Medical Cardiac Arrest Research Articles

A Systematic Review of Medical Expert Systems for Cardiac Arrest Prediction

Background:: Predicting cardiac arrest is crucial for timely intervention and improved patient outcomes. Machine learning has yielded astounding results by offering tailored prediction analyses on complex data. Despite advancements in medical expert systems, there remains a need for a comprehensive analysis of their effectiveness and limitations in cardiac arrest prediction. This need arises because there are not enough existing studies that thoroughly cover the topic. Objective:: The systematic review aims to analyze the existing literature on medical expert systems for cardiac arrest prediction, filling the gaps in knowledge and identifying key challenges. Methods:: This paper adopts the PRISMA methodology to conduct a systematic review of 37 publications obtained from PubMed, Springer, ScienceDirect, and IEEE, published within the last decade. Careful inclusion and exclusion criteria were applied during the selection process, resulting in a comprehensive analysis that utilizes five integrated layers- research objectives, data collection, feature set generation, model training and validation employing various machine learning techniques. Results and Conclusion:: The findings indicate that current studies frequently use ensemble and deep learning methods to improve machine learning predictions’ accuracy. However, they lack adequate implementation of proper pre-processing techniques. Further research is needed to address challenges related to external validation, implementation, and adoption of machine learning models in real clinical settings, as well as integrating machine learning with AI technologies like NLP. This review aims to be a valuable resource for both novice and experienced researchers, offering insights into current methods and potential future recommendations.

Emergency Medical Service Agency Practices and Cardiac Arrest Survival

Survival for out-of-hospital cardiac arrest (OHCA) varies widely across emergency medical service (EMS) agencies in the US. However, little is known about which EMS practices are associated with higher agency-level survival. To identify resuscitation practices associated with favorable neurological survival for OHCA at EMS agencies. This cohort study surveyed EMS agencies participating in the Cardiac Arrest Registry to Enhance Survival (CARES) with 10 or more OHCAs annually during January 2015 to December 2019; data analyses were performed from April to October 2023. Survey of resuscitation practices at EMS agencies. Risk-standardized rates of favorable neurological survival for OHCA at each EMS agency were estimated using hierarchical logistic regression. Multivariable linear regression then examined the association of EMS practices with rates of risk-standardized favorable neurological survival. Of 577 eligible EMS agencies, 470 agencies (81.5%) completed the survey. The mean (SD) rate of risk-standardized favorable neurological survival was 8.1% (1.8%). A total of 7 EMS practices across 3 domains (training, cardiopulmonary resuscitation [CPR], and transport) were associated with higher rates of risk-standardized favorable neurological survival. EMS agencies with higher favorable neurological survival rates were more likely to use simulation to assess CPR competency (β = 0.54; P = .05), perform frequent reassessment (at least once every 6 months) of CPR competency in new staff (β = 0.51; P = .04), use full multiperson scenario simulation for ongoing skills training (β = 0.48; P = .01), perform simulation training at least every 6 months (β = 0.63; P < .001), and conduct training in the use of mechanical CPR devices at least once annually (β = 0.43; P = .04). EMS agencies with higher risk-standardized favorable neurological survival were also more likely to use CPR feedback devices (β = 0.58; P = .007) and to transport patients to a designated cardiac arrest or ST-segment elevation myocardial infarction receiving center (β = 0.57; P = .003). Adoption of more than half (≥4) of the 7 practices was more common at EMS agencies in the highest quartile of favorable neurological survival rates (70 of 118 agencies [59.3%]) vs the lowest quartile (42 of 118 agencies [35.6%]) (P < .001). In a national registry for OHCA, 7 practices associated with higher rates of favorable neurological survival were identified at EMS agencies. Given wide variability in neurological survival across EMS agencies, these findings provide initial insights into EMS practices associated with top-performing EMS agencies in OHCA survival. Future studies are needed to validate these findings and identify best practices for EMS agencies.

Epinephrine in Cardiac Arrest: Identifying a Potential Limit for Resuscitation.

