Resuscitation Characteristics Research Articles

Clinical characteristics of extracorporeal cardiopulmonary resuscitation in China: a multicenter retrospective study

PurposeExtracorporeal cardiopulmonary resuscitation (ECPR) might markedly increase the survival of selected patients with refractory cardiac arrest. But the application situation and indications remained unclear.Materials and methodsWe respectively reviwed all adult patients who underwent ECPR from January 2017 to March 2021. Patient characteristics, initiation and management of ECMO, complications, and outcomes were collected and compared between the survivors and nonsurvivors. LASSO regression was used to screen risk factors. Multivariate logistic regression was performed with several parameters screened by LASSO regression.ResultsData were reported from 42 ECMO centers covering 19 provinces of China. A total of 648 patients were included in the study, including 491 (75.8%) males. There were 11 ECPR centers in 2017, and the number increased to 42 in 2020. The number of patients received ECPR increased from 33 in 2017 to 274 in 2020, and the survival rate increased from 24.2% to 33.6%. Neurological complications, renal replacement therapy, epinephrine dosage after ECMO, recovery of spontaneous circulation before ECMO, lactate clearance and shockable rhythm were risk factors independently associated with outcomes of whole process. Sex, recovery of spontaneous circulation before ECMO, lactate, shockable rhythm and causes of arrest were pre-ECMO risk factors independently affecting outcomes.ConclusionsFrom January 2017 to March 2021, the numbers of ECPR centers and cases in mainland China increased gradually over time, as well as the survival rate. Pre-ECMO risk factors, especially recovery of spontaneous circulation before ECMO, shockable rhythm and lactate, are as important as post-ECMO management,. Neurological complications are vital risk factors after ECMO that deserved close attention.Trial registrationNCT04158479, registered on 2019/11/08. https://clinicaltrials.gov/NCT04158479

Underlying reasons for sex difference in survival following out-of-hospital cardiac arrest: a mediation analysis.

Previous studies have indicated a poorer survival among women following out-of-hospital cardiac arrest (OHCA), but the mechanisms explaining this difference remain largely uncertain.This study aimed to assess the survival after OHCA among women and men and explore the role of potential mediators, such as resuscitation characteristics, prior comorbidity, and socioeconomic factors. This was a population-based cohort study including emergency medical service-treated OHCA reported to the Swedish Registry for Cardiopulmonary Resuscitation in 2010-2020, linked to nationwide Swedish healthcare registries. The relative risks (RR) of 30-day survival were compared among women and men, and a mediation analysis was performed to investigate the importance of potential mediators. Total of 43 226 OHCAs were included, of which 14 249 (33.0%) were women. Women were older and had a lower proportion of shockable initial rhythm. The crude 30-day survival among women was 6.2% compared to 10.7% for men [RR 0.58, 95% confidence interval (CI) = 0.54-0.62]. Stepwise adjustment for shockable initial rhythm attenuated the association to RR 0.85 (95% CI = 0.79-0.91). Further adjustments for age and resuscitation factors attenuated the survival difference to null (RR 0.98; 95% CI = 0.92-1.05). Mediation analysis showed that shockable initial rhythm explained ∼50% of the negative association of female sex on survival. Older age and lower disposable income were the second and third most important variables, respectively. Women have a lower crude 30-day survival following OHCA compared to men. The poor prognosis is largely explained by a lower proportion of shockable initial rhythm, older age at presentation, and lower income.

Early GFAP and UCH-L1 point-of-care biomarker measurements for the prediction of traumatic brain injury and progression in patients with polytrauma and hemorrhagic shock

