Non-traumatic Cardiac Arrest Research Articles

Resuscitative endovascular balloon occlusion of the aorta (REBOA) during cardiopulmonary resuscitation: A pilot study

AimResuscitative endovascular balloon occlusion of the aorta (REBOA) during cardiopulmonary resuscitation (CPR) increases coronary and cerebral perfusion pressure, which might improve neurologically intact survival after refractory cardiac arrest. We investigated the feasibility of REBOA during CPR in the emergency department. MethodsPatients in refractory cardiac arrest not qualifying for extracorporeal CPR were included in this pilot study. An introducer sheath was placed by ultrasound-guided puncture of the femoral artery, and a REBOA catheter was advanced to the thoracic aorta in 15 patients undergoing CPR.Primary outcome was correct placement within 10 min of skin disinfection. Secondary outcomes included perfusion markers (mean central arterial blood pressure, end-tidal CO2, non-invasively measured cerebral oxygenation) and procedural information (number and duration of attempts, complications, verification of correct position and occlusion). ResultsSuccessful catheter placement was achieved in 9 of the 15 patients (median 9 min 30 s). Median interval from dispatch to start of the procedure was 59 min. A small, albeit significant increase in non-invasively measured cerebral oxygenation was found, but none in blood pressure or end-tidal CO2. However, two patients with pulseless electrical activity of more than 20 min achieved return of spontaneous circulation immediately after REBOA. ConclusionIn this pilot trial, REBOA during CPR was successful in 60% of attempts. Long resuscitation times before start of the procedure might explain difficult insertion and missing effects. Nevertheless, insertion of REBOA in patients suffering from non-traumatic cardiac arrest is feasible and might increase coronary and cerebral perfusion pressures and perfusion.

Administration of sodium bicarbonate during cardiopulmonary resuscitation increases the frequency of cardiac gas on postmortem CT estimated to be CO2

• Hypercapnia increases the frequency of cardiac gas (CG) on postmortem CT (PMCT). • CG on PMCT was frequently found in the sodium bicarbonate (SB) administration group. • Administraton of SB may generate extra carbon dioxide during resuscitation. Cardiac gas (CG) on immediate postmortem computed tomography (PMCT) after cardiopulmonary resuscitation (CPR) is associated with high blood carbon dioxide (CO 2 ) levels. This study investigated whether administration of sodium bicarbonate (SB) during CPR generates extra blood CO 2 , judging from CG findings on immediate PMCT. We enrolled 210 nontraumatic cardiopulmonary arrest (CPA) patients (101 men, 109 women) who were transported to our hospital and could not be resuscitated. They underwent arterial blood gas analysis (BGA) during CPR and immediate PMCT after failed resuscitation and were assigned to a CG-negative or a CG-positive group based on the PMCT findings. CG on immediate PMCT was detected in 106 patients (50.4%). Significant differences were not observed in the demographic variables between the CG-negative and CGpositive groups. Both pH and the partial pressure of arterial oxygen were significantly lower in the CG-positive group than in the CG-negative group, and the partial pressure of arterial carbon dioxide was significantly higher in the CG-positive group than in the CG-negative group. Among the administered infusions and medications, only SB demonstrated a significant difference in the frequency of administration between the CG-negative and CG-positive groups. The positive CG rate in the SB group (44/67, 66%) was significantly higher than that in the non-SB group (62/143, 43%). The administration of SB during CPR was associated with an increased frequency of CG on immediate PMCT, suggesting that administration of SB during CPR generates extra blood CO 2 .

Computed tomographic findings of chest injuries following cardiopulmonary resuscitation: More complications for prolonged chest compressions?