Epinephrine continues to be a fundamental part of the Advanced Cardiac Life Support algorithm despite a lack of evidence that it improves neurologically intact survival. Our aim was both to identify a potential upper limit of epinephrine use in resuscitations and to demonstrate real-world epinephrine use in different patient subgroups. This was a single-center, retrospective cohort study, conducted between August 1, 2016-July 1, 2021, of patients with medical cardiac arrest who were administered a known number of epinephrine doses. The primary outcome was neurologically intact discharge defined by a modified Rankin scale ≤3, with secondary outcomes of comparing epinephrine doses by age, rhythm, and emergency medical services vs emergency department administration of epinephrine. The study included 1,330 patients, with 184 patients (13.8%) surviving to neurologically intact discharge. The primary outcome of neurologically intact discharge was found in 89 (65.4%) patients in the zero epinephrine dose group, 75 (20.0%) in the 1-3 dose group, 15 (4.3%) in the 4-6 dose group, and one (0.002%) in the ≥7 dose group (P < 0.001). Patients received similar amounts of epinephrine when stratified by age, while patients with shockable rhythms received more epinephrine than patients with non-shockable rhythms. There was a significant decrease in neurologically intact discharge with increasing number of epinephrine doses, and our data suggests that seven or more doses of epinephrine is almost always futile. While further prospective studies are needed, clinicians should consider epinephrine doses when weighing the futility or benefit of continued resuscitation efforts.

Temporal Trends in Incidence and Survival From Sudden Cardiac Arrest Manifesting With Shockable and Nonshockable Rhythms: A 16-Year Prospective Study in a Large US Community

The proportion of nonshockable sudden cardiac arrests (pulseless electrical activity and asystole) continues to rise. Survival is lower than shockable (ventricular fibrillation [VF]) sudden cardiac arrests, but there is little community-based information on temporal trends in the incidence and survival from sudden cardiac arrests based on presenting rhythms. We investigated community-based temporal trends in sudden cardiac arrest incidence and survival by presenting rhythm. We prospectively evaluated the incidence of each presenting sudden cardiac arrest rhythm and survival outcomes for out-of-hospital events in the Portland, Oregon metro area (population of approximately 1 million, 2002 to 2017). We limited inclusion to cases of likely cardiac cause with resuscitation attempted by emergency medical services. Out of 3,723 overall sudden cardiac arrest cases, 908 (24%) presented with pulseless electrical activity, 1,513 (41%) with VF, and 1,302 (35%) with asystole. The incidence of pulseless electrical activity-sudden cardiac arrest remained stable over 4-year periods (9.6/100,000 in 2002 to 2005, 7.4/100,000 in 2006 to 2009, 5.7/100,000 in 2010 to 2013, and 8.3/100,000 in 2014 to 2017; unadjusted beta [β]-0.56; 95% confidence interval [CI],-3.98 to 2.85). The incidence of VF-sudden cardiac arrests decreased over time (14.6/100,000 in 2002 to 2005, 13.4/100,000 in 2006 to 2009, 12.0/100,000 in 2010 to 2013, and 11.6/100,000 in 2014 to 2017; unadjusted β-1.05; 95% CI,-1.68 to-0.42) and asystole-sudden cardiac arrests (8.6/100,000 in 2002 to 2005, 9.0/100,000 in 2006 to 2009, 10.3/100,000 in 2010 to 2013, and 15.7/100,000 in 2014 to 2017; unadjusted β 2.25; 95% CI-1.24 to 5.73) did not change significantly over time. Survival increased over time for pulseless electrical activity-sudden cardiac arrests (5.7%, 4.3%, 9.6%, 13.6%; unadjusted β 2.8%; 95% CI 1.3 to 4.4) and VF-sudden cardiac arrests (27.5%, 29.8%, 37.9%, 36.6%; unadjusted β 3.5%; 95% CI 1.4 to 5.6), but not for asystole-sudden cardiac arrests (1.7%, 1.6%, 4.0%, 2.4%; unadjusted β 0.3%; 95% CI,-0.4 to 1.1). Enhancements in the emergency medical services system's pulseless electrical activity-sudden cardiac arrest management were temporally associated with the increasing pulseless electrical activity survival rates. Over a 16-year period, the incidence of VF/ventricular tachycardia decreased over time, but pulseless electrical activity incidence remained stable. Survival from both VF-sudden cardiac arrests and pulseless electrical activity-sudden cardiac arrests increased over time with a more than 2-fold increase for pulseless electrical activity-sudden cardiac arrests.

Determining the top research priorities in UK prehospital critical care: a modified Delphi study

BackgroundPrehospital critical care is a rapidly evolving field. There is a paucity of evidence relating to its practice, with limited progress in answering those research questions identified over a decade...

