Post-cardiac Arrest Care Research Articles

Deployment of a Clinical Pathway to Improve Postcardiac Arrest Care: A Before-After Study.

Postcardiac arrest care bundles following adult cardiac arrest are associated with improved survival to discharge. We aimed to evaluate whether a clinical pathway and computerized order entry were associated with improved pediatric postcardiac arrest care and discharge outcomes. Single-center retrospective before-after study. Academic PICU. Patients who suffered an in- or out-of-hospital cardiac arrest from January 2008 to December 2015 cared for in the PICU within 12 hours of sustained return of circulation. Deployment of a postcardiac arrest clinical pathway and computerized order entry system. There were 380 patients included-163 in the pre-pathway period and 217 in the post-pathway period. Primary outcome was percent adherence to pathway clinical goals at 0-6 and 6-24 hours post-return of circulation and to diagnostics (continuous electroencephalogram monitoring, head CT for out-of-hospital cardiac arrests, echocardiogram). Secondary outcomes included survival to hospital discharge and survival with favorable neurologic outcome (Pediatric Cerebral Performance Category of 1-3 or no change from baseline). The pre-pathway and post-pathway groups differed in their baseline Pediatric Cerebral Performance Category scores and the following causes of arrest: airway obstruction, arrhythmias, and electrolyte abnormalities. Pathway adherence was not significantly different between the pre-pathway and post-pathway groups, with the exception of higher rates of continuous electroencephalogram monitoring (45% vs 64%; p < 0.001). There was no difference in survival to hospital discharge between the two groups (56% vs 67%; adjusted odds ratio, 1.68; 95% CI, 0.95-2.84; p = 0.05). Survival to discharge was higher in the post-pathway group for the in-hospital cardiac arrest cohort (55% vs 76%; adjusted odds ratio, 3.06; 95% CI, 1.44-6.51; p < 0.01). There was no difference in favorable neurologic outcome between all patients (adjusted odds ratio, 1.21; 95% CI, 0.72-2.04) or among survivors (adjusted odds ratio, 0.72; 95% CI, 0.27-1.43). After controlling for known potential confounders, the creation and deployment of a postcardiac arrest care pathway and computerized order entry set were not associated with improvement in pathway adherence or overall outcomes, but was associated with increased survival to hospital discharge for children with in-hospital cardiac arrests.

A Population-Based Retrospective Analysis of Post-In-Hospital Cardiac Arrest Survival after Modification of the Chain of Survival.

In 2010, the American Heart Association recommended that postcardiac arrest care should be included in the chain of survival to reduce permanent neurological damage, improve quality of life, and reduce health care expenses of postcardiac arrest care. To investigate post-in-hospital cardiac arrest (IHCA) survival prior to and after modification of the chain of survival in 2010, with subgroup analyses per age and concomitant coronary heart disease (CHD). We retrospectively searched the National Health Insurance Research Database for the 2007-2015 period to collect case data coded as "427.41" or "427.5" per International Classification of Disease Clinical Modification, Ninth revision codes and analyzed the data with SPSS v22.0. The 1-day survival rate in the 2011-2015 period was 2% higher than that in the 2007-2010 period (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.01-1.04). Moreover, in the 2011-2015 period, the survival-to-discharge rate was increased by 1% in patients under 65years (OR 1.01, 95% CI 1.00-1.02) and 1% in CHD patients (OR 1.01, 95% CI 1.01-1.02) compared with that in the 2007-2010 period. For patients with IHCA, the overall short-term survival improved significantly after modification of the chain of survival. Younger patients and patients with CHD had better long-term survival.

P0250COLD DIURESIS DURING TARGETED TEMPERATURE MANAGEMENT AFTER CARDIAC ARREST, MYTH OR FACT?