OBJECTIVE Traumatic brain injury (TBI) and hemorrhage are responsible for the largest proportion of all trauma-related deaths. In polytrauma patients at risk of hemorrhage and TBI, the diagnosis, prognosis, and management of TBI remain poorly characterized. The authors sought to characterize the predictive capabilities of glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase L1 (UCH-L1) measurements in patients with hemorrhagic shock with and without concomitant TBI. METHODS The authors performed a secondary analysis on serial blood samples derived from a prospective observational cohort study that focused on comparing early whole-blood and component resuscitation. A convenience sample of patients was used in which samples were collected at three time points and the presence of TBI or no TBI via CT imaging was documented. GFAP and UCH-L1 measurements were performed on plasma samples using the i-STAT Alinity point-of-care platform. Using classification tree recursive partitioning, the authors determined the measurement cut points for each biomarker to maximize the abilities for predicting the diagnosis of TBI, Rotterdam CT imaging scores, and 6-month Glasgow Outcome Scale–Extended (GOSE) scores. RESULTS Biomarker comparisons demonstrated that GFAP and UCH-L1 measurements were associated with the presence of TBI at all time points. Classification tree analyses demonstrated that a GFAP level > 286 pg/ml for the sample taken upon the patient’s arrival had an area under the receiver operating characteristic curve of 0.77 for predicting the presence of TBI. The classification tree results demonstrated that a cut point of 3094 pg/ml for the arrival GFAP measurement was the most predictive for an elevated Rotterdam score on the initial and second CT scans and for TBI progression between scans. No significant associations between any of the most predictive cut points for UCH-L1 and Rotterdam CT scores or TBI progression were found. The predictive capabilities of UCH-L1 were limited by the range allowed by the point-of-care platform. Arrival GFAP cut points remained strong independent predictors after controlling for all potential polytrauma confounders, including injury characteristics, shock severity, and resuscitation. CONCLUSIONS Early measurements of GFAP and UCH-L1 on a point-of-care device are significantly associated with CT-diagnosed TBI in patients with polytrauma and shock. Early elevated GFAP measurements are associated with worse head CT scan Rotterdam scores, TBI progression, and worse GOSE scores, and these associations are independent of other injury attributes, shock severity, and early resuscitation characteristics.

Unveiling the distribution characteristics of rpf-like genes and indigenous resuscitation promoting factor production in PCB-contaminated soils

Resuscitation promoting factors (Rpfs), known for their anti-dormancy cytokine properties, have been extensively investigated in the medical field. Although the Rpf from Micrococcus luteus has been successfully utilized to resuscitate and stimulate microbial populations for the degradation of polychlorinated biphenyls (PCBs), the presence of indigenous Rpf homologs in PCB-contaminated soils has not been established. In this study, the distribution characteristics of rpf-like genes and indigenous strain capable of producing Rpf in PCB-contaminated soils were explored. The results revealed the widespread presence of Rpf-like domains and their associated genes, particularly in close association with heavy metals and PCBs. The rpf-like genes were predominantly found in Proteobacteria and displayed a positive correlation with genes involved in PCB degradation and viable but non-culturable (VBNC) formation. Notably, the recombinant Rpf-Ac protein derived from the indigenous strain Achromobacter sp. HR2 exhibited muralytic activity and demonstrated significant efficacy in resuscitating the growth of VBNC cells, while also stimulating the growth of normal cells. These findings shed light on the prevalent presence of Rpf homologs in PCB-contaminated soils and their potential to resuscitate functional populations in the VBNC state, thereby enhancing in situ bioremediation.

Prognostic value of arterial carbon dioxide tension during cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients receiving extracorporeal resuscitation

BackgroundCurrent guidelines on extracorporeal cardiopulmonary resuscitation (ECPR) recommend careful patient selection, but precise criteria are lacking. Arterial carbon dioxide tension (PaCO2) has prognostic value in out-of-hospital cardiac arrest (OHCA) patients but has been less studied in patients receiving ECPR. We studied the relationship between PaCO2 during cardiopulmonary resuscitation (CPR) and neurological outcomes of OHCA patients receiving ECPR and tested whether PaCO2 could help ECPR selection.MethodsThis single-centre retrospective study enrolled 152 OHCA patients who received ECPR between January 2012 and December 2020. Favorable neurological outcome (FO) at discharge was the primary outcome. We used multivariable logistic regression to determine the independent variables for FO and generalised additive model (GAM) to determine the relationship between PaCO2 and FO. Subgroup analyses were performed to test discriminative ability of PaCO2 in subgroups of OHCA patients.ResultsMultivariable logistic regression showed that PaCO2 was independently associated with FO after adjusting for other favorable resuscitation characteristics (Odds ratio [OR] 0.23, 95% Confidence Interval [CI] 0.08–0.66, p-value = 0.006). GAM showed a near-linear reverse relationship between PaCO2 and FO. PaCO2 < 70 mmHg was the cutoff point for predicting FO. PaCO2 also had prognostic value in patients with less favorable characteristics, including non-shockable rhythm (OR, 3.78) or low flow time > 60 min (OR, 4.66).ConclusionPaCO2 before ECMO implementation had prognostic value for neurological outcomes in OHCA patients. Patients with PaCO2 < 70 mmHg had higher possibility of FO, even in those with non-shockable rhythm or longer low-flow duration. PaCO2 could serve as an ECPR selection criterion.

