Resuscitation Efforts Research Articles

Causes of Death and End-of-Life Care in Patients With Intracranial High-Grade Gliomas: A Retrospective Observational Study.

Background and ObjectivesTo understand patterns of care and circumstances surrounding end of life in patients with intracranial gliomas.MethodsWe retrospectively analyzed end-of-life circumstances in patients with intracranial high-grade gliomas at Columbia University Irving Medical Center who died from January 2014 to February 2019, including cause of death, location of death, and implementation of comfort measures and resuscitative efforts.ResultsThere were 152 patients (95 men, 57 women; median age at death 61.5 years, range 24–87 years) who died from January 2014 to February 2019 with adequate data surrounding end-of-life circumstances. Clinical tumor progression (n = 117, 77.0%) was the most common cause of death, with all patients transitioned to comfort measures. Other causes included, but were not limited to, infection (19, 12.5%); intratumoral hemorrhage (5, 3.3%); seizures (8, 5.3%); cerebral edema (4, 2.6%); pulmonary embolism (4, 2.6%); autonomic failure (2, 1.3%); and hemorrhagic shock (2, 1.3%). Multiple mortal events were identified in 10 (8.5%). Seventy-three patients (48.0%) died at home with hospice. Other locations were inpatient hospice (40, 26.3%); acute care hospital (34, 22.4%), including 27 (17.8%) with and 7 (4.6%) without comfort measures; skilled nursing facility (4, 3.3%), including 3 (2.0%) with and 1 (0.7%) without comfort measures; or religious facility (1, 0.7%) with comfort measures. Acute cardiac or pulmonary resuscitation was performed in 20 patients (13.2%).DiscussionClinical tumor progression was the most common (77.0%) cause of death, followed by infection (12.5%). Hospice or comfort measures were ultimately implemented in 94.7% of patients, although resuscitation was performed in 13.2%. Improved understanding of circumstances surrounding death, frequency of use of hospice services, and frequency of resuscitative efforts in patients with gliomas may allow physicians to more accurately discuss end-of-life expectations with patients and caregivers, facilitating informed care planning.

Abstract 11964: Citizen Responders Provide Emotional Support for Relatives to Out-of-Hospital Cardiac Arrest Patients

Introduction: A citizen responder (CR) system to activate volunteer citizens by a smartphone application (HeartRunner) to nearby cardiac arrests was implemented in 2017 in the Capital Region of Denmark. Participating in resuscitation may not only involve provision of cardio-pulmonary resuscitation (CPR) but also include provision of emotional support for relatives to the cardiac arrest patient. We examined the proportion of CR who reported provision of support to relatives to out-of-hospital cardiac arrest (OHCA) patients during resuscitation attempt. Hypothesis: We hypothesized that CR not only deliver CPR but also provide emotional support to relatives of OHCA patients. Methods: All CR activated by the HeartRunner app received a follow-up questionnaire 90 minutes after the alarm including questions about how CRs participated in resuscitation and whether they provided emotional support to relatives present during the resuscitation attempt. All surveys from March 12, 2020 to June 1, 2021, from CR who accepted an alarm and arrived at the cardiac arrest location were included. Results: A total of 1,868 CR responded to the survey (median age 37 years (IQR 28-37). Half (54.4%) were male and 23.9% health care professionals. CRs arrived before the emergency medical services (EMS) in almost 1/3 (28.9%) of OHCA cases with CR activation, with 227 CRs (41.9%) performing CPR and 139 (25.7%) attaching an automated external defibrillator. In total, more than 433 CRs (23.2%) reported provision of support for relatives at the OHCA location. Even though a higher proportion of support was observed among CR who arrived before the EMS, almost 12% reported provision of support to relatives even when arriving after EMS (Figure). Conclusions: Citizen responders provide not only resuscitative efforts but offer emotional support to relatives to OHCA patients. Citizen responders may be an important resource for both EMS personnel and relatives who are present at the cardiac arrest scene.

Abstract 12464: Signs of Life as a Predictor of Survival in Patients With Out-of-Hospital Cardiac Arrest and Long Low-Flow Times

Introduction: Long low-flow times in patients with out-of-hospital cardiac arrest (OHCA) are associated with poor outcome. Signs of life during cardiopulmonary resuscitation (CPR) is a simple method to evaluate in the field, but little is known about its impact on survival in patients with long low-flow times. Hypothesis: Thirty-day survival in OHCA patients with long prehospital low-flow times is higher in patients with signs of life during CPR than in patients with no signs of life during CPR. Methods: Observational, retrospective, single center study of OHCA patients referred to a tertiary cardiac arrest center in the Central Demark Region from 2015-2018. Risk factors were assessed by univariate logistic regression. Comparisons were made by Kaplan-Meier survival curves and log-rank test. Results: In a cohort of 807 patients with OHCA, 30-day survival was seen in 364 (45%). Among patients discharged from hospital, favorable neurological outcome with CPC 1-2 was observed in 93%. Signs of life during CPR was present in 315 (39%) patients. Risk of 30-day mortality was significantly reduced in patients presenting signs of life during CPR (RR 0.25, 95% CI [0.20-0.30]). Poor survival was seen in patients with low-flow times exceeding 30 minutes compared to patients with shorter low-flow times, (11% versus 66%, p < 0.001). In patients with low-flow times > 30 min, the survival rate increased to 33 % in the presence of signs of life during CPR compared to only 3% in patients without signs of life during CPR, p < 0.001. Conclusions: In OHCA patients, low-flow times > 30 minutes were highly associated with poor survival, however signs of life during CPR predicts higher survival both in the overall population and in patients with long low-flow times. Thus, resuscitation efforts may not be futile in patients with long low-flow times presenting signs of life during CPR.

