Neurological Survival Research Articles

Extracorporeal-CPR Versus Conventional-CPR for Adult Patients in Out of Hospital Cardiac Arrest- Systematic Review and Meta-Analysis.

Extracorporeal cardiopulmonary resuscitation (ECPR) utilizes veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in cardiac arrest patients to reduce the risk of mortality and multiorgan dysfunction from systemic hypoperfusion. We aimed to compare clinical outcomes of patients receiving ECPR versus conventional cardiopulmonary resuscitation (CCPR) for refractory cardiac arrest. This was a systematic review and meta-analysis. A librarian searched the main databases, Ovid MEDLINE (including epub ahead of print, in-process & other non-indexed citations), Ovid EMBASE and Ovid Cochrane Central Register of Controlled Trials from inception through July 2024. We included randomized controlled trials and observational studies that compared the outcomes of ECPR to CCPR in cardiac arrest patients. Primary outcomes were neurological sequelae and survival. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two reviewers independently screened articles, extracted data on selected articles and performed risk of bias assessments using ROBINS-I for non-randomized controlled trials and the revised Cochrane risk of bias tool for randomized controlled trials with disagreements settled by a third independent reviewer. Out of 3458 studies identified and screened, 28 studies including 304,360 cardiac arrest patients met eligibility criteria and were included. Survival at hospital discharge was 20% for ECPR versus 3.3% for CCPR (OR 0.48 [CI 0.27, 0.84]). Favorable neurological outcome at hospital discharge was 11.8% for ECPR versus 1.9% for CCPR (OR 0.41 [CI 0.17, 1.01]). Complications from bleeding were ten times higher in the ECPR group (35.3% vs 3.7%; OR 0.08 [0.03, 0.24]). ECPR appeared to be superior to CCPR for improved neurological outcome and survival in cardiac arrest patients, although bleeding was increased. There was large heterogeneity in the included studies and outcomes reported. Future prospective studies may improve the identification of subgroups of patients that will benefit most from ECPR.Systematic review and meta-analysis registration: PROSPERO - CRD42023394128.

Hospital-Acquired Pressure Ulcers and Long-Term Motor Score Recovery in Patients With Acute Cervical Spinal Cord Injury

Pressure ulcers (PUs) are (1) prevalent secondary complications after spinal cord injury (SCI), (2) present with elevated systemic inflammatory tone, and (3) may interfere with healing processes underlying neurological recovery (disrepair). To investigate whether PUs acquired during initial hospitalization are associated with neurological and functional long-term outcome and survival after SCI. Multicenter cohort study at 20 centers of the prospective SCI Model Systems (SCIMS) Database (Birmingham, AL). Patients with acute traumatic cervical SCI with relevant motor impairment (ie, American Spinal Injury Association [ASIA] impairment scale [AIS] A, B, and C) were enrolled from January 1996 to September 2006 and followed up until June 2016. Data were analyzed from April 2021 to September 2024. PUs acquired during surgical or first rehabilitative SCI care. The change in the ASIA motor score at 1 year after SCI was the primary end point. Secondary end points included the recovery of functional independence measure (FIM) motor score at 1 year after SCI and mortality up to 10 years. ASIA and FIM motor score were analyzed applying linear mixed models with random intercept adjusted for baseline neurological level, AIS, and sociodemographic factors. Mortality was analyzed using Cox regression. The study included 1282 patients with a mean (SD) age of 38.0 (15.7) years and consisted of 1028 (80.2%) male patients. Regarding race and ethnicity, 349 of 1249 (27.9%) were African American patients, 1139 of 1273 (89.5%) were non-Hispanic patients, and 834 of 1249 (66.8%) were White patients. During initial hospitalization, 594 patients (45.7%) acquired PUs. Exposure to PUs was associated with impaired motor recovery 1 year after SCI compared with unexposed patients (-9.1 ASIA motor score points; 95% CI, -12.3 to -6.0; P < .001). In addition, PUs were associated with lower recovery of physical independence 1 year after SCI (-8.3 FIM motor score points; 95% CI: -11.1 to -5.5; P < .001). Cox regression confirmed PUs as a risk marker for death up to 10 years after SCI (hazard ratio, 1.41; 95% CI, 1.09 to 1.82; P = .01). In this cohort study, PUs acquired during initial hospitalization after SCI were independently associated with poor long-term neurofunctional outcome. PUs constitute a modifiable factor associated with risk for worse long-term disability (recovery confounder) and elevated mortality.