Abstract Background and Aims Therapeutic hypothermia or targeted temperature management (TTM) has been standard treatment for cardiac arrest survivors with suspected hypoxic ischemic brain injury for improvement in both survival and neurological outcomes. TTM is consisted of an induction phase of quickly lowering the temperature to target temperature (ranging from 32°C -36°C) as soon as possible, a hypothermia maintenance phase of keeping the body temperature at target temperature for at least 24 hours, a rewarming phase of slowly rewarming the temperature to normothermia, and a normothermia phase of keeping the body temperature at normothermia. During the dynamic changes in body temperature, cold-diuresis is a commonly described phenomenon. However, limited studies have characterized cold-induced diuresis during TTM. In this study, we sought to determine urine output changes during post cardiac arrest therapeutic hypothermia. Method This retrospective cohort study included adult patients who underwent TTM after out-of-hospital cardiac arrest and were admitted to the intensive care unit for post cardiac arrest care between January 2012 and August 2018. The exclusion criteria of this study were as follows: 1) deceased status before the completion of all phase of TTM; 2) previous end stage kidney disease patients, 3) undergoing renal replacement therapy due to AKI within 48 hours of TTM termination; 4) terminal cancer less than 6 months of life expectancy or previously cerebral performance category (CPC) 3 or more. The neurologic outcome was assessed using the CPC score after 1 month. Good neurologic outcome was defined as a CPC score of 1, 2 and poor neurologic outcome as a CPC score of 3 to 5. The post cardiac arrest protocol recommends a target temperature of 33°C unless the patient is hemodynamically unstable or has a bleeding tendency or severe infection. Rewarming rate was 0.15°C/hr or 0.25°C/hr. TTM was conducted with the use of temperature managing devices with a feedback loop system (Artic Sun Energy Transfer Pads, Medivance Corp., Louisville, CO, USA; Cool Guard Alsius Icy Heat Exchange Catheter, Alsius Corporation, Irvine, CA, USA). We calculated the hourly IV fluid input and urine output rates for each TTM phase. To compare the mean of urine volume between each TTM phase, we used repeated measure analysis of variance (ANOVA). Results 178 Patients included in the analysis. We observed a increase in urine output rates during hypothermia induction. This effect persisted even after adjustment for variable clinical confounders, including intravenous fluid input rate, mean arterial pressure (MAP), initial shockable rhythm, SOFA score, body mass index, and IV furosemide use. However, we did not detect any evidence of urine output increases or decreases during the hypothermia maintenance or rewarming phases. By repeating measures ANOVA and a linear mixed model, it was confirmed that there is a difference in urine output for each TTM phase. Even after the post hoc analysis was calibrated with several variables, only the hypotheria induction phase differed significantly from the urine output of the phase. Conclusion Although our results are some limitations, the findings support the potential presence of cold-induced dieresis, but not rewarm anti-diuresis during TTM. Our study may not fully capture the extent of renal impairment in post cardiac arrest undergoing TTM. However, our objective was to characterize urine output during TTM in post cardiac arrest patients. This has important implications for fluid management in patients undergoing TTM.

LO16: Predicting survival from out-of-hospital cardiac arrest

Introduction: Prognostication is a significant challenge early in the post-cardiac arrest period. Common prognostic factors for neurological survival are unreliable (high false positive rates) until 72 hours post-cardiac arrest. It is not known whether there are a combination of factors that can be utilized earlier in the post-cardiac arrest period to accurately predict patient outcome. Our objective was to predict neurological outcome utilizing a novel combination of patient factors early in the post-cardiac arrest period. Methods: We conducted a retrospective cohort study using data from our local cardiac arrest registry. We included adult patients who obtained a return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA). We excluded patients who did not survive for at least 24 hours post-ROSC and those who had a do not resuscitate (DNR) order within 2 hours of ROSC. We performed an ordinal regression analysis using the proportional odds model to predict neurological outcome (modified rankin score (mRS)). We included a good neurological outcome (mRS 0-2), poor neurological outcome (mRS 3-5), and dead (mRS 6) as an ordinal outcome. We included a number of patient demographics, intra- and post-cardiac arrest factors as covariates in our model. The predictive performance of our model was analyzed using receiver operating characteristic (ROC) curves for discrimination and Brier statistic for calibration. Results: We included 3448 patients in our analysis. We found that an initial shockable rhythm (odds ratio (OR) 4.1; 95% confidence interval (CI) 3.6, 5.4), the absence of pupillary reflexes (OR 3.5; 95% CI 2.4,4.8) and maximum motor score on the Glasgow Coma Scale (GCS) (OR 1.5; 95% CI 1.4,1.6) had the greatest association with improved neurologic outcome. Longer duration of resuscitation was associate with worse outcomes (OR 0.84, 95% CI 0.82,0.87). The overall performance of our model was excellent with an area under the ROC curve of 0.89 and a Brier statistic of 0.13. Conclusion: Our model predicted good neurological outcome with a high rate of accuracy, however external validation of the model is required. This model may be useful in providing initial risk stratification of patients in clinical practice and future research on post-cardiac arrest care.