Chest injuries are common and inevitable complications of chest compressions during cardiopulmonary resuscitation (CPR). This study aimed to investigate lung parenchymal and thoracic skeletal injuries after CPR by using computed tomography (CT) and to analyze the correlation between the duration of CPR and related complications.We examined 43 non-traumatic cardiac arrest patients who were successfully resuscitated after CPR and had chest CT scans within 24 hours of CPR. Lung parenchymal injuries were assessed by quantifying the lung contusion score (LCS) on the CT images, and each skeletal injury was investigated by classifying the location and the distribution. Other CPR-related chest injuries were also described, such as pleural effusion/hemothorax, pneumothorax, and retrosternal hematoma. Statistical analysis was conducted to determine whether the duration of CPR was correlated with each complication.Lung contusions were found in all of the patients (mean LCS: 22, range: 5–47). The distribution of lung contusions were predominantly in the bilateral dependent portions of the lungs (41 patients). All of the rib fractures occurred in the anterior arc (43 patients), and the sternal fractures occurred predominantly in the mid-sternal body (31 patients). In patients younger than 70 years old, the number of rib fractures significantly increased among those who underwent CPR for more than 25 minutes compared to those who received CPR for less than 25 minutes (median 4.5 vs 9; mean 8.3 vs 5.6 per person, respectively; P = .035). The risk of sternal fracture tended to be higher for patients who received CPR for more than 10 minutes compared to those who received CPR for less than 10 minutes (odds ratio: 3.60; 95% confidence interval: 0.86–15.06; P = .079). However, there was no statistically significant correlation between the duration of CPR and LCS or other CPR-related chest injuries.The duration of CPR was associated with the number of rib fractures and the occurrence of sternal fractures, but it did not affect the extent of CPR-related lung contusions or other CPR-related chest injuries. All of the rib fractures occurred in the anterior arc, while the sternal fractures occurred predominantly in the mid-sternal body. However, since this study was conducted in a single institution, the number of patients included was relatively small, thus limiting the statistical analysis.

Zone 3 REBOA does not provide hemodynamic benefits during nontraumatic cardiac arrest

BackgroundResuscitative endovascular balloon occlusion of the aorta (REBOA) may be a novel intervention to improve cardiopulmonary resuscitation (CPR) quality during cardiac arrest. Zone 1 supraceliac aortic occlusion improves coronary and cerebral blood flow. It is unknown if Zone 3 occlusion distal to the renal arteries offers a similar physiologic benefit while maintaining blood flow to organs above the point of occlusion. MethodsFifteen swine were anesthetized, instrumented, and placed into ventricular fibrillation. Mechanical CPR was immediately initiated. After 5 min of CPR, Zone 1 REBOA, Zone 3 REBOA, or no intervention (control) was initiated. Hemodynamic variables were continuously recorded for 30 min. ResultsThere were no significant differences between groups before REBOA deployment. Once REBOA was deployed, Zone 1 animals had statistically greater diastolic blood pressure compared to control (median [IQR]: 19.9 mmHg [9.5–20.5] vs 3.9 mmHg [2.4–4.8], p = .006). There were no differences in diastolic blood pressure between Zone 1 and Zone 3 (8.6 mmHg [5.1–13.1], p = .10) or between Zone 3 and control (p = .10). There were no significant differences in systolic blood pressure, cerebral blood flow, or time to return of spontaneous circulation (ROSC) between groups. ConclusionIn our swine model of cardiac arrest, Zone 1 REBOA improved diastolic blood pressure when compared to control. Zone 3 does not offer a hemodynamic benefit when compared to no occlusion. Unlike prior studies, immediate use of REBOA after arrest did not result in an increase in ROSC rate, suggesting REBOA may be more beneficial in patients with prolonged no-flow time. Institutional protocol numberFDG20180024A

Resuscitative endovascular balloon occlusion of the aorta (REBOA) : Current aspects of material, indications and limits: an overview