Epidemiology and outcomes of pediatric cardiac arrest in a cardiovascular unit at a public hospital in Argentina.

Children with congenital heart disease present a higher frequency of cardiorespiratory arrest (CRA) than the general pediatric population. The epidemiology of CRA is not exactly known in our setting, nor are the mortality risk or the neurological evolution factors. To describe the epidemiology and outcomes associated with pediatric cardiopulmonary resuscitation in a cardiovascular recovery unit. The primary endpoint was the survival to discharge and the secondary endpoints were the return to spontaneous circulation, the survival at 24 hours and the remote neurological condition. Descriptive, prospective, longitudinal cohort study in children under 18 years of age who required cardiopulmonary resuscitation between 2016 and 2019. Demographic variables, characteristics of cardiopulmonary arrest, resuscitation and outcome were analyzed. An uni- and multivariate analysis was performed comparing survivors and deceased. Out of 1,842 hospitalized patients, 4.1% presented CRA. Fifty patients with complete records were analyzed. Seventy-eight percent (39) returned to spontaneous circulation with a high survival rate of 46%. Resuscitation > 6 min and the use of vasoactive drugs were predictors of mortality; 16/23 patients were followed up, 10 of them with normal development for age at 6 months, six had pervasive developmental disorder. 4.1% of patients presented CRA, with a rate of 3.4 CRA per 1,000 patient-days. Survival at hospital discharge (n = 50) was 46%. Resuscitation > 6 min and the use of vasoactive drugs were independent predictors of mortality. At six months, 63% had normal neurological development for age.

BRAIN RESUSCITATION IN SEVERE HEAD INJURY AT SANGLAH CENTRAL GENERAL HOSPITAL DENPASAR 2020

ABSTRACT&#x0D; &#x0D; Head injury is a serious problem worldwide and causes morbidity and mortality at a young age. The increase in the number of severe head injuries continues to occur along with the number of accidents. This study aimed to examine the characteristics of brain resuscitation in patients with a severe head injury. Descriptive research with cross-sectional research method and the data obtained as many as 35. Data processing using SPSS and displayed in a distribution table according to the variables. This study found that patients with severe head injuries were most often at the age of &gt;45 years, namely 18 people (51.4%), and male sex was more common than women as many as 24 people (68.6%). The most common GCS was found with GCS 3-5 as many as 21 people (60%). The brain resuscitation regimen in patients with a severe head injury was given crystalloid solution (0.9% NaCl, Ringer's lactate) in 35 people (100%), mannitol 20% in 22 people (62.9%), and phenytoin in 33 people (94.3%). The GOS value of all patients with severe head injury with a GOS value of 1 or died (100%). Most deaths from severe head injury patients were in the first &lt;48 hours as many as 27 people (77.1%)&#x0D; Keywords : brain resuscitation, traumatic brain injury, severe head injury.

Sex Differences in Out-of-Hospital Cardiac Arrest Survival Trends.