Interaction effect between prehospital hydration and initial cardiac rhythm in traumatic out-of-hospital cardiac arrest: a nationwide observational study

Traumatic cardiac arrest (TCA) is different in etiology compared to medical cardiac arrest. In case of TCA, it is important to initiate early fluid resuscitation. Initial cardiac rhythm serves as an indicator of outcomes in case of cardiac arrest. We aimed to find the association between prehospital hydration and outcomes of TCA according to initial cardiac rhythm. This is a retrospective, observational, cross-sectional study. An examination was undertaken involving patients afflicted with TCA within the timeframe of 2014 to 2019. Exposure was defined to encompass prehospital hydration; interactive exposure was categorized by initial cardiac rhythm (non-shockable vs. shockable); the primary outcome was defined as good neurological status at discharge, whereas the secondary outcome was defined as survival to discharge. Multivariable logistic regression analysis was used to calculate adjusted odds ratios (AORs) with 95% confidence intervals (CIs). A comprehensive analysis was conducted on a cumulative of 20,247 patients. Rates of good neurological status and survival to discharge were 0.2% and 8.3% (non-shockable rhythm group) and 3.0% and 16.7%(shockable rhythm group), respectively. However, rates of good neurological status and survival to discharge were 0.2% and 7.9% (non-prehospital hydration group) and 0.3% and 10.0% (hydration group), respectively. Compared to the non-hydration group, the AORs for good neurological status at discharge was 1.44 (95% CI: 0.77–2.69) for the hydration group. Moreover, compared to the non-shockable rhythm group, the AORs for good neurological status at discharge was 19.74 (95% CI: 10.46–27.26) in the shockable rhythm group. The interaction analysis conducted between prehospital hydration and initial rhythm unveiled the efficacy of prehospital hydration in promoting favorable survival to discharge outcomes in the non-shockable rhythm group. Therefore, prehospital hydration is recommended for those with TCA characterized by a non-shockable rhythm before transport from the incident location.

Evaluating the Impact of Introducing Modified Early Warning Score to Identify Deteriorating Patients in the Wards at a Tertiary University Hospital - A before-after Study

BACKGROUND&#x0D; Modified early warning score (MEWS) is a scoring system being used in hospitals for the identification of patients who may deteriorate into medical emergencies or cardiac arrest. However, the mortality benefit of MEWS hasn’t been established. Also, there is limited data about the experience of MEWS being implemented in low-income countries. Hence, we conducted a before-after prospective observational study to evaluate the impact on ICU mortality post-introduction of the MEWS chart.&#x0D; METHODS&#x0D; MEWS before-after study is a single-centre prospective observational study in a tertiary university hospital conducted in the ICU at Kasturba Hospital, Manipal University, India. We trained ward nurses on MEWS and introduced the MEWS chart and compared the change in outcomes from two months prior (i.e. February-March 2018) to the subsequent two months (i.e. April-May 2018). The primary outcome measured was the ICU mortality between the samples. Our secondary outcomes were the length of stay (LOS) and hospital mortality. Student t-test was used to estimate the total sample size and we used the chi-square test for statistical analyses.&#x0D; RESULTS&#x0D; We enrolled 161 patients into each group and the patient demographics between groups did not show any statistically significant difference. The ICU mortality data did not show any statistically significant difference before the introduction of MEWS after using the chi-square test with a p-value of 0.33. There was no statistically significant difference in ICU LOS, ICU re-admission rates, hospital LOS, hospital mortality, bed occupancy rates, or incidence of CPR between the two periods.&#x0D; CONCLUSIONS&#x0D; Our study did not show a significant difference in the mortality after introduction of MEWS scoring charts to our wards. The introduction of critical care outreach services may improve the outcomes.

Cardiovascular complications of prehospital emergency anaesthesia in patients with return of spontaneous circulation following medical cardiac arrest: a retrospective comparison of ketamine-based and midazolam-based induction protocols

BackgroundHypotension following intubation and return of spontaneous circulation (ROSC) after cardiac arrest is associated with poorer patient outcomes. In patients with a sustained ROSC requiring emergency anaesthesia, there is limited...

