Resuscitation Characteristics Research Articles

Abstract 289: Use of Epinephrine During In-Hospital Cardiac Arrest May Not Increase Rate of Survival to Discharge

Introduction: In a recent large observational resuscitation study the use of epinephrine during out-of-hospital cardiac arrest was associated with survival to hospital admission but not with survival to discharge. Few studies have studied the impact of epinephrine on in-hospital survival outcomes. This study examines in-hospital cardiac arrest survival and the use of epinephrine. Hypothesis: The use of epinephrine during in-hospital cardiac arrest is associated with increased code survival and survival to discharge. Methods: This retrospective and observational study includes 286 cases of in-hospital cardiac arrest wherein epinephrine was administered. The outcomes were code survival and survival to discharge. The study period was between June 2010 and October 2011 at an urban, academic medical center. Resuscitation characteristics, including use of epinephrine were compared between code survivors and non-survivors. Charlson comorbidity scores were used to adjust the severity of illness for both groups. Chi-square was used for hypothesis testing. Results were considered significant for p-values < 0.05. Results: Epinephrine was used in 272 cases of in-hospital cardiac arrest. In 55% (n = 136) of the study cohort, only one dose of epinephrine was administered. There is a significant association between the use of epinephrine and code survival (X2 = 9.87, p = 0.0017). There is a statistically significant association between the use of epinephrine and not surviving to discharge (X2 = 7.69, p = 0.0056). Among persons receiving epinephrine, 13.6% (n = 37 of 272) survived to hospital discharge. There is no significant association between the initial rhythm and code survival (X2 = 75.36, p = 0.34) or survival to discharge (X2 = 4.56, p = 0.47) when epinephrine was administered. The median Charlson score for both groups was 4 (IQR = 2 to 6) and is not significantly different (Ws = 10955, z = 1.24, p = 0.21). Conclusions: Epinephrine administration during in-hospital cardiac arrest is associated with code survival, but not survival to discharge. Our observations are consistent with the findings reported regarding epinephrine use in out-of-hospital cardiac arrest but warrant larger, randomized studies to confirm our findings

213 Family Presence During Cardiopulmonary Resuscitation

Study Objectives: Family presence during cardiopulmonary resuscitation (CPR) of a loved one remains controversial. The principal aim of this trial was to determine if offering a relative the choice to observe CPR of a family member might reduce his or her psychological impact 90 days later. We also assessed the impact of family presence on medical efforts at resuscitation, the wellbeing of the health care team, and on the occurrence of medicolegal claims. Methods: This study was a multicenter prospective, cluster randomized, controlled trial. We enrolled 570 relatives of patients who were in cardiac arrest in 17 out-of-hospital emergency medical services. Centers were randomized either to 1) systematically offer the family member the opportunity to observe CPR (intervention group), or 2) to a habitual practice regarding family presence (control group). The primary endpoint was the proportion of relatives having post-traumatic stress disorder (PTSD)-related symptoms by an Impact of Event Scale (IES) >30 at 90 days. Secondary endpoints included the presence of anxiety and depression symptoms by the Hospital Anxiety and Depression Scale (HADS) and the impact of family presence on medical efforts at resuscitation, the wellbeing of the health care team, and on the occurrence of medicolegal claims. For pyschological assessment analyses, inorder to take into account the cluster structure of the design, Generalized Estimating Equations (GEE) were used. Results: In the intervention group, 211/266 (79%) relatives witnessed CPR compared to 131/304 (43%) relatives in the control group. In the intention-to-treat analysis, family members had PTSD-related symptoms significantly more frequently in the control group (adjusted odds ratio, 1.7; 95% confidence interval [CI], 1.2 to 2.5; P=0.004) and when they did not witness CPR (adjusted odds ratio, 1.6; 95% CI, 1.1 to 2.5; P=0.02). According to family presence, relatives who did not witness CPR had more frequently symptoms of anxiety and depression. Family-witnessed CPR did not affect resuscitation characteristics, patient survival, medical team stress or result in medicolegal claims. Conclusion: Our results promote family presence during CPR. This experience was associated with positive results on psychological parameters and neither interfered with medical efforts or health care team stress nor resulted in medicolegal conflicts.