Out-of-hospital cardiac arrest survival rates have improved over time. This study established whether improvements were similar for women and men, and to what extent resuscitation characteristics or in-hospital procedures contributed to sex differences in temporal trends. This retrospective cohort study included 3386 women and 8564 men from North Holland, the Netherlands, who experienced an out-of-hospital cardiac arrest from a cardiac cause in 2005 to 2017. Yearly rates of 30-day survival and secondary outcomes were calculated. Sex differences in temporal trends were evaluated with age-adjusted Poisson regression analysis, including interaction for sex and out-of-hospital cardiac arrest year. Resuscitation characteristics and in-hospital procedures were added to the model, and a spline at 2013 was considered. During the study period, the average 30-day survival was 24.9% in men and 15.7% in women. The 30-day survival rate increased in men (20% to 27.2%; P<0.001) but not in women (15.0% to 11.6%; P=0.40). The increase in the 30-day survival rate was 3% higher per year in men than in women (rate ratio, 1.03 [95% CI, 1.00-1.05]), with a stronger difference after 2013. Men had a larger increase in survival rate to the hospital arrival than women in 2005 to 2013, and, after 2013, an advantage over women in survival rate after hospital arrival. The sex differences were partly explained by differing trends in shockable initial rhythm (eg, adjusted rate ratio, 1.01 [95% CI, 0.99-1.03] for 30-day survival) and provision of in-hospital procedures. Changes in rates of 30-day survival, survival to hospital arrival, and, after 2013, survival from hospital arrival to 30 days were more beneficial in men than women. The differences in trends were partly explained by shockable initial rhythm and in-hospital procedures.

Exploring underlying reasons for the difference in sex-specific survival following out-of-hospital cardiac arrest - a mediation analysis

Abstract Background Previous studies have indicated a poorer survival among women following out-of-hospital cardiac arrest (OHCA), but the mechanisms explaining this difference remains largely uncertain. This study aimed to assess the survival after OHCA among women men and explore the role of potential mediators, such as resuscitation characteristics, prior comorbidity, and socioeconomic factors. Methods This was a population-based cohort study including all emergency medical service-treated OHCA reported to the Swedish Registry for Cardiopulmonary Resuscitation in 2010-2020, linked to nationwide Swedish healthcare registries. The relative risks (RR) of 30-day survival were compared among women (exposure) and men (comparison) using modified Poisson regression and third variable effect analysis to investigate the importance of potential mediators in a stepwise approach. Results A total of 43,226 OHCAs were included, of which 14,249 (33.0%) were women. The crude 30-day survival among women was 6.2% compared to 10.6% for men (RR 0.58, 95% CI=0.54-0.62). Stepwise adjustment for shockable initial rhythm attenuated the association to RR 0.85 (95% CI=0.80-0.92), and further adjustments for age and resuscitation factors (witness status, emergency medical service response time, and location) attenuated the survival difference between sexes to null (RR 0.98; 95% CI=0.92-1.05). Third variable effect analysis showed that shockable initial rhythm explained approximately 50% of the negative association of female sex on survival. Older age and lower disposable income were the second and third most important variables. Previously known comorbidities explained only a very small portion of the sex difference in survival. Conclusion Women have a lower 30-day survival following OHCA compared to men. The poor prognosis is largely explained by the absence of shockable initial rhythm, older age at presentation and lower disposable income.Results from regression analyses

416 Prediction of Long-Term Survival after Out-of-Hospital Cardiac Arrest using Disease, Social, and Resuscitation Characteristics in Denmark and the Netherlands

416 Prediction of Long-Term Survival after Out-of-Hospital Cardiac Arrest using Disease, Social, and Resuscitation Characteristics in Denmark and the Netherlands

Survival bias in pediatric hemorrhagic shock: Are we misrepresenting the data?