The impact of video laryngoscopy on the first-pass success rate of prehospital endotracheal intubation in The Netherlands: a retrospective observational study

PurposeThe first-pass success rate for endotracheal intubation (ETI) depends on provider experience and exposure. We hypothesize that video laryngoscopy (VL) improves first-pass and overall ETI success rates in low and intermediate experienced airway providers and prevents from unrecognized oesophageal intubations in prehospital settings.MethodsIn this study 3632 patients were included. In all cases, an ambulance nurse, HEMS nurse, or HEMS physician performed prehospital ETI using direct Laryngoscopy (DL) or VL.ResultsFirst-pass ETI success rates for ambulance nurses with DL were 45.5% (391/859) and with VL 64.8% (125/193). For HEMS nurses first-pass success rates were 57.6% (34/59) and 77.2% (125/162) respectively. For HEMS physicians these successes were 85.9% (790/920) and 86.9% (1251/1439). The overall success rate for ambulance nurses with DL was 58.4% (502/859) and 77.2% (149/193) with VL. HEMS nurses successes were 72.9% (43/59) and 87.0% (141/162), respectively. HEMS physician successes were 98.7% (908/920) and 99.0% (1425/1439), respectively. The incidence of unrecognized intubations in the oesophagus before HEMS arrival in traumatic circulatory arrest (TCA) was 30.6% with DL and 37.5% with VL. In medical cardiac arrest cases the incidence was 20% with DL and 0% with VL.ConclusionFirst-pass and overall ETI success rates for ambulance and HEMS nurses are better with VL. The used device does not affect success rates of HEMS physicians. VL resulted in less unrecognized oesophageal intubations in medical cardiac arrests. In TCA cases VL resulted in more oesophageal intubations when performed by ambulance nurses before HEMS arrival.

Early Changes in Patient Access Interval during the COVID-19 Pandemic

Background: COVID-19 was first reported in the United States in January 2020. Its spread throughout the country required EMS systems to rapidly adapt to patient needs while protecting EMS personnel. EMS agencies developed protocols requiring personnel to don enhanced personal protective equipment prior to patient contact. We hypothesized that the Patient Access Interval (PAI), defined as the time from wheels stopped on scene to initial patient contact, had increased during the COVID pandemic. This had the potential to affect patient outcomes, particularly in time-sensitive emergencies such as cardiac arrest or respiratory distress. Methods: This retrospective cohort study used commercial ambulance data from the four largest cities in Connecticut at two different time points: (Pre-COVID) March-May 2019, and (COVID) March-May 2020. PAI was calculated from contemporaneously reported scene times. Total cases were analyzed, and sub-analyses performed for calls located at extended care facilities (ECFs), for all emergent (Echo/Delta) calls, and for medical cardiac arrest calls. Results: 92,846 total cases were evaluated: 50,083 from 2019, and 42,763 from 2020. Cases that did not include necessary time data for PAI were removed, yielding 75,796 total cases (41,852 from 2019, 33,944 from 2020). The average PAI increased from 1 minute 55 seconds (1 m:55s) Pre-COVID to 2 m:18s COVID. ECF PAI increased from 2 m:39s to 3 m:42s. Echo/Delta PAI increased from 1 m:42s to 2 m:07s. Medical cardiac arrest PAI increased from 1 m:27s to 2 m:04s, and ECF cardiac arrest PAI increased from 2 m:18s to 4 m:35s (all comparisons p < 0.01). Conclusions: There were statistically significant increases in all studied PAIs during COVID. The 23 second increase in PAI for all calls may not have been clinically significant in most cases; however, for life-threatening patient presentations, the increase may have been particularly relevant. The increased PAI was compounded in the ECF environment, possibly due to state-mandated screening and temperature checks of EMS personnel before entering facilities. This was highlighted in the ECF cardiac arrest data, which demonstrated a clinically significant increase in PAI of 2m:17s. While this study was limited by the accuracy of contemporaneous time reports by EMS, the results support our hypothesis that PAI had increased during the COVID pandemic.

Laboratory-derived early warning score for the prediction of in-hospital mortality, intensive care unit admission, medical emergency team activation and cardiac arrest in general medical wards.