Abstract Su704: Body Mass Index and Outcomes of In-Hospital Cardiac Arrest

Background: Although previous studies have reported an association between a patient’s body mass index (BMI) and outcomes for various cardiovascular conditions, the relationship between BMI and survival for in-hospital cardiac arrest (IHCA), a condition for which emergent response is required, has not been fully described. Aims: Examine the association between BMI and survival outcomes for IHCA. Methods: Within the Get With The Guidelines®-Resuscitation, we identified 56,411 patients with IHCA and available BMI data during 2005-2012 when weight and height data were collected in the registry. BMI was classified as underweight [&lt;18.5 kg/m 2 ], normal [18.5 to 24.9 kg/m 2 ], overweight [25.0 to 29.9 kg/m 2 ], obese [30.0 to 34.9 kg/m 2 ], and very obese [≥35.0 kg/m 2 ]). Using multivariable hierarchical models with hospital as a random effect, we examined the association between BMI and survival to discharge, stratified by cardiac arrest rhythm type (shockable and non-shockable). As secondary outcomes, we examined rates of sustained return of spontaneous circulation for &gt; 20 minutes (ROSC) and favorable neurological survival (i.e., survival to discharge without severe neurological disability). Results: Among 10,219 patients with a shockable arrest rhythm, 3,964 (38.7%) survived to discharge. After multivariable adjustment, compared with overweight patients, those who were underweight, of normal weight, and very obese had lower survival rates, whereas obese patients had similar survival rates ( Table ). Underweight patients also had a lower rate of ROSC and favorable neurologic survival ( Table ). Among 46,192 patients with a non-shockable arrest rhythm, 7,331 (15.8%) survived to discharge. After multivariable adjustment, all BMI groups had similar rates of survival, ROSC, and favorable neurologic survival, except for underweight patients ( Table ). Conclusions: Although the association between BMI and survival outcomes for IHCA varied by initial rhythm, underweight patients consistently had lower survival rates of survival. Very obese patients generally had similar outcomes to other weight groups, underscoring that morbid obesity was not a negative predictor of survival outcomes for IHCA.

Abstract Su305: Chest Compression Fraction, Bag-mask Ventilation, And Survival From Out-of-hospital Cardiac Arrest: A Multicenter Study

Background: Ventilation during cardiopulmonary resuscitation (CPR) is poor. Better lung inflation during chest compression pauses is associated with better return of spontaneous circulation (ROSC), survival, and functional neurological survival. Chest compression quality, quantified by chest compression fraction (CCF) &gt;80%, has also served as a guideline target for improved outcomes. We hypothesized that greater chest compression fraction modifies the association between ventilation quality and outcomes. Methods: We studied patients suffering out-of-hospital cardiac arrest from six sites of the Resuscitation Outcomes Consortium (ROC) Trial of Continuous or Interrupted Chest Compressions during CPR. We performed a subanalysis of patients assigned to the 30:2 CPR arm with ≥ two minutes of thoracic bioimpedance signal recorded with a cardiac defibrillator/monitor. Detectable ventilation waveforms were defined as having a bioimpedance amplitude ≥0.5 Ohm (corresponding to ≥ 250 ml tidal volume) and duration ≥1 sec. We defined a chest compression pause as a break in chest compressions of 3 - 15 sec duration. We dichotomized ventilation into two groups: 1) better lung inflation (≥ one lung inflation waveform in ≥50% of chest compression pauses), and 2) poor lung inflation (waveforms in &lt;50% pauses). We analyzed CCF during bag-mask prior to intubation (if any). We used multivariable logistic regression to assess the relationship among CCF, ventilation, and the outcomes of ROSC, survival, and functional neurologic survival. Results: Among 1,976 patients, mean age was 65 years, 66% were male. Most patients received poor ventilation (60%, n=1177) over ventilation over 9.8 ± 4.9 minutes. Median CCF was 0.78 (0.71, 90.84) and 0.78 (0.70, 0.83) for poor and better lung inflation, respectively. For CCF &lt;85%, survival was significantly greater in those who received better ventilation, when compared to poor ventilation, and had greater pauses per minute (Figure A). The beneficial interaction between ventilation and outcome was greater with CCFs of 85% or less, compared to higher CCFs (Figure B). With CCFs &gt;85%, survival did not improve significantly with better ventilation. These results persisted after adjustment for Ustein variables and ROC site. Conclusions: We observed improved survival with better ventilation until CCF exceeded 85% in the preintubation period, suggesting an optimal strategy with better ventilation and chest compression fractions of 85% or less.

Heart rhythm at hospital admission: A factor for survival and neurological outcome among ECPR recipients?