Studies of hemorrhage following pediatric injury often use the occurrence of transfusion as a surrogate definition for the clinical need for a transfusion. Using this approach, patients who are bleeding but die before receiving a transfusion are misclassified as not needing a transfusion. In this study, we aimed to evaluate the potential for this survival bias and to estimate its presence among a retrospective observational cohort of children and adolescents who died from injury. We obtained patient, injury, and resuscitation characteristics from the 2017 to 2020 Trauma Quality Improvement Program database of children and adolescents (younger than 18 years) who arrived with or without signs of life and died. We performed univariate analysis and a multivariable logistic regression to analyze the association between the time to death and the occurrence of transfusion within 4 hours after hospital arrival controlling for initial vital signs, injury type, body regions injured, and scene versus transfer status. We included 6,063 children who died from either a blunt or penetrating injury. We observed that children who died within 15 minutes had lower odds of receiving a transfusion (odds ratio, 0.1; 95% confidence interval, 0.1-0.2) compared with those who survived longer. We estimated that survival bias that occurs when using transfusion administration alone to define hemorrhagic shock may occur in up to 11% of all children who died following a blunt or penetrating injury but less than 1% of all children managed as trauma activations. Using the occurrence of transfusion alone may underestimate the number of children who die from uncontrolled hemorrhage early after injury. Additional variables than just transfusion administration are needed to more accurately identify the presence of hemorrhagic shock among injured children and adolescents. Prognostic and Epidemiological; Level III.

Should surgeon-performed intraoperative ultrasound be the preferred test for detecting main pancreatic duct injuries in operative trauma cases?

The diagnostic performance of multiple tests for detecting the presence of a main pancreatic duct injury remains poor. Given the central importance of main duct integrity for both subsequent treatment algorithms and patient outcomes, poor test reliability is problematic. The primary aim was to evaluate the comparative test performance of computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and intraoperative ultrasound (IOUS) for detecting main pancreatic duct injuries. All severely injured adult patients with pancreatic trauma (2010-2021) were evaluated. Patients who received an IOUS pancreas-focused evaluation, with Grades III, IV, and V injuries (main duct injury) were compared with those with Grade I and Grade II trauma (no main duct injury). Test performances were analyzed. Of 248 pancreatic injuries, 74 underwent an IOUS. The additional mix of diagnostic studies (CT, MRCP, ERCP) was variable across grade of injury. Of these 74 IOUS cases for pancreatic injuries, 48 (64.8%) were confirmed as Grades III, IV, or V main duct injuries. The patients were predominantly young (median age = 33, IQR:21-45) blunt injured (70%) males (74%) with severe injury demographics (injury severity score = 28, (IQR:19-36); 30% hemodynamic instability; 91% synchronous intra-abdominal injuries). Thirty-five percent of patients required damage-control surgery. Patient outcomes included a median 13-day hospital length of stay and 1% mortality rate. Test performance was variable across groups (CT = 58% sensitive/77% specific; MRCP = 71% sensitive/100% specific; ERCP = 100% sensitive; IOUS = 98% sensitive/100% specific). Intraoperative ultrasound is a highly sensitive and specific test for detecting main pancreatic duct injuries. This technology is simple to learn, readily available, and should be considered in patients who require concurrent non-damage-control abdominal operations. Diagnostic Test/Criteria; Level III.

Characteristics and resuscitation effects of out-of-hospital sudden death: a study based on Internet data