Novel wearable cooling device for early initiation of targeted temperature management in the Emergency Department

Background: Targeted temperature management (TTM) is an important component of post-cardiac arrest care. Studies have suggested that cooling is associated with better outcomes. The aim of this study was to evaluate the cooling efficacy of a protocol including a novel cooling device in the Emergency Department. Methods: This was a single-center, pre-post cohort study of post-cardiac arrest patients with return of spontaneous circulation (ROSC), for whom TTM was initiated at a tertiary hospital between April 2010 and December 2017. A surface cooling device which uses a graphite cooling material in an insulating suit was introduced in July 2015. The target temperature was 34.0 °C with TTM continued in the ICUs. The primary outcome was time from ROSC to target temperature (TT). Results: Of 124 patients included, 40 were in the intervention period and 84 in the control period. Time from ROSC to TT was significantly lower in the intervention period at 119 [interquartile range (IQR), 65–250] minutes versus 482 (IQR, 356–596) minutes (P Conclusions: Use of a novel cooling device in the ED resulted in a shorter time to target temperature. As it is reusable and does not require a power source, it has potential to be an affordable solution for pre- hospital and transport cooling.

Poor Long-Term Survival of Out-of-Hospital Cardiac Arrest in Children.

The effect of post-cardiac arrest care in children with out-of-hospital cardiac arrest (OHCA) has not been adequately established, and the long-term outcome after pediatric OHCA has not been sufficiently investigated. We describe here detailed in-hospital characteristics, actual management, and survival, including neurological status, 90 days after OHCA occurrence in children with OHCA transported to critical care medical centers (CCMCs).We analyzed the database of the Comprehensive Registry of Intensive Care for OHCA Survival (CRITICAL) study, which is a multicenter, prospective observational data registry designed to accumulate both pre- and in-hospital data on OHCA treatments. We enrolled all consecutive pediatric patients aged <18 years who had an OHCA and for whom resuscitation was attempted and who were transported to CCMCs between 2012 and 2016.A total of 263 pediatric patients with OHCA were enrolled. The average age of the patients was 6.3 years, 38.0% were aged < 1 year, and 60.8% were male. After hospital arrival, 4.9% of these pediatric patients received defibrillation; 1.9%, extracorporeal life support; 6.5%, target temperature management; and 88.2% adrenaline administration. The proportions of patients with 90-day survival and a pediatric cerebral performance category (PCPC) score of 1 or 2 were 6.1% and 1.9%, respectively. The proportion of patients with a PCPC score of 1 or 2 at 90 days after OHCA occurrence did not significantly improve during the study period.The proportion of pediatric patients with a 90-day PCPC score of 1 or 2 transported to CCMCs was extremely low, and no significant improvements were observed during the study period.

The optimal peripheral oxygen saturation may be 95-97% for post-cardiac arrest patients: A retrospective observational study.

Current post-resuscitation guidelines recommend oxygen titration in adults with the return of spontaneous circulation after cardiac arrest. However, the optimal peripheral oxygen saturation (SpO2) is still unclear for post-cardiac arrest care. We conducted a retrospective observational study of prospectively collected data of all cardiac arrest patients admitted to the intensive care units between 2014 and 2015. The main exposure was SpO2, which were interfaced from bedside vital signs monitors as 1-min averages, and archived as 5-min median values. The proportion of time spent in different SpO2 categories was included in separate multivariable regression models along with covariates. The primary outcome measure was hospital mortality and the proportion of discharged home as the secondary outcome was reported. 2836 post-cardiac arrest patients in ICUs of 156 hospitals were included. 1235 (44%) patients died during hospitalization and 818 (29%) patients discharged home. With multivariate regression analysis, the proportion of time spent in SpO2 of ≤89%, 90%, 91%, and 92% were associated with higher hospital mortality. The proportion of time spent in SpO2 of 95%, 96%, and 97% were associated with a higher proportion of discharged home outcome, but not associated with hospital mortality. In this retrospective observational study, the optimal SpO2 for patients admitted to the intensive care unit after cardiac arrest may be 95-97%. Further investigation is warranted to determine if targeting SpO2 of 95-97% would improve patient-centered outcomes after cardiac arrest.