Abstract 13412: Gender Based Differences in Duration of Cardiopulmonary Resuscitation in the Inpatient Setting

Introduction: The decision to terminate cardiopulmonary resuscitation (CPR) prior to return of spontaneous circulation (ROSC) may be impacted by resuscitation parameters or by patient demographics. Studies show that longer resuscitation efforts have a higher likelihood of ROSC and survival to discharge. It is unclear if gender of the code leader and the patient may be associated with duration of unsuccessful CPR attempt. Methods: Retrospective chart review of inpatient CA that occurred at the UC San Diego Health System between 2011-2019. All adult inpatients with an index cardiac arrest who expired within three days of admission were included. Exclusion criteria included patients who achieved ROSC, CA that occurred outside of the wards or ICU, those with active pre-arrest DNR status, and patients with CA > 3 days after admission (done to minimize provider bias based on prior knowledge of the patient). Data were identified from an internal cardiac arrest quality improvement database. Patient gender was self-reported and code leader gender was identified. Primary outcome was duration of resuscitation efforts. To determine differences in duration of CPR between code leader and patient gender a one-sided ANOVA test was used. A p value < 0.05 was considered statistically significant. Results: We identified 91 patients between 2011 and 2019 that met inclusion criteria. Thirty-eight patients (41.8%) identified as female, fifty-three identified as male (58.2%), the average age was 62.7 years old, and seventeen (18.7%) had initial shockable rhythm. Thirty (33%) of the code leaders identified as female and sixty-one (67%) identified as male. Average duration of CPR was 31.6 minutes (2 - 135 minutes) for male patients with male code leader, 32.2 minutes (9 - 71 minutes) for male patients with female code leader, 27.0 minutes (7 - 60 minutes) for female patients with female code leader, and 33.7 minutes (10 - 73 minutes) for female patients with male code leader. No significant difference in duration of unsuccessful CPR attempt associated with gender of code leader and gender of patient in ANOVA analysis was found (p = 0.512). Conclusions: We did not identify a significant association between code leader and patient gender on duration of CPR in the inpatient setting.

Abstract 13013: Survival After In-Hospital Cardiopulmonary Resuscitation for Cardiac Arrest in Patients With COVID-19: An Updated Meta-Analysis

Introduction: Several small studies have reported variable outcomes following in-hospital cardiac arrest (IHCA) in patients with COVID-19. A clear estimate is important in prognostication and guiding resuscitation efforts and policies for these patients. Methods: A search of PubMed, Embase, and Scopus databases was conducted to identify studies reporting outcomes after IHCA in adult patients with confirmed COVID-19. The cumulative characteristics of the patients were described. The primary outcome studied was survival at 30 days or at hospital discharge (short term survival). Additional outcomes of interest were proportional prevalence of the initial rhythm at arrest, return of spontaneous circulation (ROSC), and neurological recovery (defined as Cerebral Performance Category Score of 1-2 ). Metanalysis of proportions was performed utilizing the Metaprop command. A random effects model was chosen to account for interstudy variance. Results: A total of 13 eligible studies were identified and included in the analyses. Out of all the hospitalized patients with COVID-19, 1,618 underwent advanced cardiac resuscitation after an IHCA. Patients who had a cardiac arrest had a median age between 50-69 years. IHCA occurred predominantly in men, and in the ICU setting. Shockable rhythms were identified in 8% (95% CI 5-10%, I2; 56%) and non-shockable rhythms in 89% (95% CI 85-94% I2; 84%) of patients (Fig. 1a). ROSC was achieved in 40% (95% CI 31-48% I2; 90%) (Fig. 1b). Only 7 % ( 95% CI 3-12% I2; 86%) of patients survived at 30 days/hospital discharge (Fig. 1c). Neurological recovery was seen in 5% (95% CI 3-9% I2; 67%) of patients who suffered a IHCA (Fig. 1d). Conclusions: Our meta-analysis demonstrates the majority of the cardiac arrests in patients with COVID-19 have non-shockable rhythms. Survival rate in these patients is low, and neurological recovery is unfavorable. This study provides further insight in guiding resuscitation efforts in these patients.