To collect the Internet news about "sudden death", analyze its characteristics and resuscitation effects, so as to provide reference for formulating intervention strategies. The Internet was used to search for "sudden death" and "cardiac arrest" on "Baidu" and "360" websites. Reports of sudden death events were collected from January 2013 to December 2022. The age, gender, characteristics of sudden death, implementation characteristics of cardiopulmonary resuscitation (CPR), and pre-hospital and final clinical outcomes of sudden death patients were recorded and analyzed. Subgroup analyses were performed for pre-hospital and final clinical outcomes. Unconditional multivariate Logistic regression analysis was used to screen the related factors affecting the pre-hospital and final clinical outcomes in patients with sudden death. 177 news reports were finally confirmed, involving 177 sudden death patients, including 152 males (85.9%) and 25 females (14.1%), aged (37.27±16.82) years old, and 53.1% in the 16-45 years old group. Triggering factors included strenuous exercise (29.9%), heart disease history (7.9%), overwork (6.2%), staying up late and insomnia (4.0%), activation of emotion (2.8%), and no obvious inducement (48.0%). After on-site first aid, 104 cases (58.8%) achieved restoration of spontaneous circulation (ROSC) before hospital admission, and 18 cases (10.2%) recovered consciousness. After clinical treatment, 109 cases (61.6%) achieved ROSC, 86 cases (48.6%) recovered consciousness, and 22 cases (12.4%) did not report the final outcome. Subgroup analysis showed that compared with patients who achieved pre-hospital ROSC (n = 104), sudden death in non-ROSC patients (n = 73) mainly occurred during sleep, in residence and without immediate CPR, full CPR, or automated external defibrillator (AED); and patients who ultimately did not recover consciousness clinically (n = 91) showed similar characteristics compared with patients who recovered consciousness (n = 86). Multifactorial Logistic regression analysis showed that immediate CPR [pre-hospital ROSC: odds ratio (OR) = 8.06, 95% confidence interval (95%CI) was 2.36-27.46; final recovery of consciousness: OR = 9.10, 95%CI was 2.46-33.68] and AED defibrillation (pre-hospital ROSC: OR = 36.31, 95%CI was 4.53-291.19; final recovery of consciousness: OR = 3.53, 95%CI was 1.45-8.61) facilitated pre-hospital achievement of sudden death patients ROSC and final recovery of consciousness. Out-of-hospital sudden death mainly occurs in young people, and vigorous exercise is one of the potential factors for out-of-hospital sudden death, with nearly half having no obvious cause. Immediate and rapid CPR and defibrillation are the simplest and most effective on-site first aid methods. Strengthening public CPR and defibrillation education and training, and advocating healthy lifestyle are effective ways to improve the survival rate of sudden death and reduce the occurrence of sudden death. Based on practical clinical rescue experience, the implementation of bystander CPR by medical personnel is also a factor that cannot be ignored in affecting the clinical outcomes of sudden death patients.

Plasma Thrombin Generation Kinetics Vary by Injury Pattern and Resuscitation Characteristics in Pediatric and Young Adult Trauma Patients.

Thrombin generation kinetics are not well studied in children. This study aimed to assess how thrombin generation kinetics vary in pediatric and young adult (YA) trauma patients by clinical characteristics and injury pattern. Prospective cohort study where plasma samples were obtained from pediatric (ages 0-17) and YA (ages 18-21) trauma patients upon Emergency Department arrival. Thrombin generation (Calibrated Automated Thrombogram, CAT) was quantified as lag time (LT, minutes), peak height (PH, nM), time to peak (ttPeak, minutes), and endogenous thrombin potential (ETP, nm*minute). Results are expressed as median and quartiles [Q1, Q3] and compared using Wilcoxon rank sum testing with p < 0.05 considered significant. We enrolled 47 pediatric (median age 15 [14, 17] years, 78% male, 87% blunt, median ISS 12) and 49 YA (median age 20 [18, 21] years, 67% male, 84% blunt, median ISS 12) patients. Pediatric and YA patients had similar rates of operative intervention (51% vs. 57%), transfusion (25% vs. 20%), and TBI (53% vs. 49%). Pediatric patients who required an operation had accelerated initiation of thrombin generation, with shorter LT than those who did not (2.58 [2.33, 2.67]; 2.92 [2.54, 3.00], p = 0.034). Shorter LT (2.41 [2.22, 2.67]; 2.67 [2.53, 3.00]) and ttPeak (4.50 [4.23, 4.73]; 5.22 [4.69, 5.75], both p < 0.01) were noted in pediatric patients who required transfusion as compared to those who did not. YA patients requiring transfusion had shorter LT (2.33 [2.19, 2.74]; 2.83 [2.67, 3.27]) and ttPeak (4.48 [4.33, 5.65]; 5.33 [4.85, 6.28] both p < 0.04) than those who were not transfused. YAs with traumatic brain injury had greater ETP than those without (1509 [1356, 1671]; 1284 [1154, 1471], p = 0.032). Thrombin generation kinetics in pediatric trauma patients prior to intervention vary with need for operation and transfusion, while thrombin generation kinetics in young adult patients are influenced by TBI and need for operation or transfusion. This is a promising tool for assessing coagulopathy in young trauma patients. Level IV, Prognostic/epidemiological.