Improvement of consciousness before initiating targeted temperature management

IntroductionFollowing cardiac arrest, return of spontaneous circulation (ROSC) in patients may be followed by spontaneous neurological recovery, which may decrease the potential adverse effects of treatments in post-cardiac arrest care, including those of Targeted Temperature Management (TTM). We investigated the percentage of post-arrest patients who experienced spontaneous neurological recovery, and the characteristics and neurological outcomes of these patients. MethodsA total of 540 patients with ROSC were retrospectively enrolled in this single-center observational study. The patients’ motor responses were documented immediately and at 3 h following ROSC. Predictors of spontaneous neurological recovery were assessed by multiple logistic regression analysis. ResultsA total of 221 patients (41%) showed a change in their GCS (Glasgow Coma Score) M score (motor score) during the 3-h interval following ROSC, with improvement evident in 215 patients. Among 96 patients with GCS M6 at 3 h, 83 (86%) were discharged with a favorable neurological outcome. GCS M6 at 3 h post ROSC, was an independent predictor for a favorable neurological outcome, but GCS M6 at ROSC was not. There were four factors predicting the GCS M6 at 3 h; including in-hospital cardiac arrest (OR 3.057; 95% CI: 1.370–6.824, P = 0.006); bystander CPR (OR 13.311; 95% CI: 6.455–27.447, P < 0.0001); the CPR duration (OR, 0.941; 95% CI: 0.91–0.974; P < 0.0001), and the initial shockable rhythm (OR, 4.41; 95% CI: 2.44–7.95; P < 0.0001). ConclusionsA significant portion of patients had spontaneous neurological recovery to GCS M6 within 3 h post ROSC, and had a favorable neurological outcome. Close monitoring of GCS and later initiation of TTM should be considered in those patients with a substantial likelihood of neurological recovery.

2019 American Heart Association Focused Update on Pediatric Advanced Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

This 2019 focused update to the American Heart Association pediatric advanced life support guidelines follows the 2018 and 2019 systematic reviews performed by the Pediatric Life Support Task Force of the International Liaison Committee on Resuscitation. It aligns with the continuous evidence review process of the International Liaison Committee on Resuscitation, with updates published when the International Liaison Committee on Resuscitation completes a literature review based on new published evidence. This update provides the evidence review and treatment recommendations for advanced airway management in pediatric cardiac arrest, extracorporeal cardiopulmonary resuscitation in pediatric cardiac arrest, and pediatric targeted temperature management during post-cardiac arrest care. The writing group analyzed the systematic reviews and the original research published for each of these topics. For airway management, the writing group concluded that it is reasonable to continue bag-mask ventilation (versus attempting an advanced airway such as endotracheal intubation) in patients with out-of-hospital cardiac arrest. When extracorporeal membrane oxygenation protocols and teams are readily available, extracorporeal cardiopulmonary resuscitation should be considered for patients with cardiac diagnoses and in-hospital cardiac arrest. Finally, it is reasonable to use targeted temperature management of 32°C to 34°C followed by 36°C to 37.5°C, or to use targeted temperature management of 36°C to 37.5°C, for pediatric patients who remain comatose after resuscitation from out-of-hospital cardiac arrest or in-hospital cardiac arrest.

Improving the quality of CPR in the Community

An out of hospital cardiac arrest (OHCA) is defined as cessation of cardiac mechanical activity, confirmed by the absence of signs of circulation and that which occurs outside the hospital setting (Roger VL, 2011) About 70–85% of these events have a cardiac cause. Published literature identifies acute coronary syndrome (ACS) as the most frequent cause of OHCA, particularly among elderly and coronary vasospasm as a considerable cause among young healthy individuals. It can also occur from non-cardiac causes such as trauma, drowning, drug overdose, asphyxia, electrocution and primary respiratory arrests. (Sasson C, Kellermann AL. 2010). Early cardiopulmonary resuscitation (CPR), therapeutic hypothermia and early advanced care have a crucial role in management of OHCA. Every minute lost in initiating CPR leads to 10% decrease in survival rates of the victim (Go AS, Mozaffarian D-2013) since members of the community are the first to witness OHCA, there is an increasing recognition of the need to coordinate with the community in providing emergency medical care to optimize patient survival after an OHCA. American Heart Association (AHA) guidelines for cardiopulmonary resuscitation and emergency cardiovascular care describes a “chain of survival” to reduce mortality and improve survival. The “chain of survival” comprises of five elements, namely, immediate recognition and rapid access, rapid CPR, rapid defibrillation, effective advanced care and integrated post cardiac arrest care. (Travers AH-: 2010)