General medical wards admit a varied cohort of patients from the emergency department, some of whom deteriorate during their hospital stay. Currently, we use vital signs based warning scores to predict patients at risk of imminent deterioration, but there is now a growing body of literature that commonly available laboratory results may also help to identify those at risk. To assess whether a laboratory-based admission score can predict in hospital mortality, intensive care unit (ICU) admission, medical emergency team (MET) activation or cardiac arrest in a cohort of Australian general medical patients admitted through the emergency department (ED). We performed a retrospective observational study of all general medical admissions to hospital through the ED in 2015. Admission pathology was used to calculate a risk score. In-patient outcomes of death, ICU transfer, MET call activation or cardiac arrest were collected from hospital records. We studied 2942 admissions derived from 2521 patients, with a median age of 81 years. There were 143 in-patient deaths, 82 ICU admissions, 277 MET calls and 14 cardiac arrest calls. The laboratory-based admission score had an area under the receiver operating characteristic curve (AUC-ROC) of 0.76 (95% confidence interval (CI): 0.72-0.80) for inpatient death, an AUC-ROC of 0.79 (95% CI: 0.66-0.93) for inpatient cardiac arrest, an AUC-ROC of 0.64 (95% CI: 0.58-0.70) for ICU transfer and an AUC-ROC of 0.59 (95% CI: 0.55-0.62) for MET call activation. When patients aged over 75 were analysed separately, the AUC-ROC for prediction of in-patient death was 0.74 (95% CI: 0.70-0.78) and increased to 0.86 (95% CI: 0.73-0.98) for the prediction of in-patient cardiac arrest. A simple laboratory-derived score obtained at patient admission is a fair to good predictor of subsequent in-patient death or cardiac arrest in general medical patients and in the older patient cohort. Prospective interventional studies are required to ascertain the clinical utility of this admission score.

176 Use of Disposable Pressure Transducer With Resuscitative Endovascular Balloon Occlusion of the Aorta in Medical Cardiac Arrest

Study Objectives: The objective of this study is to assess the feasibility of using a disposable pressure transducer to obtain mean aortic pressure (MAP) during CPR and placement of resuscitative endovascular balloon occlusion of the aorta (REBOA) within an emergency medicine (EM)-initiated multi-disciplinary protocol in non-traumatic out-of-hospital cardiac arrest (OHCA) Methods: During medical cardiac arrest obtaining a MAP >55 mmHg has been associated with greater survivorship Use of an arterial line and monitor requires calibration which may demand additional personnel resources during management of a cardiac arrest A disposable pressure transducer (Centurion Compass® Pressure Monitor) is able to detect and display mean aortic pressure within seconds of placement onto an arterial line We are conducting a single-arm early feasibility study of REBOA initiated in the emergency department (ED) for OHCA using an Food and Drug Administration (FDA) investigational device approval with an exception from informed consent During this study we are evaluating the feasibility of using disposable pressure transducers to determine MAP during CPR and REBOA placement Our goal is to enroll 20 patients as part of this feasibility study Results: Two of the initial twenty patients were enrolled between January and February 2020, with a temporary pause in enrollment due to the COVID pandemic from March to July 2020 A disposable pressure transducer was used to obtain continuous MAPs in both patients Our initial patient was a 77-year-old man who presented in refractory ventricular fibrillation and we were able to obtain pre- and post- REBOA inflation MAPs After inflation of the aortic balloon, investigators noted immediate improvements in mean aortic pressure (MAP) (37 to 50 mmHg) The second patient, a 63-year-old man, underwent successful REBOA placement with similar improvements in MAP (22 to 50 mmHg) Investigators were also able to identify large differences in MAPs generated between individuals performing CPR, noting MAPs between 34 and 50 between multiple CPR providers despite visually adequate chest depth compressions Conclusion: The use of disposable pressure transducers during CPR and REBOA in OHCA to rapidly obtain MAP may be feasible Further, use of these transducers may assist in guiding CPR to achieve target MAPs during cardiac arrest More research is needed to determine what impact a targeted MAP has on patient outcomes, and whether or not it correlates with changes in end-tidal carbon dioxide (ETCO2)

170 Use of Transthoracic Ultrasound to Confirm Placement of Resuscitative Endovascular Balloon Occlusion of the Aorta in Medical Cardiac Arrest

