INCEPTION trial aims to determine the clinical benefit for the use of ECPR in patients with refractory OHCA presenting with VF/VT. Additionally, the feasibility and cost-effectiveness of ECPR will be evaluated.

Abstract 129: Effect of Defibrillation Dose and Waveform Characteristics on Defibrillation Success in Pediatric In-Hospital Cardiac Arrest

Introduction: Amplitude spectral area (AMSA) predicts successful defibrillation (DF) and return of spontaneous circulation (ROSC) in adults but has not been studied during pediatric in-hospital cardiac arrest (IHCA). Hypothesis: We characterized DF dose and AMSA during pediatric IHCA from a pediatric resuscitation quality (pediRES-Q) collaborative and hypothesized that a threshold value of AMSA could predict successful DF. Methods: Children &lt;18 years with witnessed IHCA, ventricular fibrillation (VF) as the initial rhythm, and those who had complete CPR quality metric data captured from the bedside defibrillator (ZOLL R-Series, Chelmsford, MA) were studied. Energy dose, initial AMSA ( i AMSA) and pre-shock AMSA ( p AMSA) [2.5-sec ECG window before defibrillation] for predicting DF success were calculated, together with receiver operator (ROC) curves. Successful DF (sDF) was defined as return of an organized rhythm 5 seconds after DF. Sustained ROSC was defined as &gt;20 minutes without chest compressions. Events with DF due to ventricular tachycardia, inappropriate shocks (i.e. supraventricular tachycardia, conduction block), unavailable AMSA values, and VF events using &lt;1 J/kg for DF were excluded. Results: Between 2015-2018, 34 subjects (median age 7.4 years [1.3,13.1]; median weight 19.4 kgs [8.9, 41.7]) with IHCA due to VF were enrolled. We analyzed 26 shocks in 18 children &lt; 8 years and 25 shocks in 16 children 8 to &lt;18 years. For children &lt; 8 years, the initial DF median dose/kg was 2.5 [2.3,3.3] J/kg with sDF in 14/26 (54%) shocks and sustained ROSC in 10/18 (56%) children. For those 8 to &lt;18 years, initial DF median dose/kg was 3.0 [2.5,3.4] J/kg with sDF in 10/25 (40%) shocks and sustained ROSC in 10/16 (63%). AMSA was significantly higher prior to sDF than in unsuccessful DF ( p AMSA 19.14±8.11 vs.12.0±7.38 mV-Hz, p = 0.0021; i AMSA 19.08±7.38 vs. 11.04±6.57 mV-Hz, p = 0.0053). Area under the ROC curve was 0.765 for p AMSA and 0.796 for i AMSA. Conclusions: We characterized DF dose and AMSA during pediatric IHCA with an initial rhythm of VF and found that sDF was significantly associated with AMSA &gt;19 mV-Hz. Future studies should determine the AMSA threshold that predicts sDF in children due to differences in heart size and cardiac arrest etiology.

Predictors of Resuscitation Outcomes with Global Assessment of Neurologic Status and Overall Survival in Sudden Cardiac Arrest (PROGNOSIS Cardiac Arrest): A Prospective Cohort Study