ACLS protocol for Acute Coronary Syndrome

Background:- The American Heart Association (AHA) and European Resuscitation Council (ERC) developed the most recent ACLS Guidelines in 2010 using the comprehensive review of resuscitation literature performed by the International Liaison Committee on Resuscitation (ILCOR), and these were updated in 2015 and 2018. Acute coronary syndrome (ACS) refers to a spectrum of clinical presentations ranging from those for ST-segment elevation myocardial infarction (STEMI) to presentations found in non– ST-segment elevation myocardial infarction (NSTEMI) or in unstable angina. Aim of the study: impart both cognitive knowledge and psychomotor skills of ACLS to provide a standardized care in cardiac arrest victims by accordance of the specific guidelines. Conclusion: Practitioner’s experts would apply the ACLS protocol for cardiac arrest, and once the patient’s return of spontaneous circulation Restore (ROSC). However, we will start post-cardiac arrest care along with the treatment of ACS algorithm.

Dynamic determination of functional liver capacity with the LiMAx test in post-cardiac arrest patients undergoing targeted temperature management-A prospective trial.

Transiently increased transaminases is a common finding after cardiac arrest but little is known about the functional liver capacity (LiMAx) during the post-cardiac arrest syndrome and treatment in the intensive care unit (ICU). The aim of this trial was to evaluate liver function capacity in post-cardiac arrest survivors undergoing targeted temperature management (TTM) in ICU. Thirty-two post-cardiac arrest survivors were prospectively included with all patients undergoing TTM at 33°C for 24hours. Blood samples were collected, and LiMAx testing was performed at days 1, 2, 5, and 10 post-cardiac arrest. LiMAx is a non-invasive, in vivo, dynamic breath test determining cytochrome P450 1A2 (CYP1A2) capacity using intravenous (IV) 13 C-methacetin, thus reflecting maximum liver function capacity. Static liver parameters were determined and compared to LiMAx values. A typical pattern of transiently, mildly increased transaminases was demonstrated without fulfilling the criteria for hypoxic hepatitis (HH). CYP1A2 activity was reduced with slow normalization over 10days (lowest median 48hours after cardiac arrest: 228.5 (25-75 percentile 105.2-301.7μg/kg/h, P<.05). Parameters reflecting the liver synthetic function were not impaired, as assessed by, in standard laboratory testing. Liver functional capacity is impaired in patients after cardiac arrest undergoing TTM at 33°C. More data are needed to determine if liver functional capacity may add relevant information, especially in the context of pharmacotherapy, to individualize post-cardiac arrest care.

2019 American Heart Association Focused Update on Pediatric Advanced Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

This 2019 focused update to the American Heart Association pediatric advanced life support guidelines follows the 2018 and 2019 systematic reviews performed by the Pediatric Life Support Task Force of the International Liaison Committee on Resuscitation. It aligns with the continuous evidence review process of the International Liaison Committee on Resuscitation, with updates published when the International Liaison Committee on Resuscitation completes a literature review based on new published evidence. This update provides the evidence review and treatment recommendations for advanced airway management in pediatric cardiac arrest, extracorporeal cardiopulmonary resuscitation in pediatric cardiac arrest, and pediatric targeted temperature management during post-cardiac arrest care. The writing group analyzed the systematic reviews and the original research published for each of these topics. For airway management, the writing group concluded that it is reasonable to continue bag-mask ventilation (versus attempting an advanced airway such as endotracheal intubation) in patients with out-of-hospital cardiac arrest. When extracorporeal membrane oxygenation protocols and teams are readily available, extracorporeal cardiopulmonary resuscitation should be considered for patients with cardiac diagnoses and in-hospital cardiac arrest. Finally, it is reasonable to use targeted temperature management of 32°C to 34°C followed by 36°C to 37.5°C, or to use targeted temperature management of 36°C to 37.5°C, for pediatric patients who remain comatose after resuscitation from out-of-hospital cardiac arrest or in-hospital cardiac arrest.