Hintergrund„Resuscitative endovascular balloon occlusion of the aorta“ (REBOA) stellt ein endovaskuläres Verfahren dar, bei dem ein Blockballon in die Aorta eingeführt wird, um eine distal des Ballons gelegene Blutung zu verringern und gleichzeitig die kardiale und zerebrale Oxygenierung zu verbessern.Ziel der ArbeitVorstellung der REBOA-Technik, der möglichen Indikationen, der benötigen Materialien und der möglichen Komplikationen des Verfahrens.Material und MethodenNichtsystematischer Übersichtsartikel über die aktuelle Literatur.ErgebnisseREBOA stellt gerade bei traumatisch bedingten Blutungen und rupturierten Aortenaneurysmen ein mögliches additives Verfahren zur hämodynamischen Stabilisierung dar. Die Komplikationsrate des Verfahrens liegt bei ungefähr 5 %, wobei Zugangskomplikationen im Vordergrund stehen, jedoch auch letale Komplikationen möglich sind.DiskussionEine aortale Ballonblockade wird bei der Versorgung rupturierter Aortenaneurysmen standardmäßig eingesetzt. Es gibt wachsende Evidenz, dass REBOA bei der Versorgung polytraumatisierter Patienten mit einem hämorrhagischen Schock aufgrund einer abdominellen oder viszeralen Blutung eine vergleichsweise minimal-invasive Alternative zur offen chirurgischen Aortenklemmung mittels Thorakotomie darstellt. Mit der Entwicklung neuer Ballonkatheter, die ohne Führungsdraht und mit geringeren Schleusendurchmessern auskommen, wird auch ein Einsatz bei anderen Krankheitsbildern wie postoperativen abdominellen Nachblutungen, gynäkologischen Blutungen oder als additives Verfahren bei der kardiopulmonalen Reanimation diskutiert.

Maximum emergency department overcrowding is correlated with occurrence of unexpected cardiac arrest

BackgroundEmergency department overcrowding negatively impacts critically ill patients and could lead to the occurrence of cardiac arrest. However, the association between emergency department crowding and the occurrence of in-hospital cardiac arrest has not been thoroughly investigated. This study aimed to evaluate the correlation between emergency department occupancy rates and the incidence of in-hospital cardiac arrest.MethodsA single-center, observational, registry-based cohort study was performed including all consecutive adult, non-traumatic in-hospital cardiac arrest patients between January 2014 and June 2017. We used emergency department occupancy rates as a crowding index at the time of presentation of cardiac arrest and at the time of maximum crowding, and the average crowding rate for the duration of emergency department stay for each patient. To calculate incidence rate, we divided the number of arrest cases for each emergency department occupancy period by accumulated time. The primary outcome is the association between the incidence of in-hospital cardiac arrest and emergency department occupancy rates.ResultsDuring the study period, 629 adult, non-traumatic cardiac arrest patients were enrolled in our registry. Among these, 187 patients experienced in-hospital cardiac arrest. Overall survival discharge rate was 24.6%, and 20.3% of patients showed favorable neurologic outcomes at discharge. Emergency department occupancy rates were positively correlated with in-hospital cardiac arrest occurrence. Moreover, maximum emergency department occupancy in the critical zone had the strongest positive correlation with in-hospital cardiac arrest occurrence (Spearman rank correlation ρ = 1.0, P < .01). Meanwhile, occupancy rates were not associated with the ED mortality.ConclusionMaximum emergency department occupancy was strongly associated with in-hospital cardiac arrest occurrence. Adequate monitoring and managing the maximum occupancy rate would be important to reduce unexpected cardiac arrest.

Electrocardiographic changes in patients undergoing targeted temperature management.

ObjectivesTargeted temperature management is the recommended therapy for comatose patients after an out‐of‐hospital cardiac arrest resuscitation due to the reduction in neurological damage and improved outcomes. However, there may result in electrocardiographic instability depending on the degree of targeted temperature management, including minor or life‐threatening dysrhythmias or conduction delays. This project aims to describe the frequency of ECG interval changes and clinically relevant dysrhythmias in targeted temperature management patients.MethodsThis is a retrospective observational study from January 2009 to December 2015. Patients who qualified for the study had a non‐traumatic cardiac arrest with a return of spontaneous circulation, received targeted temperature management at 33.5°C for 24 hours followed by 16 hours of rewarming. ECG interval changes and dysrhythmias were recorded immediately after return of spontaneous circulation, and at 24 and 48 hours post return of spontaneous circulation.ResultsA total of 322 patients (age 61.0 ± 16.9 years) had targeted temperature management initiated during the study period, of which 169 had complete data and 13 died prior to completing 24 hours of hypothermia. There were statistically significant changes during targeted temperature management in heart rate (96.7 ± 26.0/min before targeted temperature management; 69.5 ± 19.1/min during, P < 0.001), QRS duration (115.1 ± 32.6 ms before targeted temperature management; 107.8 ± 27.9 ms during targeted temperature management, P < 0.001), and QTc (486.3 ± 52.8 ms before targeted temperature management; 526.9 ± 61.7 ms during targeted temperature management, P < 0.001). There were cardiac dysrhythmias that received treatment during cooling and rewarming.ConclusionDuring the period of targeted temperature management and rewarming, we observed few self‐limiting ECG interval changes and no clinically significant dysrhythmias in this population during the period of targeted temperature management.