INTRODUCTION: Global survival rates from out-of-hospital cardiac arrest (OHCA) remain poor, particularly in the Asian region. Literature on OHCA in the Philippines is limited. Better characterization of outcomes of patients with OHCA and predictors of improved survival may help improve the management of OHCA. This study aimed to determine the clinical profiles of patients who had OHCA and identify predictors of survival. Methods: This was a single-center, prospective cohort study that included adult patients who had OHCA and brought to the Philippine Heart Center emergency room (ER) from May 2016 to September 2017. The clinical profiles and Utstein-based factors of cardiac arrest were collected and tabulated. The study outcomes were survival at 20 minutes, 24 hours, seven days and 30 days. Predictors of survival were determined using binary logistic regression. Results: Two hundred nine patients were included in the study, with a mean age of 62 ± 16.8 years. Majority were males, had witnessed arrest, had OHCA that occurred during morning hours at the place of residence and had comorbidities. Only 12% received pre-hospital cardiopulmonary resuscitation (CPR) and &lt;1% had automated external defibrillator (AED) administration. The most common initial rhythm was asystole. The mean arrest-to-hospital and initial-in-hospital CPR duration were 25 minutes and 30 minutes, respectively. The survival rate was 26.3% at 20 minutes, 12.0% at 24 hours, 4.8% at 7 days and 2.4% at 30 days. Neurologic outcome was poor across all time intervals. Predictors of survival at 20 minutes included initial rhythm of ventricular fibrillation (VF) (OR 6.64; 95% CI 1.56-28.17; p=0.010), arrest-to-hospital arrival time interval ≤10 minutes (OR 12.02; 95% CI 4.12-35.06; p≤0.001) and initial-in-hospital CPR duration ≤20 minutes (OR 33.89; 95% CI 12.43-92.42; p≤0.001). Conclusion: Overall survival rates of OHCA remain dismal and were associated with poor neurologic outcomes. Initial rhythm of VF, arrest-to-hospital arrival time interval of ≤ 10 minutes, and initial-in-hospital CPR duration of ≤ 20 minutes were positive predictors of survival. Keywords: Sudden cardiac arrest, OHCA, survival predictors, PROGNOSIS.

Current recommendations on adult resuscitation

### Key points Cardiorespiratory arrest remains the most challenging of medical emergencies with ∼18% of in-hospital cardiac arrests surviving to leave hospital in the UK.1 Despite data showing improvement in survival rates after cardiac arrest internationally, only 7–8% of out-of-hospital cardiac arrest (OHCA)2 survive to hospital discharge in England compared with higher rates in other developed countries. In Seattle, North America, survival rates of 62% have been reported in patients who had witnessed OHCA with an initial rhythm of ventricular fibrillation (VF). Continual evaluation and adjustments in resuscitation guidelines aim to improve survival rates. Adult resuscitation guidelines were last reviewed in this journal in 2007. There have been two Resuscitation Council (UK) [RC (UK)] guideline updates since then: in 2010, and most recently October 2015.3 This article will discuss and summarize the main changes. In 1767, a Society in Amsterdam was established for the Recovery of Drowned Persons.4 This was the first resuscitation organization dealing with education, guidelines, and collaboration between physicians and lay people. Despite some rather unusual techniques, many described are still used in modern-day resuscitation, that is, warming the victim and artificial respiration. The first scientific paper on survival after closed chest compressions was published in 19605 and was followed by a national cardiopulmonary resuscitation …

Predictors of death among cardiac arrest patients after therapeutic hypothermia: A non-tertiary care center's initial experience

Introduction and ObjectivesTherapeutic hypothermia (TH) is recommended for patients with return of spontaneous circulation (ROSC) after cardiac arrest (CA). There is still uncertainty about management, target temperature and duration of TH. In the present study we aim to describe the initial experience of a non-tertiary care center with TH after CA and to determine predictors of mortality. MethodsDuring the period 2011-2014, out of 2279 patients hospitalized in the intensive care unit, 82 had a diagnosis of CA with ROSC. We determined predictors of mortality and neurological outcome in comatose patients with ROSC after CA treated by TH. ResultsA total of 15 patients were included, mean age 47.3±14 years, 10 (67.0%) male. CA occurred out-of-hospital (n=11; 73.3%) or in-hospital (n=4; 26.7%), in initial shockable (n=10; 66.7%) or non-shockable (n=5, 33.3%) rhythm. The mean time from CA to ROSC (CA-ROSC) was 44.7±36.5 min. All patients met the 24-hour TH target temperature of 33°C. The mean neuron-specific enolase (NSE) level was 93.7±109.0 μg/l. Seven patients (46.7%) were discharged with good cerebral performance and eight (53.3%) died. Patients who survived had lower median age (p=0.032), shorter CA-ROSC (p=0.048), lower NSE levels (p=0.020) and initial ventricular fibrillation rhythm (p=NS). ConclusionsThe effectiveness of TH appears to be related to younger age, shockable initial rhythm and shorter CA-ROSC time. This results indicates some lines of inquiry that should be developed in appropriate prospective studies. The role of biomarkers as predictors of prognosis is an open question, with NSE potentially playing an important role.