BackgroundThe initial rhythm is a known predictor of survival in extracorporeal cardiopulmonary resuscitation (ECPR) patients. However, the effect of the rhythm at hospital admission on outcomes in these patients is less clear. MethodsThis observational, single-center study assessed the influence of the rhythm at hospital admission on 30-day survival and neurological outcomes at discharge in patients who underwent ECPR for out-of-hospital cardiac arrest (OHCA). ResultsBetween January 2012 and December 2023, 1,219 OHCA patients were admitted, and 210 received ECPR. Of these, 196 patients were analyzed. The average age was 52.9 years (±13), with 80.6 % male. The median time to ECPR initiation was 61 min (IQR 54–72). Patients with ventricular fibrillation as both the initial and admission rhythm had the highest 30-day survival rate (52 %: 35/67), while those with asystole in both instances had the lowest (6 %: 1/17, log-rank p < 0.00001). After adjusting for age, sex, initial rhythm, resuscitation time, location, bystander, and witnessed status, asystole at admission was linked to higher 30-day mortality (OR 4.03, 95 % CI 1.49–12.38, p = 0.009) and worse neurological outcomes (Cerebral Performance Category 3–5) at discharge (OR 4.61, 95 % CI 1.49–17.62, p = 0.013). ConclusionsThe rhythm at hospital admission affects ECPR outcomes. Patients presenting with and maintaining ventricular fibrillation have a higher chance of favorable neurological survival, whereas those presenting with or converting to asystole have poor outcomes. The rhythm at hospital admission appears to be a valuable criterion for deciding on ECPR initiation.

The Role of Different Feedback Devices in the Survival of Patients in Cardiac Arrest: Systematic Review with Meta-Analysis

Background: Cardiac arrest is a critical condition affecting approximately 1 in every 1000 people in Europe. Feedback devices have been developed to enhance the quality of chest compressions during CPR, but their clinical impact remains uncertain. This study aims to evaluate the effect of feedback devices on key clinical outcomes in adult patients experiencing both out-of-hospital (OHCA) and in-hospital cardiac arrest (IHCA). The primary objective is to assess their impact on the return of spontaneous circulation (ROSC); secondary objectives include the evaluation of neurological status and survival to discharge. Methods: A systematic review was conducted following PRISMA guidelines, utilizing databases including PubMed, Scopus, Web of Science, and Embase. Studies published between 2000 and 2023 comparing CPR with and without the use of feedback devices were included. A fixed-effects network meta-analysis was performed for ROSC and survival, while a frequentist meta-analysis was conducted for neurological outcomes. Results: Twelve relevant studies met the inclusion criteria. The meta-analysis results showed that the use of audiovisual feedback devices significantly increases the likelihood of ROSC (OR 1.26, 95% CI 1.13–1.41, p &lt; 0.0001) and survival (OR 1.52, 95% CI 1.27–1.81, p &lt; 0.0001) compared to CPR without feedback. However, the effect of metronomes did not reach statistical significance. Conclusions: Feedback devices, particularly audiovisual ones, are associated with improved clinical outcomes in cardiac arrest patients. Their use should be encouraged in both training settings and real-life emergency scenarios to enhance survival rates and ROSC. However, further studies are needed to confirm long-term impacts and to explore the potential benefits of metronomes.

Targeted Temperature Management for Out-of-Hospital Cardiac Arrest Survivors.

Targeted temperature management (TTM), specifically therapeutic hypothermia, has been proposed to provide neuroprotective and mortality benefits for out-of-hospital cardiac arrest (OHCA) survivors. This proposition was based on small-scale trials from the early 2000s, leading to its incorporation into various international guidelines. The proposed neuroprotective mechanisms include reducing cerebral metabolic rate, stabilizing the blood-brain barrier, reducing the release of excitatory neurotransmitters, and suppressing apoptotic pathways. However, these early trials have been criticized for their high risk of bias and lack of standardized protocols. Recent evidence from more rigorously controlled randomized trials indicates no significant association between hypothermia and improved neurological outcomes or survival rates. This review explores the latest clinical evidence on TTM for OHCA patients, discussing the pathophysiology, evaluating the effectiveness of hypothermia through various clinical trials, and providing recommendations for future research and clinical practice.

The association of intravenous vs. humeral-intraosseous vascular access with patient outcomes in adult out-of-hospital cardiac arrests

AimWhile intravenous (IV) vascular access for out-of-hospital cardiac arrest (OHCA) resuscitation is standard, humeral-intraosseous (IO) access is commonly used, despite few supporting data. We investigated the association between IV vs. humeral-IO and outcomes. MethodsWe utilized BC Cardiac Arrest Registry data, including adult OHCA where the first-attempted intra-arrest vascular access route performed by advanced life support (ALS)-trained paramedics was IV or humeral-IO. We fit a propensity-score adjusted model with inverse probability treatment weighting to estimate the association between IV vs. humeral-IO routes and favorable neurological outcomes (CPC 1–2) and survival at hospital discharge. We repeated models within subgroups defined by initial cardiac rhythm. ResultsWe included 2,112 cases; the first-attempted route was IV (n = 1,575) or humeral-IO (n = 537). Time intervals from ALS-paramedic on-scene arrival to vascular access (6.6 vs. 6.9 min) and epinephrine administration (9.0 vs. 9.3 min) were similar between IV and IO groups, respectively. Among IV and humeral-IO groups, 98 (6.2%) and 20 (3.7%) had favorable neurological outcomes. Compared to humeral-IO, an IV-first approach was associated with improved hospital-discharge favorable neurological outcomes (AOR 1.7; 95% CI 1.1–2.7) and survival (AOR 1.5; 95% CI 1.0–2.3). Among shockable rhythm cases, an IV-first approach was associated with improved favorable neurological outcomes (AOR 4.2; 95% CI 2.1–8.2), but not among non-shockable rhythm cases (AOR 0.73; 95% CI 0.39–1.4). ConclusionAn IV-first approach, compared to humeral-IO, for intra-arrest resuscitation was associated with an improved odds of favorable neurological outcomes and survival to hospital discharge. This association was seen among an initial shockable rhythm, but not non-shockable rhythm, subgroups.