Prehospital Protocols for Post-Return of Spontaneous Circulation Are Highly Variable

Background Up to 44% of out-of-hospital cardiac arrest (OHCA) patients will rearrest in the immediate post-return of spontaneous circulation (post-ROSC) period, and rearrest is associated with decreased survival. Cardiac arrest guidelines are often equivocal regarding what post-ROSC care should be provided in the prehospital setting and when hospital transport should be initiated. Prehospital protocols must balance the benefit of time-dependent hospital-based care with the risk of early rearrest. We sought to describe current prehospital protocols for post-ROSC care in the treatment of OHCA. Methods A single trained abstractor systematically reviewed a purposeful sample of prehospital protocols for adult non-traumatic cardiac arrest from the United States using an a priori standardized data abstraction form. Protocols were either stand-alone or integrated into intra-arrest care. Exclusion criteria were non-911 ground transport agencies and protocols not revised since the 2015 American Heart Association guideline update. All protocols were publicly available via the Internet. Data abstraction was conducted in May 2019. Measures of interest were counted and summarized. Proportions and 95% confidence intervals were calculated. Results We identified and reviewed 82 prehospital protocols from 46 states and the District of Columbia. Seven protocols were excluded due to the revision date, leaving 75 protocols included in the study. Six protocols (8%; CI 3.7–16%) provide no guidance on prehospital post-ROSC care. 12-lead electrocardiogram (ECG) acquisition (63/75 [84%; CI 73–91%]) and transport to percutaneous coronary intervention-capable hospitals (55/75 [73%; CI 62–83%]) are common, although not ubiquitous. Of those that do require a 12-lead ECG, 40% [CI 27–54%] required the presence of an ST-elevation myocardial infarction to inform their transport decision. Only 9 (12%; CI 6.4–22%) provide any guidance on when to initiate transport post-ROSC, with 4 (5%; CI 2–13%) requiring a post-ROSC stabilization period prior to transport. Conclusion Prehospital treatment and transport protocols for post-ROSC care are highly variable across the United States.

Resuscitative endovascular balloon occlusion of the aorta in zone I versus zone III in a porcine model of non-traumatic cardiac arrest and cardiopulmonary resuscitation: A randomized study

IntroductionResuscitative endovascular balloon occlusion of the aorta (REBOA) in zone I increases systemic blood pressure during cardiopulmonary resuscitation (CPR), while also obstructing the blood flow to distal organs. The aim of the study was to compare the effects on systemic blood pressure and visceral blood flow of REBOA-III (zone III, infrarenal) and REBOA-I (zone I, supraceliac) during non-traumatic cardiac arrest and CPR. MethodsCardiac arrest was induced in 61 anesthetized pigs. Thirty-two pigs were allocated to a hemodynamic study group where the primary outcomes were systemic arterial pressures and 29 pigs were allocated to a blood flow study group where the primary outcomes were superior mesenteric arterial (SMA) and internal carotid arterial (ICA) blood flow. After 7–8 min of CPR with a mechanical compression device, REBOA-I, REBOA-III or no aortic occlusion (control group) were initiated after randomization. ResultsSystemic mean and diastolic arterial pressures were statistically higher during CPR with REBOA-I compared to REBOA-III (50 mmHg and 16 mmHg in REBOA-I vs 38 mmHg and 1 mmHg in REBOA-III). Systemic systolic, mean and diastolic arterial pressures were statistically elevated during CPR in the REBOA-I group compared to the controls. The SMA blood flow increased by 49% in REBOA-III but dropped to the levels of the controls within minutes. The ICA blood flow increased the most in REBOA-I compared to REBOA-III and the control group (54%, 19% and 0%, respectively). ConclusionIn experimental non-traumatic cardiac arrest and CPR, REBOA-I increased systemic blood pressures more than REBOA-III, and the potential enhancement of visceral organ blood flow by REBOA-III was short-lived.