Impact of Changes in Resuscitation Practice on Survival and Neurological Outcome After Out-of-Hospital Cardiac Arrest Resulting From Nonshockable Arrhythmias

Out-of-hospital cardiac arrest (OHCA) claims millions of lives worldwide each year. OHCA survival from shockable arrhythmias (ventricular fibrillation/ tachycardia) improved in several communities after implementation of American Heart Association resuscitation guidelines that eliminated "stacked" shocks and emphasized chest compressions. "Nonshockable" rhythms are now the predominant presentation of OHCA; the benefit of such treatments on nonshockable rhythms is uncertain. We studied 3960 patients with nontraumatic OHCA from nonshockable initial rhythms treated by prehospital providers in King County, Washington, over a 10-year period. Outcomes during a 5-year intervention period after adoption of new resuscitation guidelines were compared with the previous 5-year historical control period. The primary outcome was 1-year survival. Patient demographics and resuscitation characteristics were similar between the control (n=1774) and intervention (n=2186) groups, among whom 471 of 1774 patients (27%) versus 742 of 2186 patients (34%), respectively, achieved return of spontaneous circulation; 82 (4.6%) versus 149 (6.8%) were discharged from hospital, 60 (3.4%) versus 112 (5.1%) with favorable neurological outcome; 73 (4.1%) versus 135 (6.2%) survived 1 month; and 48 (2.7%) versus 106 patients (4.9%) survived 1 year (all P≤0.005). After adjustment for potential confounders, the intervention period was associated with an improved odds of 1.50 (95% confidence interval, 1.29-1.74) for return of spontaneous circulation, 1.53 (95% confidence interval, 1.14-2.05) for hospital survival, 1.56 (95% confidence interval, 1.11-2.18) for favorable neurological status, 1.54 (95% confidence interval, 1.14-2.10) for 1-month survival, and 1.85 (95% confidence interval, 1.29-2.66) for 1-year survival. Outcomes from OHCA resulting from nonshockable rhythms, although poor by comparison with shockable rhythm presentations, improved significantly after implementation of resuscitation guideline changes, suggesting their potential to benefit all presentations of OHCA.

Procainamide and Survival in Ventricular Fibrillation Out‐of‐hospital Cardiac Arrest

Procainamide is an antiarrhythmic drug of unproven efficacy in cardiac arrest. The association between procainamide and survival from out-of-hospital cardiac arrest was investigated to better determine the drug's potential role in resuscitation. The authors conducted a 10-year study of all witnessed, out-of-hospital, ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) cardiac arrests treated by emergency medical services (EMS) in King County, Washington. Patients were considered eligible for procainamide if they received more than three defibrillation shocks and intravenous (IV) bolus lidocaine. Four logistic regression models were used to calculate odds ratios (ORs) and 95% confidence intervals (CI) describing the relationship between procainamide and survival. Of the 665 eligible patients, 176 received procainamide, and 489 did not. On average, procainamide recipients received more shocks and pharmacologic interventions and had lengthier resuscitations. Adjusted for their clinical and resuscitation characteristics, procainamide recipients had a lower likelihood of survival to hospital discharge (OR = 0.52; 95% CI = 0.36 to 0.75). Further adjustment for receipt of other cardiac medications during resuscitation negated this apparent adverse association (OR = 1.02; 95% CI = 0.66 to 1.57). In this observational study of out-of-hospital VF and pulseless VT arrest, procainamide as second-line antiarrhythmic treatment was not associated with survival in models attempting to best account for confounding. The results suggest that procainamide, as administered in this investigation, does not have a large impact on outcome, but cannot eliminate the possibility of a smaller, clinically relevant effect on survival.