Impact of extracorporeal cardiopulmonary resuscitation on neurological prognosis and survival in adult patients after cardiac arrest: An individual pooled patient data meta-analysis

BackgroundWe aimed to estimate the effect of extracorporeal cardiopulmonary resuscitation (ECPR) on neurological outcome and mortality, when compared to conventional cardiopulmonary resuscitation (CCPR), using an individual patient data meta-analysis (IPDMA). MethodsA systematic literature search was performed up to the 20th of October 2022 in the PubMed, EMBASE and CENTRAL databases. For observational studies with unmatched populations, a propensity score including age, location of arrest and initial rhythm was used to match ECPR and CCPR patients in a 1:1 ratio. The primary and secondary outcomes were unfavorable neurological outcome (Cerebral Performance Category of 3–5) and mortality, respectively, which were both collected at different time-points. ResultsData from 17 studies, including 2064 matched cardiac arrest (CA) patients (1031 ECPR and 1033 CCPR cases) were included. In comparison to CCPR, ECPR was associated with a decreased odds of unfavorable neurological outcome (847, 82.2% vs. 897, 86.8% − OR 0.68 [95%CI 0.53–0.87]; p = 0.002) and death (803, 77.9% vs. 860, 83.3% − OR 0.68 [95%CI 0.54–0.86]; p = 0.001). These results were consistent across most of the prespecified subgroups. Moreover, the odds of both unfavorable neurological outcome and mortality were significantly influenced by initial rhythm, cause of arrest and combinations of lactate levels on admission and duration of resuscitation. ConclusionsThis IPDMA showed that ECPR was associated with significantly lower rates of unfavorable neurological outcome and mortality in refractory CA. The overall effect could be influenced by CA characteristics and the severity of the initial injury.

The association of non-prescription drug use preceding out-of-hospital cardiac arrest and clinical outcomes

BackgroundClinicians may make prognostication decisions for out-of-hospital cardiac arrest (OHCA) using historical details pertaining to non-prescription drug use. However, differences in outcomes between OHCAs with evidence of non-prescription drug use, compared to other OHCAs, have not been well described. MethodsWe included emergency medical service-treated OHCA in the British Columbia Cardiac Arrest Registry (January/2019–June/2023). We classified cases as “non-prescription drug-associated cardiac arrests” (DA-OHCA) if there was evidence of non-prescription drug use preceding the OHCA, including witness accounts of use within 24 h or paraphernalia at the scene. We fit logistic regression models to investigate the association between DA-OHCA (vs. other cases) and favourable neurological outcome (Cerebral Performance Category [CPC] 1–2) and survival at hospital discharge, and return of spontaneous circulation (ROSC). ResultsOf 18,426 OHCA, 2,171 (12%) were classified as DA-OHCA. DA-OHCA tended to be younger, unwitnessed, occur during the evening or night, and present with a non-shockable rhythm, compared to other OHCA. DA-OHCA (221 [10%]) had a greater proportion (difference 1.8%; 95% CI 0.49–3.2) with favourable neurological outcomes compared to other OHCA (1,365 [8.4%]). Adjusted models did not identify an association of DA-OHCA with favourable neurological outcome (OR 1.08, 95% CI 0.87–1.33) or survival to hospital discharge (OR 1.13, 95% CI 0.93–1.38), but did demonstrate an association with ROSC (OR 1.13, 95% CI 1.004–1.27). ConclusionIn unadjusted models, DA-OHCA was associated with an improved odds of survival and favourable neurological outcomes at hospital discharge, compared to other OHCA. However, we did not detect an association in adjusted analyses.

Effect of cardiopulmonary resuscitation training for layperson bystanders on outcomes of out-of-hospital cardiac arrest: A prospective multicenter observational study