A needs assessment of resuscitative endovascular balloon occlusion of the aorta (REBOA) in non-traumatic out-of-hospital cardiac arrest in Norway

IntroductionOut of hospital cardiac arrest (OHCA) carries an 86% mortality rate in Norway. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potential adjunct in management of non-traumatic cardiac arrest and is feasible in pre-hospital setting without compromising standard cardiopulmonary resuscitation (CPR). However, number of patients potentially eligible for REBOA remain unknown. In preparation for a clinical trial to investigate any benefit of pre-hospital REBOA, we sought to assess the need for REBOA in Norway as an adjunct treatment in OHCA.MethodsRetrospective observational cohort study of data from the Norwegian Cardiac Arrest Registry in the 3-year period 2016–2018. We identified number of patients potentially eligible for pre-hospital REBOA during CPR, defined by suspected non-traumatic origin, age 18–75 years, witnessed arrest, ambulance response time less than 15 min, treated by ambulance personnel and resuscitation effort over 30 min.ResultsIn the 3-year period, ambulance personnel resuscitated 8339 cases. Of these, a group of 720 patients (8.6%) were eligible for REBOA. Only 18% in this group achieved return of spontaneous circulation and 7% survived for 30 days or more.ConclusionThis national registry data analysis constitutes a needs assessment of REBOA in OHCA. We found that each year approximately 240 patients, or nearly 9% of ambulance treated OHCA, in Norway is potentially eligible for pre-hospital REBOA as an adjunct treatment to standard resuscitation. This needs assessment suggests that there is sufficient patient population in Norway to study REBOA as an adjunct treatment in OHCA.

Extracorporeal cardiopulmonary resuscitation at the emergency department: A retrospective patient selection evaluation.

There is an increasing use of extracorporeal life support in refractory cardiac arrest. Recent studies highlighted the importance of an early and accurate patient selection for this invasive procedure. The aim of this study was to retrospectively validate a six-criteria-screening-checklist (witnessed collapse, bystander-cardiopulmonary resuscitation/first medical contact <5 min, shockable, age <70 years, end tidal carbon dioxide >14 mmHg and pupils not anisocoric/distorted/mydriatic) as an early screening tool in patients treated with extracorporeal cardiopulmonary resuscitation (eCPR) at the emergency department. Retrospective observational study. All patients at least 18 years of age with nontraumatic cardiac arrest and without return of spontaneous circulation before eCPR treatment at our department between January 2013 and December 2018 were included in this retrospective observational study. No specific intervention was set in this observational study. Primary outcome was the rate of patients who fulfilled all criteria, secondary outcome was 30-day and 6-month survival in accordance with the criteria. Overall, data from a total of 92 patients were eligible for analyses. Out of these, 27 patients (29%) met all criteria. Patients, who fulfilled all criteria, showed significantly higher odds for 30-day survival [OR 6.0 (95% CI 1.78 to 20.19)] P = 0.004. Patients, who did not fulfil all criteria, showed significantly higher rates of early mortality after eCPR initiation [OR 4.57 (95% CI 1.69 to 12.37)] P = 0.003. Patients fulfilling all inclusion criteria showed higher rates of survival after eCPR. Our results affirm that there is a possibility and even an obvious necessity for early patient selection based on standardised criteria before eCPR treatment. Large randomised trials are urgently needed to answer this question accurately.

Prevention strategies for traumatic cardiac arrest

The fatality rate of traumatic cardiac arrest (TCA) is extremely high, and it is very different from that of non-traumatic cardiac arrest (NTCA) in resuscitation strategy. Only when the standard resuscitation process is combined with rapid treatment of various reversible causes can the mortality rate of patients be decreased. In this paper, the key factors leading to TCA are reviewed, such as hypovolemic shock, asphyxia, tension pneumothorax, pericardial tamponade, crush syndrome, craniocerebral injury, cerebral hernia, and the control measures are elaborated respectively, so as to provide references for clinical treatment of patients with severe trauma, and reduce TCA incidence and mortality.