일부지역 초등학생들의 심폐소생술 지식 및 태도가 자신감에 미치는 영향

본 연구는 일부지역 초등학생들의 심폐소생술 지식 및 태도가 자신감에 미치는 영향에 대하여 알아보고자 시도 하였으며, 심정지 환자에게 효과적인 심폐소생술 수행과 자신감에 도움을 주고자 하는데 그 목적이 있다. 2009년 6월 25일부터 7월 15일까지 J도 소재 J시 K시 4개교에 재학하는 초등학생 381명에 대하여 실시하였다. 통계처리는 SPSS WIN 12.0 Version 프로그램을 사용하였으며, 통계적 유의성은 p<.05로 설정하였다. 심폐소생술 특성의 변수들과 지식, 태도, 자신감의 상관관계는 정보습득유무(r=.174, p<.01), 심폐소생술 경험유무(r=.143, p<.01), 심폐소생술 교육유무(r=.164, p<.01), 교육필요성(r=.184, p<.01), 지식(r=.342, p<.01), 태도(r=.736, p<.01)가 자신감에 상관관계를 보였다. 심폐소생술 지식 및 태도가 자신감에 미치는 영향은 태도(<TEX>$\beta=.703$</TEX>, t=17.884, p<.01)가 자신감에 유의한 영향을 주는 것으로 나타났다. 초등학생들이 응급상황 시 효과적으로 대처 할 수 있도록 심폐소생술 교육 프로그램 마련과 효과적인 인력 배치와 제도적 장치가 마련되어야 할 것으로 여겨진다. This study was attempted in order to examine about influence of knowledge and attitude toward CPR(Cardiopulmonary Resuscitation) in elementary school students of some regions upon self-confidence. The aim is to be conducive to effective performance and self-confidence in CPR for cardiac arrest patients. We carried out targeting 381 elementary school students who attend 4 schools in J city and K city of J province from June 25 to July 15, 2009. The statistical processing was done by SPSS WIN 12.0 Version. The statistical significance was set to p<.05. As for correlation between variables of cardiopulmonary resuscitation characteristics with knowledge, attitude, and self-confidence, the appearance of acquiring information(r=.174, p<.01), the appearance of experiencing cardiopulmonary resuscitation(r=.143, p<.01), the appearance of educating cardiopulmonary resuscitation(r=.164, p<.01), necessity for education(r=.184, p<.01), knowledge(r=.342, p<.01), and attitude(r=.736, p<.01) showed correlation with self-confidence. As for influence of knowledge and attitude toward cardiopulmonary resuscitation upon self-confidence, the attitude(<TEX>$\beta=.703$</TEX>, t=17.884, p<.01) had significant influence upon self-confidence. It is necessary to arrange educational program of cardiopulmonary resuscitation, to distribute effective manpower, and to provide elementary school students to cope with emergent situation.

Community cardiopulmonary resuscitation training in Greece

There is a lack of information about the status and characteristics of community cardiopulmonary resuscitation (CPR) training in Greece. The purpose of this study was to evaluate the knowledge of basic aspects of CPR practice, characteristics of training, and areas in need of improvement to increase CPR competence in the community. Using a random-digit-dialing telephone survey, 390 residents of a large county were interviewed. Weighting methods were used to estimate population statistics. Results indicated a low prevalence of current training and lack of basic CPR knowledge, reflecting the limited extent of and access to training. Results suggest the need for a standardized, widespread CPR program.

Characteristics of cardiac arrest and resuscitation by age group: an analysis from the Swedish Cardiac Arrest Registry

Aim The objective of this study was to describe patients who experienced an out-of-hospital cardiac arrest (OHCA) by age group. Methods All patients who suffered from an OHCA between 1990 and 2005 and are included in the Swedish Cardiac Arrest Registry (n = 40,503) were classified into the following age groups: neonates, younger than 1 year; young children, between 1 and 4 years; older children, between 5 and 12 years; adolescents, between 13 and 17 years; young adults, between 18 and 35 years; adults not retired, between 36 and 64 years; adults retired, between 65 and 79 years; and older adults, 80 years or older. Results Ventricular fibrillation was lowest in young children (3%) and highest in adults (35%). Survival to 1 month was lowest in neonates (2.6%) and highest in older children (7.8%). Children (<18 years), young adults (18-35 years), and adults (>35 years) survived to 1 month 24.5%, 21.2%, and 13.6% of cases, respectively ( P = .0003 for trend) when found in a shockable rhythm. The corresponding figures for nonshockable rhythms were 3.8%, 3.2%, and 1.6%, respectively ( P < .0001 for trend). Conclusions There is a large variability in characteristics and outcome among patients in various age groups who experienced an OHCA. Among the large age groups, there was a successive decline in survival with increasing age in shockable and nonshockable rhythms.

Out-of-hospital cardiac arrests in Amsterdam and its surrounding areas: results from the Amsterdam resuscitation study (ARREST) in Utstein style.

The purpose of this study was to describe the chain of survival in Amsterdam and its surroundings and to suggest areas for improvement. To ensure accurate data, collection was made by research personnel during the resuscitation, according to the Utstein recommendations. Between June 1, 1995 and August 1, 1997 all consecutive cardiac arrests were registered. Patient characteristics, resuscitation characteristics and time intervals were analyzed in relation to survival. From the 1046 arrests with a cardiac etiology and where resuscitation was attempted, 918 cases were not witnessed by EMS personnel. The analysis focussed on these 918 patients of whom 686 (75%) died during resuscitation, 148 (16%) died during hospital admission and 84 patients (9%) survived to hospital discharge. Patient and resuscitation characteristics associated with survival were: age, VF as initial rhythm, witnessed arrest and bystander CPR. EMS arrival time was significantly shorter for survivors (median 9 min) compared to non-survivors (median 11 min). In 151 cases the police was also alerted and arrived 5 min (median) earlier than EMS personnel. Using the OPC/CPC good functional health was observed in 50% of the survivors and moderate performance in 29%. All links in the chain of survival must be strengthened, but equipping the police with semi-automatic defibrillators may be the most useful intervention to improve survival.