The objective of this study is to assess the feasibility of using bedside ultrasound to visualize and confirm aortic placement of resuscitative endovascular balloon occlusion of the aorta (REBOA) within an emergency medicine (EM)-initiated multi-disciplinary protocol in non-traumatic OHCA. REBOA is a hemorrhage control technique involving the intra-vascular occlusion of the thoracic aorta using a balloon catheter and may help to increase coronary and cerebral perfusion during non-traumatic out-of-hospital cardiac arrest (OHCA) by directing blood flow to the upper body. We are conducting a single-arm early feasibility study of REBOA initiated in the emergency department (ED) for OHCA using an investigational device approval by the Food and Drug Administration (FDA) with an exception from informed consent. During CPR, an emergency physician obtains common femoral access using a 7Fr introducer sheath while the REBOA catheter is prepared and subsequently advanced by an interventional radiologist (IR). While sheath introducer placement can be confirmed with ultrasound views of the common femoral artery, we seek to confirm intrathoracic REBOA placement using transthoracic bedside ultrasound. Our goal is to enroll 20 patients into this study and use transthoracic ultrasound to confirm REBOA placement in each. Two of the initial twenty patients were enrolled between January and February 2020, with a temporary pause in enrollment due to the COVID pandemic from March to July 2020. In both enrolled patients, transthoracic views were obtained confirming intra-thoracic aortic placement of REBOA by an emergency physician. In our initial two cases, thoracic aortic placement of the REBOA in non-traumatic OHCA was confirmed by emergency physicians using transthoracic ultrasound. This demonstrates correct placement of aortic endovascular devices can be confirmed using emergency physician operated ultrasound. Further research is needed to determine what factors may impact emergency physicians’ ability to successfully identify and confirm aortic device placement.

364 Feasibility Study of Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta in Medical Cardiac Arrest

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a hemorrhage control technique involving the intra-vascular occlusion of the thoracic aorta using a balloon catheter and may help to increase coronary and cerebral perfusion during out-of-hospital cardiac arrest (OHCA) by blocking blood flow to the lower body. Primary Objective: The primary objective of this study is to assess the feasibility of an emergency medicine (EM)-initiated multi-disciplinary protocol for REBOA in non-traumatic OHCA. Secondary Objectives: Secondary objectives are procedural outcomes (eg, attempts required for common femoral access), hemodynamic outcomes before and after aortic occlusion (end-tidal carbon dioxide, diastolic blood pressure), and rates of return of spontaneous circulation (ROSC) and survival to hospital discharge with a favorable neurologic outcome. This single-arm early feasibility study of REBOA initiated in the emergency department (ED) for OHCA uses an investigational device approval with a community exception from informed consent. Subjects under 80 years of age with witnessed OHCA and down time under 45 minutes are eligible. On arrival to the ED, an emergency physician obtains common femoral access using a 7Fr introducer sheath while the REBOA catheter is prepared and subsequently advanced by an interventional radiologist (IR). Two patients were enrolled between January and February 2020, with a temporary pause in enrollment due to the COVID pandemic from March - August 2020. To our knowledge, this is the first trial of ED-initiated REBOA involving emergency physicians for non-traumatic OHCA (two similar recent reports exist in the anesthesia and critical care literature). Our initial patient was a 77-year-old man who presented in refractory ventricular fibrillation. The emergency physician placed the common femoral sheath on the first attempt using ultrasound guidance under chest compressions and the REBOA catheter was then advanced by the interventional radiologist. After inflation of the aortic balloon, investigators noted immediate improvements in mean arterial pressure (MAP) (37 to 50 mmHg) and end-tidal carbon dioxide (ETCO2) (35 to 50 mmHg), with transient non-sustained ROSC. The second patient, a 63-year-old man, underwent successful REBOA placement with similar improvements in MAP (22 to 50 mmHg) and ETCO2 (33 to 43 mmHg). Unfortunately, both patients were in refractory ventricular fibrillation and despite multiple defibrillation attempts and antiarrhythmics they did not survive to hospital admission. REBOA has been hypothesized to improve outcomes in OHCA by blocking blood flow to the lower body and redirecting it towards the heart and brain, improving the perfusion of these vital organs. In both cases, REBOA was temporally associated with improved hemodynamics during chest compressions with transient ROSC in one case. Performance of REBOA by a multi-disciplinary team for OHCA in the ED was feasible in these initial two cases. Future research will examine the feasibility of REBOA catheter advancement by the emergency physician and further quantify the hemodynamic effects associated with aortic occlusion.