Correlation between blood gas analysis and cardiac gas on immediate postmortem computed tomography after cardiopulmonary resuscitation

Abstract Purpose Cardiac gas (CG) is a characteristic postmortem computed tomography (PMCT) finding. This study investigated the correlation between blood gas analysis (BGA) and CG presence on immediate PMCT after cardiopulmonary resuscitation (CPR). Materials and methods We enrolled 132 nontraumatic cardiopulmonary arrest (CPA) patients (69 males, 63 females) who were transported to our hospital and could not be resuscitated. They underwent arterial BGA during CPR and immediate PMCT after failed resuscitation and were classified into a CG-negative or a CG-positive group on the basis of computed tomography (CT) findings. We also compared BGA values between the two groups. Results The mean age of the 132 people was 81.4 ± 11.8 years. CG on immediate PMCT was found in 60 patients (45.5%), with gas in the right atrium (RA) in 31 patients (23.5%) and in the right ventricle (RV) in 51 patients (38.8%). We did not detect gas in the left atrium (LA) or left ventricle (LV) in any of the patients. Both pH and partial pressure of arterial oxygen (PaO2) were significantly lower and partial pressure of arterial carbon dioxide (PaCO2) significantly higher in the CG-positive group compared to the CG-negative group. Conclusion CG occurrence on immediate PMCT post-CPR might be related to high PaCO2 levels.

Diagnosis of aortic dissection by transesophageal echocardiography during cardiopulmonary resuscitation.

Early identification of the causes of cardiac arrest is helpful in determining the resuscitation measures during cardiopulmonary resuscitation (CPR). We aimed to evaluate the feasibility of transesophageal echocardiography (TEE) during CPR in diagnosing aortic dissection and the influence of aortic dissection on resuscitation outcome in adult patients with prolonged non-traumatic cardiac arrest. Adult patients aged >20years with non-traumatic cardiac arrest who underwent prolonged CPR (>10min) and TEE examination during CPR were enrolled. The enrolled patients were grouped according to the presence of aortic dissection on TEE: the aortic dissection (AD) group and the non-AD group. Variables related to cardiac arrest event, CPR, and resuscitation outcome were compared between the two groups. Forty-five patients (median age, 71years; 26 men) were enrolled. Ten (22.2%) and 35 (77.8%) patients were included in the AD and non-AD groups, respectively. No patients in the AD group survived. Aortic dissection on TEE was inversely related to the rate of return of spontaneous circulation on multivariate analysis (odds ratio, 0.019; 95% confidence interval, 0.001-0.750; p=.035). TEE is a useful tool for diagnosing aortic dissection as a cause of cardiac arrest during CPR. Aortic dissection is associated with poor resuscitation outcomes.

Impact of age on one-year mortality in patients managed for cardiac arrest

Mortality for patients hospitalized for cardiac arrest is still very high. In France, as in Europe, population is growing older and management of cardiac arrest in the elderly raises medical and ethical questions. To compare one-year mortality according to the age (< 70 years, ≥ 70 years) for patients admitted for cardiac arrest, and to describe predictors of survival in the group ≥ 70 years. All patients admitted for non-traumatic cardiac arrest in our center from 1 January 2015 to 31 December 2016 were retrospectively included. Patients were analyzed depending on the age: under and over 70 years old. Two hundred and ninety one patients were included (203 under 70 years, 88 over 70 years), whose 38 for in-hospital cardiac arrest. In-hospital mortality (138 (67.9%) vs. 71 (80.7%); P = 0.27), one-month (140 (68.9%) vs. 74 (84.1%); P = 0.001) and one-year mortality (144 (70.9%) vs. 78 (88.6%); P = 0.001) were significantly higher in the group over 70 years. In this group, initial shockable rhythm (OR 0.25; IC 95% 0.05-0.73) and a medical or para-medical witness (OR 0.28; IC 95% 0.09–0.83) were associated with a good prognosis whereas diabetes (OR 8.7; IC 95% 1.08–69.7), cardiac arrest at home (OR 3.5; IC 95% 1.1–10.8), longer low-flow (OR 1.2; IC 95% 1.08–1.4) and higher lactates (OR 1.22; IC 95% 1.04–1.43) were associated with lower survival to hospital discharge. Older age is associated with a higher mortality after a cardiac arrest. In patients under 70 y.o, initial shockable rhythm and medical or para-medical witness were associated with a better prognosis, whereas diabetes, cardiac arrest at home, a longer low-flow and higher lactates were associated with a poor prognosis.