BackgroundEffective bystander cardiopulmonary resuscitation (CPR) improves outcomes in out-of-hospital cardiac arrest (OHCA) patients. However, the effect of CPR training on the rate of return of spontaneous circulation (ROSC) among laypersons has yet to be thoroughly evaluated. MethodsThis prospective, multicenter observational study was conducted across 42 centers in Japan. We assessed OHCA patients who received bystander CPR from a layperson, excluding those performed by healthcare staff. The primary outcome was the ROSC rate. Secondary outcomes included pre-hospital ROSC, ROSC after hospital arrival, favorable neurological outcomes, and 30-day survival. Propensity score with inverse probability treatment weighting (IPTW) was used to adjust for confounders, including age, sex, presence or absence of witnesses, and past medical history. ResultsA total of 969 OHCA patients were included, divided into CPR-trained (n = 322) and control (n = 647). Before adjustment, the ROSC rate was higher in the trained group than the control (40.1% vs. 30.1%, P < 0.01). After IPTW adjustment, the trained group showed a significantly higher ROSC rate (36.7% vs. 30.6%; P = 0.02). All secondary outcomes in the trained group were significantly improved before adjustment. After IPTW adjustment, the trained group showed improved rates of pre-hospital ROSC and ROSC after hospital arrival (30.7% vs. 24.0%; P < 0.01, 23.9% vs. 20.7%; P = 0.04). There were no differences in neurological outcomes and 30-day survival. ConclusionThis study demonstrated that CPR training for laypersons was associated with increased ROSC rates in OHCA patients, indicating potential advantages of CPR training for non-healthcare professionals.

Survival and Neurologic Outcomes From Pharmacologic Peptide Administration During Cardiopulmonary Resuscitation of Pulseless Electrical Activity.

Outcomes from cardiopulmonary resuscitation (CPR) following sudden cardiac arrest are suboptimal. Postresuscitation targeted temperature management has been shown to have benefit in subjects with sudden cardiac arrest due to ventricular fibrillation, but there are few data for outcomes from sudden cardiac arrest due to pulseless electrical activity. In addition, intra-CPR cooling is more effective than postresuscitation cooling. Physical cooling is associated with increased protein kinase B activity. Therefore, our group developed a novel peptide, TAT-PHLPP9c, which regulates protein kinase B. We hypothesized that when given during CPR, TAT-PHLPP9c would improve survival and neurologic outcomes following pulseless electrical activity arrest. In 24 female pigs, pulseless electrical activity was induced by inflating balloon catheters in the right coronary and left anterior descending arteries for ≈7 minutes. Advanced life support was initiated. In 12 control animals, epinephrine was given after 1 and 3 minutes. In 12 peptide-treated animals, 7.5 mg/kg TAT-PHLPP9c was also administered at 1 and 3 minutes of CPR. The balloons were removed after 2 minutes of support. Animals were recovered and neurologically scored 24 hours after return of spontaneous circulation. Return of spontaneous circulation was more common in the peptide group, but this difference was not significant (8/12 control versus 12/12 peptide; P=0.093), while fully intact neurologic survival was significantly more common in the peptide group (0/12 control versus 11/12 peptide; P<0.00001). TAT-PHLPP9c significantly increased myocardial nicotinamide adenine dinucleotide levels. TAT-PHLPP9c resulted in improved survival with full neurologic function after sudden cardiac arrest in a swine model of pulseless electrical activity, and the peptide shows potential as an intra-CPR pharmacologic agent.

Temperature Control Parameters Are Important: Earlier Preinduction Is Associated With Improved Outcomes Following Out-of-Hospital Cardiac Arrest

Temperature control trials in cardiac arrest patients have not reliably conferred neuroprotective benefit but have been limited by inconsistent treatment parameters. To evaluate the presence of a time dependent treatment effect, we assessed the association between preinduction time and clinical outcomes. In this retrospective, single academic center study between 2014 and 2022, consecutive out-of-hospital cardiac arrest (OHCA) patients treated with temperature control were identified. Preinduction was defined as the time from hospital arrival to initiation of a closed-loop temperature feedback device [door to temperature control initiation time], and early door to temperature control device time was defined a priori as <3 hours. We assessed the association between good neurologic outcome (cerebral performance category 1 to 2) and door to temperature control device time using logistic regression. The proportion of patients who survived to hospital discharge was evaluated as a secondary outcome. A sensitivity analysis using inverse probability treatment weighting, created using a propensity score, was performed to minimize measurable confounding. Three hundred and forty-seven OHCA patients were included; the early door to temperature control device cohort included 75 (21.6%) patients with a median (interquartile range) door to temperature control device time of 2.50 (2.03 to 2.75) hours, whereas the late door to temperature control device cohort included 272 (78.4%) patients with a median (interquartile range) door to temperature control device time of 5.18 (4.19 to 6.41) hours. In the multivariable logistic regression model, early door to temperature control device time was associated with improved good neurologic outcome and survival before [adjusted odds ratio (OR) (95% confidence interval) 2.36 (1.16 to 4.81) and 3.02 (1.54 to 6.02)] and after [adjusted OR (95% confidence interval) 1.95 (1.19 to 3.79) and 2.14 (1.33 to 3.36)] inverse probability of treatment weighting, respectively. In our study of OHCA patients, a shorter preinduction time for temperature control was associated with improved good neurologic outcome and survival. This finding may indicate that early initiation in the emergency department will confer benefit. Our findings are hypothesis generating and need to be validated in future prospective trials.