Implementing a multi-site cardiac arrest quality improvement initiative

Background: &#x0D; Medical cardiac arrest care in Edmonton Zone Emergency Departments does not undergo structured quality monitoring or continuous improvement. Prior to this work, quality indicators had not been selected, nor had tracking or reporting activities been undertaken. This work brings the Edmonton Zone EDs to the forefront of the continuous quality improvement recommendations made by Heart and Stroke Canada and the American Heart Association that are believed to improve both patient outcomes and overall system performance.&#x0D; For this project quality indicator development and implementation takes three perspectives: patients and families, frontline staff and the health care system. This work is informed by the Institute for Healthcare Improvement, the National Institute of Science and the International Liaison Committee on Resuscitation’s work on Systems of Care and Continuous Quality Improvement for Emergency Cardiovascular Care. This work is motivated by the desire to improve patient/family experience and outcome, provider experience while improving system performance.&#x0D; &#x0D; Implementation: &#x0D; An iterative process identified the lowest resource/highest impact areas for improvement. This process was informed through a Delphi survey conducted by the Alberta Cardiac Arrest Stakeholders group and stakeholder engagement. Four areas for improvement were identified: support of patients and families, support of staff, improvement in care metrics, and system level interventions. Support of patients and families was accomplished through the development of an advisory network, by linking families with existing supports, and through the implementation of a bereavement package. Supporting staff was accomplished through the development of a formal and informal debriefing processes. Improving clinical care was accomplished through the integration of chest compression feedback devices into clinical care. Improvements at the system level will be accomplished through the creation of a cardiac arrest registry.&#x0D; &#x0D; Evaluation Methods:&#x0D; Mixed methods approaches are used to evaluate this project. Post cardiac arrest quality track forms are being filled out. Chest compression feedback device data was obtained through simulated patient-care scenarios, staff experiences were obtained through a structured survey. Clinically chest compression data was collected from the feedback devices by Clinical educators, through tracking forms, and pre-and-post surveys of frontline staff measuring burnout and occupational stress are underway. Data is being collected in a local registry to generate accurate incidence and survival rates. Eventual post-implementation interviews with providers, survivors and families will be conducted.&#x0D; &#x0D; Results:&#x0D; A patient/family advisor network has been established. Survivor and families can be connected with the Bystander Support Network and the Heart and Stroke Foundation portal through the bereavement packages being offered at one of the QI sites. Two sites have developed staff debriefing processes: an interdisciplinary Critical Incident Stress Management (CISM) team at one site, and referral to an existing CISM team at two other sites. Chest compression feedback is being used at two sites, staff feedback has been positive. One site is tracking resuscitation metrics which are being used to guide and evaluate the interventions: continued improvement in chest compression quality has been noted. Data analytics are being used at all sites to identify additional opportunities to improve resuscitation care and efforts are underway to expand data collection to other sites and to unify pre-hospital and in-hospital cardiac arrest data.&#x0D; &#x0D; Advice and Lessons Learned:&#x0D; &#x0D; Pre-intervention data would have allowed for more meaningful comparisons in patient care. Efforts should be put into identifying what these measures could be.&#x0D; High levels of staff engagement at one site appear to have influenced the uptake of chest compression feedback. Effort should identify key stakeholders and gain buy in to increase uptake&#x0D; There are significant barriers to unifying pre-hospital and in-hospital cardiac arrest data. It is our belief that a continuous record offers some greatest opportunity to collect data on resuscitation care. Efforts should focus on building a linkage between these data sources and creating a shared data set.&#x0D;

Prevalence and risk factors for post‐traumatic stress disorder in Japanese relatives of out‐of‐hospital cardiac arrest patients after receiving a pamphlet concerning the grieving process

To investigate the prospective frequency of post-traumatic stress disorder (PTSD) among relatives of sudden death patients following provision of a pamphlet explaining the stages of the complicated grief process and self-regulating techniques. From May 2017 to February 2018, we prospectively and consecutively provided a pamphlet to relatives of out-of-hospital sudden cardiac arrest victims who failed to obtain spontaneous circulation. We investigated the psychiatric status of the bereaved relatives using the Impact of Event Scale - Revised (IES-R). An IES-R score over 24 was defined as PTSD. Fifty-four relatives of the 54 dead patients (victims) provided permission of entry to this research. All subjects and victims were Japanese. Among them, 24 subjects had an IES-R score of 0 and 5 (9.3%) had PTSD approximately 1month after their bereavement. There were no relatives who received spontaneous psychiatric treatment. The IES-R scores for non-medical cardiac arrest, death inquests, and parent variables were significantly higher compared with medical cardiac arrest, no inquest, and no parent, respectively. The IES-R scores in those who were a child of the victim were significantly lower than in those who were not. The present study showed that the frequency of PTSD was 9.3% at 1month following bereavement among Japanese relatives of sudden death victims after an intervention. This frequency was minimal compared with previous reports.