Termination of resuscitation in out-of-hospital cardiac arrest in women and men: An ESCAPE-NET project

AimWomen have less favorable resuscitation characteristics than men. We investigated whether the Advanced Life Support Termination of Resuscitation rule (ALS-TOR) performs equally in women and men. Additionally, we studied whether adding or removing criteria from the ALS-TOR improved classification into survivors and non-survivors. MethodsWe analyzed 6,931 female and 14,548 male out-of-hospital cardiac arrest (OHCA) patients from Dutch and Swedish registries, and validated in 10,772 female and 21,808 male Danish OHCA patients. Performance measures were calculated for ALS-TOR in relation to 30-day survival. Recursive partitioning analysis was performed with the ALS-TOR criteria, as well as age, comorbidities, and additional resuscitation characteristics (e.g. initial rhythm, OHCA location). Finally, we explored if we could reduce the number of ALS-TOR criteria without loss of prognostic value. ResultsThe ALS-TOR had a specificity and positive predictive value (PPV) of ≥99% in both women and men (e.g. PPV 99.9 in men). Classification by recursive partitioning analysis showed a high sensitivity but a PPV below 99%, thereby exceeding the acceptable miss rate of 1%. A combination of no return of spontaneous circulation (ROSC) before transport to the hospital and unwitnessed OHCA resulted in nearly equal specificity and PPV, higher sensitivity, and a lower transport rate to the hospital than the ALS-TOR. ConclusionFor both women and men, the ALS-TOR has high specificity and low miss rate for predicting 30-day OHCA survival. We could not improve the classification with additional characteristics. Employing a simplified version may decrease the number of futile transports to the hospital.

Factors Affecting Peripheral Intravenous Catheter Placement During Pediatric Trauma Resuscitation

IntroductionIntravenous access is required for resuscitation of injured patients but may be delayed in children because of challenges associated with peripheral intravenous (PIV) catheter placement. Early identification of factors predisposing patients to difficult PIV placement can assist in deciding strategies for timely intravenous access. MethodsWe conducted a retrospective, video-based review of injured children and adolescents treated between April 2018 and May 2019. Patient demographic, physiological, injury, and resuscitation characteristics were obtained from the patient record, including age, race, weight, injury type, Injury Severity Score, initial systolic blood pressure, initial Glasgow Coma Score, intubation status, activation level, and presence of prearrival notification. Video review was used to determine the time to PIV placement, the number of attempts required, the purpose for additional access, and the reason for abandonment of PIV placement. Multivariable regressions were used to determine factors associated with successful placement. ResultsDuring the study period, 154 consented patients underwent attempts at PIV placement in the trauma bay. Placement was successful in 139 (90.3%) patients. Older patients (OR [odds ratio]: 0.9, 95% confidence interval [CI]: 0.9, 0.9) and patients who required the highest level activation response (OR: 0.0, 95% CI: 0.0, 0.3) were less likely to have an attempt at PIV placement abandoned. Children with nonblunt injuries (OR: 11.6, 95% CI: 1.3, 119.2) and pre-existing access (OR: 39.6, 95% CI: 7.0, 350.6) were more likely to have an attempt at PIV placement abandoned. Among patients with successful PIV placement, the time required for establishing PIV access was faster as age increased (−0.5 s, 95% CI: −1.1, −0.0). ConclusionsYounger age was associated with abandonment of PIV attempts and, when successful, increased time to placement. Strategies to improve successful PIV placement and alternate routes of access should be considered early to prevent treatment delays in younger children.

Evaluation of Missing Prehospital Physiological Values in Injured Children and Adolescents