Frequency analysis of heart rate variability may predict seizure in the early post-cardiac arrest phase

Introduction: Seizure is frequently encountered in the post-cardiac arrest phase and is an important predictor of poor prognosis. Early detection of seizure with in-time effective treatment is clinically challenging, especially in this era of target temperature management. Heart rate variability (HRV) signals has been shown the potentials to predict epilepsy. However, few focused on seizure prediction by continuous electroencephalography (EEG) and electrocardiogram (ECG) recordings. Objectives/Aims: To verify the roles of HRV in predicting seizure episodes in the early post-cardiac arrest phase. Methods: This is a prospective cohort study conducted in the Emergency Intensive Care Unit of National Taiwan University Hospital from January 2018 to December 2018. Adult non-traumatic cardiac arrest patients receiving CPR with sustained return of spontaneous circulation were recruited. ECG and EEG were continuously recorded (IntelliVue MX800®, Philips) in the first 72 h post-cardiac arrest. EEG signals around seizure episodes were decomposed by empirical mode decomposition (EMD). Approximate entropy (ApEn) of the intrinsic mode function (IMF) 4 was calculated. HRV was processed from ECG recorded 5 minutes before onset of candidate seizure using Pan-Tompkin’s algorithm, Fourier transformation and sample entropy. A set algorithm including support vector machine (SVM) classification and leave-one-out cross validation was launched to clarify the association of HRV and subsequent seizures. Results: A total of 27 candidate events from 15 patients (male: 7, mean age 67.4 years old) were analysed. Nine (33%) were confirmed seizure attacks. The results showed that power of high frequency (pHF), low-to-high frequency ratio (LF/HF), and sample entropy were the best parameters to match the prediction model, with sensitivity of 66.7% and specificity of 83.3%. The overall prediction accuracy was 77.8%. Conclusion: The frequency parameters of HRV may predict seizures in the early post-cardiac arrest phase. Further validation is needed to clarify its roles in clinical application.

An investigation of the use of SCUBE1 protein as an early prognostic marker in predicting prognosis after cardiopulmonary resuscitation in cardiac arrest patients

Aim: To evaluate the usefulness of Signal Peptide-CUB-EGF Domain-Containing Protein-1 (SCUBE1) protein as an early prognostic marker in predicting survival, resuscitation success, and good neurological outcome following cardiopulmonary resuscitation (CPR) in cardiac arrest patients.Material and Methods: Non-traumatic cardiac arrest patients presenting to the emergency department over a six-month period were included in the study. Blood specimens were collected for SCUBE1 measurement at the start of CPR. SCUBE1 levels investigated at the start of CPR were compared, and their usefulness in predicting patients with long-term survival and exhibiting good neurological prognosis was evaluated.Results: The study group consisted of 65 non-traumatic cardiac arrest patients. Sustained return of spontaneous circulation (ROSC) was achieved in 26 (40%) of these 65 patients, and five (7.7%) cases concluded with good neurological prognosis after three months. Comparison of the patient groups with and without sustained ROSC in terms of SCUBE1 levels investigated at the start of CPR revealed no statistically significant difference between them (p=0.462). However, comparison of the patient groups with good and poor neurological prognosis in terms of SCUBE1 levels at the start of CPR revealed that SCUBE1 levels were twice as high in the poor neurological prognosis group as in the good neurological prognosis group, although the difference was not statistically significant.Conclusion: SCUBE1 levels measured at the start of CPR are not sufficient for predicting post-CPR survival and good neurological outcome.

The incidence of airway haemorrhage in manual versus mechanical cardiopulmonary resuscitation

ObjectiveThe aim of this study was to compare the incidence of airway haemorrhage between participants who received manual cardiopulmonary resuscitation (CPR) and those who had received mechanical CPR using the...