Identifying Subgroups with Differential Responses to Amiodarone among Cardiac Arrest Patients with a Shockable Rhythm at Hospital Arrival using the Machine Learning Approach.

There are few reports of studies on the differential effects of amiodarone among out-of-hospital cardiac arrest (OHCA) patients with a shockable rhythm at hospital arrival. The present study aimed to investigate the clinical heterogeneity of OHCA patients with a shockable rhythm upon hospital arrival and to identify subgroups with differential responses to amiodarone, using a machine learning approach. We used the Japanese nationwide OHCA registry of the Japanese Association for Acute Medicine for this study; data from OHCA patients with a shockable rhythm at hospital arrival were included in the analyses. The primary outcome was a favorable neurological outcome at 30 days. We developed a scoring system by the weighting method with logistic likelihood loss to identify patient subgroups showing differential effects of amiodarone from the point of view of the neurological outcome and survival at 30 days. Among the 68,111 cases of OHCA in the registry, the data of 2333 OHCA patients with an initial shockable rhythm at hospital arrival were analyzed. The developed score identified higher age, longer interval between the call to the emergency medical service and hospital arrival, absence of a "witness", no defibrillation prior to hospital arrival, hypothermia at hospital arrival, and pre-hospital epinephrine administration as variables that were significantly associated with a beneficial effect of amiodarone. Based on the results of the developed scoring system, 47% (1107/2333) of the patients were considered to greatly benefit from amiodarone administration, whereas 53% (1226/2333) of patients were considered to not benefit from amiodarone administration. The effect of amiodarone on the neurological outcome at 30 days varied significantly among the subgroups identified by the developed score ( : 1.07 [95% confidence interval (CI): 0.99-1.13], p = 0.005). We successfully developed a model that could discriminate between OHCA patients with an initial shockable rhythm at hospital arrival who would benefit or not benefit from the administration of amiodarone in terms of the neurological outcome at 30 days. There was clinical heterogeneity among OHCA patients with a shockable rhythm in terms of their response to amiodarone.

The impact of injuries at the time of cardiac arrest on the prognosis of extracorporeal cardiopulmonary resuscitation (ECPR) in out-of-hospital cardiac arrest patients

AimExtracorporeal cardiopulmonary resuscitation (ECPR) is an effective treatment for out-of-hospital cardiac arrest and refractory ventricular fibrillation. Despite the success of this intervention, trauma is a potential complication that may adversely impact patient outcomes. This study assessed the incidence and impact of trauma in patients who underwent ECPR. We hypothesized that all trauma incurred until the conclusion of ECPR would have a significant negative effect on survival and neurological outcomes. MethodsThis retrospective observational study examined all ECPR patients admitted to a tertiary emergency medical center between January 2015 and December 2021. All patients underwent pan-scan computed tomography (CT) before admission to the intensive care unit. The head and body trauma were assessed from CT images taken after ECPR. Trauma was defined as all trauma affecting post-ECPR management. In other words, all trauma caused by collapse, trauma caused by resuscitative actions such as chest compressions, and vascular injuries associated with ECPR were included. Univariate analysis of neurological prognosis and 30-day survival due to complicated trauma was performed. ResultsA total of 189 patients (mean age 55.2 ± 13.4 years; 85.2% male) were included in this study. Four patients (2.1%) had head trauma, and 31 patients (16.4%) had torso trauma. All patients with head trauma died during extracorporeal membrane oxygenation management. In patients with torso trauma, 30-day survival was not significantly different compared with that in those without trauma (31.5% vs. 41.9%, P = 0.60); good neurological outcomes were almost the same (26.0% vs. 25.8%, P = 1.00). Approximately half of the patients with torso trauma (48%) underwent transarterial embolization. ConclusionPatients treated with ECPR can suffer a variety of traumatic injuries from the time of collapse to the establishment of ECMO. Head trauma may be lethal and warrants caution. With appropriate treatment, patients with torso trauma may have an equivalent prognosis to those without traumatic complications.

Patients suffering traumatic brain injury: patient characteristics, prehospital triage, primary referral and mortality - A population-based follow-up study