Resuscitation of thermally injured patients with oxygen transport criteria as goals of therapy.

Resuscitation from shock based on oxygen transport criteria has been widely used in trauma and surgical patients, but has not been examined in thermally injured patients. To study the possible efficacy of this type of resuscitation, the oxygen transport characteristics of burn resuscitation were studied in nine adults, of whom six had inhalation injuries, with a mean burn size of 45% total body surface area and a mean age of 33.4 years, who were resuscitated based on oxygen transport criteria. Pulmonary artery balloon flotation catheters were placed and hemodynamic and oxygen transport parameters (Fick method) were measured hourly for 6 hours. Patients received fluid boluses in addition to resuscitation calculated by the Parkland formula, until the pulmonary artery wedge pressure reached 15 mm Hg, after which dobutamine infusions (5 micrograms/kg/min) were initiated. Cardiac index increased from 2.51 to 6.57 L/min/m2 (p < 0.05), whereas systemic vascular resistance fell from 1534 to 584 dyne sec/cm5 (p < 0.05). Oxygen delivery (DO2I) and oxygen consumption (VO2I) indexes increased significantly during the study period (573 +/- 47 to 1028 +/- 57, and 132 +/- 8 to 172 +/- 16 ml/min/m2, respectively; p < 0.05). VO2I appeared dependent on DO2I at levels of DO2I less than 800 ml/min/m2. In this study, depressed cardiovascular function in patients with burn injuries responded to volume loading and inotropic support much as it does in patients with shock of other etiologies. Whether oxygen transport-based resuscitation is effective in improving survival or the incidence of multiple organ failure is unknown and will need to be evaluated in randomized trials.

Flavonoid tannins — structural wood components for drought-resistance mechanisms of plants

Myrothamnus flabellifolia Welw., Eragrostis nindensis Fic. and Hiern, Xerophyta villosa, Th. Dur and Schinz, and Sporobolus stapfianus Gand, present a so-called “resuscitation” behaviour when subjected to drought and subsequent rehydration. Absence of cell wall cracking is one, if not the main cause of this behaviour. Polyflavonoid tannins content of Myrothamnus flabellifolia is high and increases under drought-induced stress. It does not increase in the other plants where a surge of the content of the amino acid proline occurs instead. The authors now present the hypothesis and circumstantial evidence that the helicoidal tridimensional structures of these tannins function as the springs disallowing cracking of the cell walls and rendering possible the resuscitation characteristics of Myrothamnus flabellifolia and of the other plants through two slightly different mechanisms. This explains why many trees originally of Southern Africa, a drought area, are high producers of tannins. It infers that tannins are structural wood components just as much as cellulose, hemicelluloses and lignin.

Effect of inhalation injury on fluid resuscitation requirements after thermal injury

The presence of inhalation injury has been reported to increase fluid requirements for resuscitation from burn shock after thermal injury. To evaluate the effect of inhalation injury on the magnitude of burn-induced shock, the characteristics of resuscitation of 171 patients with burns covering at least 25 percent of the total body surface area were reviewed. When inhalation injury was suspected, confirmation by xenon-133 scanning, bronchoscopy, or both was obtained. Initial fluid resuscitation was calculated according to the Parkland formula, and titration was initiated to maintain a urine output of 30 to 50 ml/hour. Fifty-one patients had inhalation injuries. Patients with inhalation injuries had a mean fluid requirement of 5.76 ml/kg per percentage of total body surface area burned and a mean sodium requirement of 0.94 mEq/kg per percentage of total body surface area burned to achieve successful resuscitation, compared with a fluid requirement of 3.98 ml/kg per percentage of total body surface area burned and a sodium requirement of 0.68 mEq/kg per percentage of total body surface area burned for the group without inhalation injury (p < 0.05). These data confirm and quantitate that inhalation injury accompanying thermal trauma increases the magnitude of total body injury and requires increased volumes of fluid and sodium to achieve resuscitation from early burn shock.