IntroductionPrehospital vital signs and the Glasgow Coma Scale score are often missing in clinical practice and not recorded in trauma databases. Our study aimed to identify factors associated with missing prehospital physiological values, including systolic blood pressure, heart rate, respiratory rate, peripheral oxygen saturation, and Glasgow Coma Scale. MethodsWe used our hospital trauma registry to obtain patient, injury, resuscitation, and transportation characteristics for injured children and adolescents (age <15 y). We evaluated the association of missing documentation of prehospital values with other patient, injury, transportation, and resuscitation characteristics using multivariable regression. We standardized vital sign values using age-adjusted z-scores. ResultsThe odds of a missing physiological value decreased with age (odds ratio [OR] = 0.9, 95% confidence interval [CI] = 0.9, 0.9) and were higher when prehospital cardiopulmonary resuscitation was required (OR = 3.3, 95% CI = 1.9, 5.7). Among the physiological values considered, we observed the highest odds of missingness of systolic blood pressure, respiratory rate, and oxygen saturation. The odds of observing normal emergency department physiological values were lower when prehospital physiological values were missing (OR = 0.9, 95% CI = 0.9, 1.0; P = 0.04). ConclusionsMissing prehospital physiological values were associated with younger age and cardiopulmonary resuscitation among the injured children treated at our hospital. Measurement and documentation of physiological variables of patients with these characteristics should be targeted.

Non-beneficial resuscitation during inhospital cardiac arrests in a metropolitan teaching hospital.

There is increasing recognition that a proportion of hospitalised patients receive non-beneficial resuscitation, with the potential to cause harm. To describe the prevalence of non-beneficial resuscitation attempts in hospitalised patients and identify interventions that could be used to reduce these events. A retrospective analysis was conducted of all adult inhospital cardiac arrests (IHCA) receiving cardiopulmonary resuscitation (CPR) in a teaching hospital over 9 years. Demographics and arrest characteristics were obtained from a prospectively collected database. Non-beneficial CPR was defined as CPR being administered to patients who had a current not-for-resuscitation (NFR) order in place or who had a NFR order enacted on a previous hospital admission. Further antecedent factors and resuscitation characteristics were collected for these patients. There were 257 IHCA, of which 115 (44.7%) occurred on general wards, with 19.8% of all patients surviving to discharge home. There were 39 (15.2%) instances of non-beneficial CPR, of which 28 (72%) of 39 occurred in unmonitored patients on the ward comprising nearly one-quarter (28/115) of all arrests in this patient group. A specialist had reviewed 30 (76.9%) of 39 of these patients, and 33.3% (13/39) had a medical emergency team (MET) review prior to their arrest. Over one in seven resuscitation attempts were non-beneficial. MET reviews and specialist ward rounds provide opportunities to improve the documentation and visibility of NFR status.

Survival Rates After Pediatric Traumatic Out-of-Hospital Cardiac Arrest Suggest an Underappreciated Therapeutic Opportunity.

Children with traumatic arrests represent almost one third of annual pediatric out-of-hospital cardiac arrests (OHCAs). However, traumatic arrests are often excluded from study populations because survival posttraumatic arrest is thought to be negligible. We hypothesized that children treated and transported by emergency medical services (EMS) personnel after traumatic OHCA would have lower survival compared with children treated after medical OHCA. We performed a secondary, observational study of children younger than 18 years treated and transported by 78 EMS agencies in southwestern Pennsylvania after OHCA from 2010 to 2014. Etiology was determined as trauma or medical by EMS services. We analyzed patient, cardiac arrest, and resuscitation characteristics and ascertained vital status using the National Death Index. We used multivariable logistic regression to test the association of etiology with mortality after covariate adjustment. Forty eight of 209 children (23%) had traumatic OHCA. Children with trauma were older than those with medical OHCA (13.2 [3.8-15.9] vs 0.5 [0.2-2.4] years, P < 0.001). Prehospital return of spontaneous circulation frequency for trauma versus medical etiology was similar (90% vs 87%, P = 0.84). Patients with trauma had higher mortality (69% vs 45% P = 0.004). More than 8 of 10 children with EMS treated and transported OHCA achieved return of spontaneous circulation. Despite lower survival rates than medical OHCA patients, almost one third of children with a traumatic etiology survived throughout the study period. Future research programs warrant inclusion of children with traumatic OHCA to improve outcomes.

Individual-level income and out-of-hospital cardiac arrest survival in men and women

ObjectiveArea-level socioeconomic factors are known to associate with chances to survive out-of-hospital cardiac arrest (OHCA survival). However, the relationship between individual-level socioeconomic factors and OHCA survival in men and women...