BackgroundTraumatic brain injury (TBI) is a potential high-risk condition, but appropriate care pathways, including prehospital triage and primary referral to a specialised neurosurgical centre, can improve neurological outcome and survival. The care pathway starts with layman triage, wherein the patient or bystander decides whether to contact a general practitioner (GP) or emergency services (1-1-2 call) as an entryway into the health care system. The GP or 112-health care professional then decides on the level of urgency and dispatches emergency medical services (EMS) when needed. Finally, a decision is made regarding referral of the TBI patient to a specialised neurotrauma centre or a local hospital. Recent studies have shown that injuries are generally more severe in patients entering the health care system through EMS (112-calls) than through GPs; however, no information exists on whether mortality and morbidity outcomes differ depending on the referral choice. The aim of this study was to examine triage pathways, including the method of entry into the health care system, as well as patient characteristics and place of primary referral, to determine the associated 30-day and 1-year mortality rates in TBI patients with confirmed intracranial lesions.MethodsThis retrospective observational population-based follow-up study was conducted in the Central Denmark Region from 1 February 2017 to 31 January 2019. We included all adult patients who contacted hospitals and were ascribed a predefined TBI ICD-10 diagnosis code in the Danish National Patient Register. The obtained TBI cohort was merged with prehospital data from the Prehospital Emergency Medical Services, Central Denmark Region, and vital status from the Danish Civil Registration System. Binary logistic regression analysis of mortality was conducted. In all patients with TBI (including concussions), the primary outcome was primary referral to a specialised centre based on mode of entry (‘GP/HCP’, ‘112-call’ or ‘Unreferred’) into the health care system. In the subgroup of patients with confirmed intracranial lesions, the secondary outcomes were the relative risk of death at day 30 and 1 year based on the place of primary referral.ResultsOf 5,257 first TBI hospital contacts of adult patients included in the cohort, 1,430 (27.2%) entered the health care system via 1-1-2 emergency medical calls. TBI patients triaged by 112-calls were more likely to receive the highest level of emergency response (15.6% vs. 50.3%; p < 0.001) and second-tier resources and were more frequently referred directly to a specialised centre than were patients entering through GPs or other health care personnel. In the subgroup of 1188/5257 (22.4%) patients with confirmed intracranial lesions, we found no difference in the risk ratio of 30 day (RR 1.04 (95%CI 0.65–1.63)) or 1 year (RR 0.96 (95%CI 0.72–1.25)) all-cause mortality between patients primarily referred to a regional hospital or to a specialised centre when adjusting for age, sex, comorbidities, antiplatelet/anticoagulant treatment and type of intracranial lesions.ConclusionTBI patients mainly enter the health system by contact with GPs or other health care professionals. However, patients entering through 112-calls are more frequently triaged directly to specialised centres. We were unable to demonstrate any significant difference in the adjusted 30-day and 1-year mortality based on e primary referral to a specialised centre. The inability to demonstrate an effect on mortality based on primary referral to a specialised centre may reflect a lack of clinical data in the registries used. Considerable differences may exist in nondocumented baseline characteristics (i.e., GCS, blood pressure and injury severity) between the groups and may limit conclusions about differences in mortality. Further research providing high-quality evidence on the effect of primary referral is needed to secure early neurosurgical interventions in TBI patients.

Impact of Bystander Cardiopulmonary Resuscitation on Out-of-Hospital Cardiac Arrest Outcome in Vietnam.

Patients experiencing an out-of-hospital cardiac arrest (OHCA) frequently do not receive bystander cardiopulmonary resuscitation (CPR), especially in low- and middle-income countries (LMIC). In this study we sought to determine the prevalence of OHCA patients in Vietnam who received bystander CPR and its effects on survival outcomes. We performed a multicenter, retrospective observational study of patients (≥18years) presenting with OHCA at three major hospitals in an LMIC from February 2014-December 2018. We collected data on the hospital and patient characteristics, the cardiac arrest events, the emergency medical services (EMS) system, the therapy methods, and the outcomes and compared these data, before and after pairwise 1:1 propensity score matching, between patients who received bystander CPR and those who did not. Upon admission, we assessed factors associated with good neurological survival at hospital discharge in univariable and multivariable logistic models. Of 521 patients, 388 (74.5%) were men, and the mean age was 56.7years (SD 17.3). Although most cardiac arrests (68.7%, 358/521) occurred at home and 78.8% (410/520) were witnessed, a low proportion (22.1%, 115/521) of these patients received bystander CPR. Only half of the patients were brought by EMS (8.1%, 42/521) or private ambulance (42.8%, 223/521), 50.8% (133/262) of whom had resuscitation attempts. Before matching, there was a significant difference in good neurological survival between patients who received bystander CPR (12.2%, 14/115) and patients who did not (4.7%, 19/406; P < .001). After matching, good neurological survival was absent in all OHCA patients who did not receive CPR from a bystander. The multivariable analysis showed that bystander CPR (adjusted odds ratio: 3.624; 95% confidence interval 1.629-8.063) was an independent predictor of good neurological survival. In our study, only 22.1% of total OHCA patients received bystander CPR, which contributed significantly to a low rate of good neurological survival in Vietnam. To improve the chances of survival with good neurological functions of OHCA patients, more people should be trained to perform bystander CPR and teach others as well. A standard program for emergency first-aid training is necessary for this purpose.

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.