Should we resuscitate elderly patients with blunt traumatic cardiac arrest? Analysis of National Trauma Registry Data in Japan

ObjectivesRecent studies suggest that survival after traumatic cardiac arrest (TCA) has been improving. Many elderly adults enjoy active lifestyles, which occasionally result in TCA. The epidemiology and efficacy of resuscitative...

Closed chest compressions reduce survival in an animal model of haemorrhage-induced traumatic cardiac arrest

Closed chest compressions (CCC) are recommended for medical cardiac arrest, but there is little evidence to support their inclusion for traumatic cardiac arrest (TCA).This laboratory study evaluated CCC following haemorrhage-induced TCA and whether resuscitation with blood improved survival compared to saline.The study was conducted with the authority of UK Animals (Scientific Procedures) Act 1986 (received institutional ethical approval and a Home Office Licence) using 39 terminally anesthetised, instrumented, juvenile Large White pigs. Following baseline measurements, animals underwent captive bolt injury to the right thigh and controlled haemorrhage (30% blood volume). Sixty minutes later there was a further haemorrhage to a MAP of 20 mmHg. The randomised resuscitation protocol was initiated within 5 min: CCC (Group 1); IV whole blood (Group 2); IV 0.9% saline (Group 3); IV whole blood + CCC (Group 4); and IV saline + CCC (Group 5). Fluid was administered as 3 × 10 ml/kg boluses using the Belmont® Rapid Infuser. The LUCAS™ II Chest Compression System delivered CCC. Primary Outcome was attainment of return of spontaneous circulation (ROSC MAP ≥ 50 mmHg) at Study End (fifteen minutes post-resuscitation) and secondary outcomes included haemodynamics.Mortality (MAP≤10 mmHg) was significantly higher in Group 1 compared to Groups 2 and 3 (P < 0.0001). Resuscitation with whole blood was significantly better than saline (P = 0.0069), no animals in Group 3 attained ROSC. The addition of chest compressions to fluid resuscitation resulted in a significantly worse outcome with saline resuscitation (P = 0.0023) but not with whole blood (P = 0.4411). Cardiovascular variables at the end of the Resuscitation Phase and Study End were significantly worse for Group 5 compared to Group 3. Some significant differences were present at the end of the Resuscitation Phase for Group 4 versus Group 2 but these differences were no longer present by Study End.CCC were associated with increased mortality and compromised haemodynamics compared to intravenous fluid resuscitation. Whole blood resuscitation was better than saline.

Emergency medical services and cardiac arrest from drug overdose: a protocol for a systematic review of incidence and survival outcomes.

The primary review question is: what is the global incidence rate of emergency medical services (EMS)-attended and EMS-treated out-of-hospital cardiac arrest (OHCA) precipitated by drug overdose in adults?The secondary review questions are: what proportion of adults with EMS-treated overdose OHCA: i) survived to hospital discharge or 30 days, ii) survived with intact neurological function at hospital discharge (i.e. Cerebral Performance Category or modified Rankin Scale ≤ 2), iii) achieved prehospital return of spontaneous circulation, iv) survived to hospital, and v) survived to 12 months?

Traumatic cardiac arrest is associated with lower survival rate vs. medical cardiac arrest – Results from the French national registry

IntroductionThe survival from traumatic vs. medical out-of-hospital cardiac arrest (OHCA) are not yet well described. The objective of this study was to compare survival to hospital discharge and 30-day survival of non-matched and matched traumatic and medical OHCA cohorts. Material & methodsNational case-control, multicentre study based on the French national cardiac arrest registry. Following descriptive analysis, we compared survival rates of traumatic and medical cardiac arrest patients after propensity score matching. ResultsCompared with medical OHCA (n = 40,878) trauma victims (n = 3209) were younger, more likely to be male and away from home at the time and less likely to be resuscitated. At hospital admission and at 30 days their survival odds were lower (OR: respectively 0.456 [0.353;0.558] and 0.240 [0.186;0.329]). After adjustment the survival odds for traumatic OHCA were 2.4 times lower at admission (OR: 0.416 [0.359;0.482]) and 6 times lower at day 30 (OR: 0.168 [0.117;0.241]). ConclusionsThe survival rates for traumatic OHCA were lower than for medical OHCA, with wider difference in matched vs. non-matched cohorts. Although the probability of survival is lower for trauma victims, the efforts are not futile and pre-hospital resuscitation efforts seem worthwhile.