Abstract 336: A Machine Learning Algorithm for Detecting Pulse During Out-Of-Hospital Cardiac Arrest

Introduction: Pulse detection during out-of-hospital cardiac arrest (OHCA) is a challenge still not satisfactorily solved. An automated and accurate method for detecting pulse would reduce hands-off intervals and allow for more prompt post-cardiac arrest care. The aim of this study was to develop a method based on machine learning (ML) to detect pulse during OHCA. Materials and methods: Data were gathered from 187 OHCA patients treated by Tualatin Valley Fire &amp; Rescue (Tigard, OR, USA) using the Philips HeartStart MRx monitor/defibrillator between 2010 and 2014. The dataset used in the study contained 1140 5-s epochs presenting organized rhythms, 792 pulse-generating rhythms (PRs) and 348 pulseless electrical activity (PEA), annotated by consensus between two clinicians and a biomedical engineer using the available clinical information and the capnography signal. The dataset was split patient-wise into training (60%) and test (40%) sets. Each epoch contained the ECG and the thoracic impedance that were first preprocessed and then used to adaptively extract the impedance circulation component (ICC). The ICC shows a small fluctuation with each effective heartbeat. A total of 7 well-known waveform features were computed from the ECG and ICC and fed as observations to a discrete observation density hidden Markov model that classified each observation as PR (pulse) or PEA (no-pulse). The training set was used to develop and optimize the method, while the test set was used to measure the performance in terms of sensitivity (PR detection) and specificity (PEA detection). This procedure was repeated 50 times to estimate the distributions of the performance metrics. Results: The method showed a mean (SD) sensitivity and specificity of 95.4%(2.2) and 91.6% (3.4), respectively. Results were slightly above those previously reported by other authors using different ML techniques. Conclusions: A method based on a discrete observation density hidden Markov model can accurately detect pulse during OHCA. Further studies with larger datasets are needed to confirm these findings.

Abstract 418: Categorization of Post-Cardiac Arrest Patients According to the Pattern of Amplitude-Integrated Electroencephalography After Return of Spontaneous Circulation: Analysis of Long-Term Prognosis

Introduction: Amplitude-integrated electroencephalography (aEEG) is a type of quantitative EEG easily interpreted by emergency physicians and intensivists at the bedside. We previously reported that categorizing post-cardiac arrest patients according to the pattern of aEEG, after return of spontaneous circulation (ROSC), could help predict the neurological function at hospital discharge (Critical Care. 2018;20:226). In post-cardiac arrest patients, increasing importance is being placed on long-term prognosis. In this study we evaluated the neurological outcome of patients in each category from our previous study, one year after cardiac arrest. Methods: We assessed the outcomes of patients who received post-cardiac arrest care, including targeted temperature management (TTM) and aEEG monitoring, in our tertiary emergency center, between March 2013 and April 2017. The patients were divided into four categories: C1 included those who displayed continuous normal voltage (CNV), within 12 hours of ROSC, and the best aEEG pattern in post-cardiac arrest patients; C2 included those who recovered CNV between 12 and 36 hours after ROSC; C3 included those with no CNV up to 36 hours after ROSC; and C4 included those who revealed burst suppression any time after ROSC. A good outcome was defined as a cerebral performance category (CPC) of 1 or 2, one year after cardiac arrest. Results: A total of 60 patients, with a median age of 60 years, were assessed; of them, 41 (68%) had an initial shockable rhythm. A good outcome was recorded in 18/19 (95%) C1 patients, 8/14 (57%) C2 patients, 1/10 (10%) C3 patients, and 0/14 C4 patients. Three patients could not be categorized because the recording period was too short. Conclusion: The categorization of post-cardiac arrest patients according to the pattern of aEEG after ROSC may be useful to predict long-term neurological function. C1 patients had excellent prognosis, while C3 and C4 patients had poor prognosis. However, one patient in the C3 group had CPC 3 at hospital discharge and then recovered to CPC 2 within one year. Withdrawal of care should be considered cautiously, using a multimodal approach, for patients in this category. C2 patients have borderline prognosis and are targets for intensive post-cardiac neurological care.