Neoadjuvant pyrotinib and inetetamab in combination with chemotherapy for locally advanced HER2-positive breast cancer (NeoPICD study): A prospective, multicenter, open-label, single-arm study.

e12627 Background: Inetetamab, a novel monoclonal antibody targeting HER2, alters the Fc region amino acids, which induces ADCC stronger than trastuzumab. Pyrotinib is a small chemical inhibitor of pan-HER receptor tyrosine kinase. The globally recommended first-line neoadjuvant treatment for HER2-positive breast cancer is chemotherapy and two large-molecule monoclonal antibodies, which have unsatisfactory benefits for 50% of patients. This study aims to investigate the effectiveness and safety of targeted medicines, specifically inetetamab and pyrotinib, in conjunction with chemotherapy for patients diagnosed with locally advanced HER2-positive breast cancer. Methods: The trial was structured as a multicenter, open-label, single-arm, prospective study. 143 treatment-naive HER2-positive locally advanced breast cancer patients were planned for the trial. Eligible patients will be administered six cycles of neoadjuvant treatment, including carboplatin (AUC=6mg/mL×min, ivgtt), doxorubicin (75mg/m2, ivgtt), inetetamab (initial loading dosage of 8mg/kg, maintenance dose of 6mg/kg), and pyrotinib (400mg/day, po). The surgery was conducted after the neoadjuvant phase, subsequent to a one-year course of targeted therapy with inetetamab and pyrotinib. The primary endpoint of the study is the total pathologic complete response (tpCR). The secondary endpoints include event-free survival (EFS), disease-free survival (DFS), distant metastasis-free survival (DMFS), neurologic disease-free survival (NDFS), overall survival (OS), and safety. Results: A cohort of 70 patients was enrolled between Nov. 27, 2021 and Feb. 1, 2024. Most patients completed the six-cycle neoadjuvant therapy with inetetamab, pyrotinib, and chemotherapy. The pathological findings of 49 patients who had radical surgery revealed that 65.3% (32/49, 95% CI, 0.515-0.791) of them achieved tpCR (ypT0/Tis ypN0). The initial subgroup analysis revealed that among patients with negative hormone receptors, the rate of tpCR was 80.0% (24/30, 95% CI, 64.8-95.2). Moreover, hormone receptor was statistically determined to be an independent factor influencing the effectiveness of the new treatment regimen ( p=0.032). The prevailing grade 3 or more severe adverse events included anemia (12.8%), diarrhea (10.0%), leukopenia (4.2%), liver dysfunction (4.2%) and renal dysfunction (4.2%). As of now, no treatment-related deaths have been documented. Conclusions: The ongoing study is actively enrolling participants. Preliminary findings from the study indicate that the combination of neoadjuvant inetetamab and pyrotinib with chemotherapy has demonstrated satisfactory effectiveness and manageable side effects. This offers a promising alternative for patients with locally advanced breast cancer that is HER2-positive. Clinical trial information: NCT06234137 .

Prognostic Impact of Heart Rhythm Shockability Trajectory in Out-of-Hospital Cardiac Arrest: A Multicenter Retrospective Study.

This study aimed to investigate the association between the temporal transitions in heart rhythms during cardiopulmonary resuscitation (CPR) and outcomes after out-of-hospital cardiac arrest. This was an analysis of the prospectively collected databases in 3 academic hospitals in northern and central Taiwan. Adult patients with out-of-hospital cardiac arrest transported by emergency medical service between 2015 and 2022 were included. Favorable neurological recovery and survival to hospital discharge were the primary and secondary outcomes, respectively. Time-specific heart rhythm shockability was defined as the probability of shockable rhythms at a particular time point during CPR. The temporal changes in the time-specific heart rhythm shockability were calculated by group-based trajectory modeling. Multivariable logistic regression analyses were performed to examine the association between the trajectory group and outcomes. Subgroup analyses examined the effects of extracorporeal CPR in different trajectories. The study comprised 2118 patients. The median patient age was 69.1 years, and 1376 (65.0%) patients were male. Three distinct trajectories were identified: high-shockability (52 patients; 2.5%), intermediate-shockability (262 patients; 12.4%), and low-shockability (1804 patients; 85.2%) trajectories. The median proportion of shockable rhythms over the course of CPR for the 3 trajectories was 81.7% (interquartile range, 73.2%-100.0%), 26.7% (interquartile range, 16.7%-37.5%), and 0% (interquartile range, 0%-0%), respectively. The multivariable analysis indicated both intermediate- and high-shockability trajectories were associated with favorable neurological recovery (intermediate-shockability: adjusted odds ratio [aOR], 4.98 [95% CI, 2.34-10.59]; high-shockability: aOR, 5.40 [95% CI, 2.03-14.32]) and survival (intermediate-shockability: aOR, 2.46 [95% CI, 1.44-4.18]; high-shockability: aOR, 2.76 [95% CI, 1.20-6.38]). The subgroup analysis further indicated extracorporeal CPR was significantly associated with favorable neurological outcomes (aOR, 4.06 [95% CI, 1.11-14.81]) only in the intermediate-shockability trajectory. Heart rhythm shockability trajectories were associated with out-of-hospital cardiac arrest outcomes, which may be a supplementary factor in guiding the allocation of medical resources, such as extracorporeal CPR.