Abstract 368: A Cardiac Arrest Simulation-Based Feasibility Cadaver Study Investigating Time for Semi Surgical Cut Down Procedure Followed by Insertion of a Novel REBOA Catheter

Aim: Non-traumatic cardiac arrest is a major public health problem that carries an extremely high mortality rate. The Resuscitative endovascular balloon occlusion of the aorta (REBOA) procedure is currently being discussed as a possible technique to be used during Advanced Life Support (ALS) in humans with Cardiac arrest (CA). The aim of this study was to assess the training of emergency physicians in the procedures related to insertion of a novel REBOA catheter. Methods: We developed a training program using a simulated CA model on human cadavers. CPR was performed using the LUCAS device (Stryker/Jolife AB, Lund, Sweden). All cadavers were hemodynamically monitored. The Neurescue REBOA catheter (Neurescue REBOA device, Neurescue ApS, Copenhagen, Denmark) was inserted using a semi-surgical cut-down and sheath placement technique. Time needed to perform the procedures was measured. The procedures were instructed by 2 experts using video, procedural simulation on manikin and full-scale training on cadavers. Results: Six human cadavers were enrolled and a total of 12 procedures were performed by 2 expert investigators and 10 novice investigators. Eight semi-surgical cut-down producers including placements of the introducer sheath were performed on the first attempt and 4 required a second attempt. The median time required for the semi-surgical cutdown procedure and sheath placement by the novice investigators was: 6 min 48 sec (Min: 3 min 45 sec and Max: 26 min 25 sec). The median time required for the insertion and occlusion of the REBOA catheter by the novice investigators was: 3 min 22 sec (Min: 1 min 22 sec and Max: 7 min 5 sec). The median time required for full insertion for the novice investigators was: 11 min 14 sec (Min: 6 min 49 sec and Max: 28 min 15 sec). The mean aortic pressure during compression was: 31.9 mmHg (±17.0). Conclusions: Semi surgical cut-down and introducer sheath placement were performed in 1 or two 2 attempts for all novice investigators with an insertion time compatible with ALS during refractory CA. Simulation training on cadavers brings clinical realism and could be an important addition to the use of manikin or animal training models.

Abstract 28: Feasibility and Safety of Pre-Hospital Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in Non-Traumatic Out-Of-Hospital Cardiac Arrest

Introduction: The proportion of patients surviving to hospital discharge after out of hospital cardiac arrest (OHCA) is low and any measure that may improve circulation to vital organs during cardiopulmonary resuscitation (CPR) is beneficial. The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) will redistribute cardiac output to the organs proximal to the occlusion. Animal studies supports that aortic occlusion during CPR might benefit patients suffering from OHCA, but human data are scarce. Methods: We performed an observational study at the helicopter emergency medical service in Trondheim (Norway) to assess the feasibility and safety of establishing REBOA in OHCA patients. The femoral artery was identified by ultrasound and a REBOA catheter was placed in the thoracic aorta. All patients received advanced cardiac life support (ACLS) during the procedure. REBOA eligibility, procedural success and time intervals were registered. A safety monitoring program was conducted to ensure that the procedure did not interfere with the quality of ACLS. Results: REBOA was initiated in ten of 98 OHCA patients. The mean age was 63 years (55-71) and 7 were male. The REBOA procedure was successful in all cases (100%), with 80% success rate on first cannulation attempt. Mean REBOA procedural time was 11,7 minutes (8-16, SD 3,2). End-tidal CO2 (EtCO2) increased by a mean of 1.9 kPa at 60 seconds after inflation compared to baseline (p &lt; 0.001). Six of 10 patients (60%) achieved return of spontaneous circulation, 3 (30%) was admitted to hospital. 30-day survival was 10%. The mean width of the femoral artery and vein during CPR was 5,9 mm (3,6 - 7,4, SD 1,2) and 9,4 mm (5,0 - 12,9, SD 2,9), respectively. The safety monitoring group identified no negative influence on the ACLS quality. Conclusions: This is the first study to assess the pre-hospital use of REBOA in patients with non-traumatic cardiac arrest. The REBOA procedure does not interfere with the quality of the ACLS. REBOA is a feasible adjunct treatment in OHCA. The significant increase in EtCO2 after occlusion suggests improved organ circulation during CPR.