2019 American Heart Association Focused Update on Advanced Cardiovascular Life Support: Use of Advanced Airways, Vasopressors, and Extracorporeal Cardiopulmonary Resuscitation During Cardiac Arrest: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

The fundamentals of cardiac resuscitation include the immediate provision of high-quality cardiopulmonary resuscitation combined with rapid defibrillation (as appropriate). These mainstays of therapy set the groundwork for other possible interventions such as medications, advanced airways, extracorporeal cardiopulmonary resuscitation, and post-cardiac arrest care, including targeted temperature management, cardiorespiratory support, and percutaneous coronary intervention. Since 2015, an increased number of studies have been published evaluating some of these interventions, requiring a reassessment of their use and impact on survival from cardiac arrest. This 2019 focused update to the American Heart Association advanced cardiovascular life support guidelines summarizes the most recent published evidence for and recommendations on the use of advanced airways, vasopressors, and extracorporeal cardiopulmonary resuscitation during cardiac arrest. It includes revised recommendations for all 3 areas, including the choice of advanced airway devices and strategies during cardiac arrest (eg, bag-mask ventilation, supraglottic airway, or endotracheal intubation), the training and retraining required, the administration of standard-dose epinephrine, and the decisions involved in the application of extracorporeal cardiopulmonary resuscitation and its potential impact on cardiac arrest survival.

A BUNDLE IN THE HEART: WOLFF-PARKINSON-WHITE SYNDROME PRESENTING AS CARDIAC ARREST

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Ventricular fibrillation (VF) is a rare complication of Wolff-Parkinson-White (WPW) Syndrome. We present a case of WPW presenting as VF arrest. CASE PRESENTATION: A 21-year-old man with no past medical history was brought to emergency department after he experienced an out of hospital VF cardiac arrest after having a cold slushy. Post arrest electrocardiogram revealed atrial fibrillation with rapid ventricular rate. Patient achieved return of spontaneous circulation after 30 minutes of advanced cardiac life support. Patient was admitted to Intensive Care Unit for post cardiac arrest care which included targeted temperature management. During his hospitalization, elevated troponin and EKG changes in the inferior leads (II, III and aVF) prompted left heart catheterization. No evidence of coronary artery disease was found. Patient was successfully extubated with good neurological status after rewarming. On review of EKG patient was noted to have shortened PR interval and delta waves in the setting of normal sinus rhythm, thus fulfilling the criteria for WPW syndrome. The morphology of delta waves in the inferior leads was noted to be of pseudo-Q waves. Electrophysiology was consulted and patient underwent successful ablation of the left posterolateral accessory pathway. It was hypothesized that he had an acute vasovagal episode in response to the cold slushy which lead to conduction of atrial fibrillation through accessory pathway into ventricular fibrillation. EKG (figure 1) showing pseudo Q waves in leads II, III and aVF which represent Delta waves. Pathognomic Delta waves seen in precordial leads. DISCUSSION: WPW is a pre-excitation syndrome involving an accessory pathway called bundle of kent. AV nodal blockade in the setting of atrial fibrillation in patients with WPW syndrome leads to pre-excitation of ventricles which can induce ventricular arrythmias. Therefore drugs or conditions leading to AV nodal blockade should be avoided in patients with WPW syndrome as ventricular arrythmias are associated with high morbidity and mortality. CONCLUSIONS: VF accounts for many sudden cardiac deaths (SCD) in WPW syndrome. SCD is more common in patients symptomatic with WPW. AV nodal blockade should be avoided in patients with WPW syndrome. Guidelines and treatment strategies need to be established to screen patients for WPW syndrome. Reference #1: Centurion OA. Atrial Fibrillation in the Wolff-Parkinson-White Syndrome. J Atr Fibrillation. 2011;4(1):287. Published 2011 May 4. https://doi.org/10.4022/jafib.287 DISCLOSURES: No relevant relationships by Anandbir Bath, source=Web Response No relevant relationships by Syed Sami Haider, source=Web Response

Prognostic Factors for Re-Arrest with Shockable Rhythm during Target Temperature Management in Out-Of-Hospital Shockable Cardiac Arrest Patients

Re-arrest during post-cardiac arrest care after the return of spontaneous circulation is not uncommon. However, little is known about the risk factors associated with re-arrest. A previous study failed to show a benefit of prophylactic antiarrhythmic drug infusion in all kinds of out-of-hospital cardiac arrest (OHCA) survivors. This study evaluated high-risk OHCA survivors who may have re-arrest with shockable rhythm during targeted temperature management (TTM). Medical records of consecutive OHCA survivors treated with TTM at four tertiary referral university hospitals in the Republic of Korea between January 2010 and December 2016 were retrospectively reviewed. Patients who did not have any shockable rhythm during cardiopulmonary resuscitation (CPR) or unknown initial rhythm were excluded. The primary outcome of interest was the recurrence of shockable cardiac arrest during TTM. There were 289 cases of initial shockable arrest rhythm and 132 cases of shockable rhythm during CPR. Of the 421 included patients, 11.4% of patients had a shockable re-arrest during TTM. Survival to discharge and good neurologic outcomes did not differ between non-shockable and shockable re-arrest patients (78.3% vs. 72.9%, p = 0.401; 53.1% vs. 54.2% p = 0.887). Initial serum magnesium level, ST segment depression or ventricular premature complex (VPC) in initial electrocardiography (ECG), prophylactic amiodarone infusion, and dopamine and norepinephrine infusion during TTM were significantly higher and more frequent in the shockable re-arrest group (all p values < 0.05). Normal ST and T wave in initial ECG was common in the non-shockable re-arrest group (p = 0.038). However, in multivariate logistic regression analysis, only VPC was an independent prognostic factor for shockable re-arrest (OR 2.806 (95% CI 1.276–6.171), p = 0.010). Initial VPC may be a prognostic risk factor for shockable re-arrest in OHCA survivors with shockable rhythm.

Management of post-cardiac arrest syndrome.

Post-cardiac arrest syndrome is a complex and critical issue in resuscitated patients undergone cardiac arrest. Ischemic-reperfusion injury occurs in multiple organs due to the return of spontaneous circulation. Bundle of management practicies are required for post-cardiac arrest care. Early invasive coronary angiography should be considered to identify and treat coronary artery obstructive disease. Vasopressors such as norepinephrine and dobutamine are the first-line treatment for shock. Maintainance of oxyhemoglobin saturation greater than 94% but less than 100% is recommended to avoid fatality. Target temperature therapeutic hypothermia helps to resuscitated patients. Strict temperature control is required and is maintained with the help of cooling devices and monitoring the core temperature. Montorings include electrocardiogram, oxymetry, capnography, and electroencephalography (EEG) along with blood pressue, temprature, and vital signs. Seizure should be treated if EEG shows evidence of seizure or epileptiform activity. Clinical neurologic examination and magnetic resonance imaging are considered to predict neurological outcome. Glycemic control and metabolic management are favorable for a good neurological outcome. Recovery from acute kidney injury is essential for survival and a good neurological outcome.

Early whole-body CT for treatment guidance in patients with return of spontaneous circulation after cardiac arrest.

Non-traumatic cardiac arrest (CA) and return of spontaneous circulation (ROSC) after cardiopulmonary resuscitation (CPR) are often associated with multiple pathologies. Expecting a high prevalence of important findings, a whole-body CT (WBCT) could be of relevance for therapy. The aim of this study is to investigate the feasibility and diagnostic yield of an early WBCT in this setting. This single-center retrospective study included 100 consecutive patients (27 female; 73 male; mean age 68.5± 12.57years) with non-traumatic, in- and out-of-hospital CA and ROSC following CPR, who underwent a contrast-enhanced WBCT within 6h after ROSC over 12months. CT findings were determined corresponding to anatomical region. Early WBCT was successfully carried out in 100% of the patients with CA and ROSC after CPR. Acute pathologies were found not only in the chest but also in the head (15%) and the abdomen (6%). Early global brain edema (n = 12), acute stroke (n = 3), pulmonary embolism (n = 10), pneumothorax (26%), acute abdominal pathologies (n = 6), iatrogenic bleeding (4%), and CPR-related injuries (93%) were detected by CT right from the beginning of the post-cardiac arrest care. An early WBCT is feasible and provides added diagnostic value for patients with ROSC after non-traumatic CA.