Abstract 9382: Outcomes After Traumatic Out-of-Hospital Cardiac Arrest in Vietnam: A Multicenter Prospective Cohort Study

Introduction: Pre-hospital services are not well developed in Vietnam, especially the immature of a trauma system of care. The prognosis of traumatic out-of-hospital cardiac arrest (OHCA) might differ from that of other countries. This study aimed to investigate the survival rate from traumatic OHCA and to measure the critical components of the chain of survival following a traumatic OHCA in the country. Hypothesis: Although the outcome in cardiac arrest following trauma is dismal, pre-hospital resuscitation efforts are not futile and seem worthwhile. Understanding the country-specific causes, risk, and prognosis of traumatic OHCA is important to reduce mortality in Vietnam. Methods: We performed a multicenter prospective observational study of consecutive patients (>16 years) presenting with traumatic OHCA to 3 central hospitals in Vietnam from February 2014 to December 2018. We collected data on characteristics, management, and outcomes of patients with traumatic OHCA and compared these data between patients who died before hospital discharge and patients who survived to discharge from the hospital. Results: Of 111 eligible patients with traumatic OHCA, 92 (82.9%) were male and the mean age was 39.27 years (standard deviation: 16.38). Only 5.4% (6/111) survived to discharge from the hospital. Most cardiac arrests (62.2%; 69/111) occurred on the street or highway, 31.2% (29/93) were witnessed by bystanders, and 33.7% (32/95) were given cardiopulmonary resuscitation (CPR) by a bystander. Only 26.1% (29/111) of the patients were taken by the emergency medical services (EMS), 90% (27/30) received pre-hospital advanced airway, and 54.7% (29/53) were given resuscitation attempts by EMS or private ambulance. No significant difference between patients who died before hospital discharge and patients who survived to discharge from the hospital was found for bystander CPR (33.7%, 30/89 and 33.3%, 2/6, P>0.999; respectively) and resuscitation attempts (56.3%, 27/48, and 40.0%, 2/5, P=0.649; respectively). Conclusion: Improvements are needed in the EMS in Vietnam, such as increasing bystander first-aid and developing a trauma system of care, as well as developing a standard emergency first-aid program for both healthcare personnel and the community.

Outcome of infants with 10 min Apgar scores of 0–1 in a low-resource setting

BackgroundIn high-resource settings, postponing the interruption of cardiopulmonary resuscitation from 10 to 20 min after birth has been recently suggested, but data from low-resource settings are lacking. We investigated the...

PENGARUH PEMBERIAN PENDIDIKAN KESEHATAN BANTUAN HIDUP DASAR (BHD) AWAM MELALUI VIDEO TERHADAP TINGKAT PENGETAHUAN ANAK SEKOLAH MENENGAH ATAS (SMA) DI KOTA PONTIANAK


 Abstract
 Background : Cardiac arrests are the leading cause of death outside the hospital and in the hospital. Previous research has shown that as many as 70% of out-of-hospital cardiac arrests (OHCAs) occur at home. The outcome of the OHCA was poor, only 10.8% of adult victims with non-traumatic cardiac arrest who had received resuscitation efforts from the emergency medical service (EMS) were able to survive until hospital. In everyday life, it is often found that someone suddenly loses consciousness or finds a victim on the street. To deal with this, what has to be done is to provide Basic Life Support (BLS). The provision of information can be started from the school age so that they can easily practice and share information on handling BLS on lay people with their families.
 Objective: Seeing the effect of providing basic life support (BLS) health education to the community through videos on the level of knowledge of high school children (SMA) in Pontianak city.
 Methods: This type of research is quantitative research, using a quasi-experimental research design in the form of pre-test and post-test without control. Audiovisual media is effective in increasing the knowledge and skills of respondents. Several studies have stated that self-directed videos can improve the knowledge, attitudes and skills of cardiopulmonary resuscitation (CPR) in high school students. This research was conducted using the method of providing general BLS health education to high school students in Pontianak City.
 Result: After measuring using a questionnaire, the results of the Wilcoxon test showed a difference in knowledge between pre-test and post-test with a p-value of 0.000 (p<0.05).
 Conclusion: There was a significant influence on the provision of basic life support (BLS) health education for lay people through video on the level of knowledge of high school children in Pontianak City.
 
 Keywords: Basic life support, health education, video, level of knowledge.

Increased plasma disequilibrium between pro- and anti-oxidants during the early phase resuscitation after cardiac arrest is associated with increased levels of oxidative stress end-products

BackgroundCardiac arrest (CA) results in loss of blood circulation to all tissues leading to oxygen and metabolite dysfunction. Return of blood flow and oxygen during resuscitative efforts is the beginning of reperfusion injury and is marked by the generation of reactive oxygen species (ROS) that can directly damage tissues. The plasma serves as a reservoir and transportation medium for oxygen and metabolites critical for survival as well as ROS that are generated. However, the complicated interplay among various ROS species and antioxidant counterparts, particularly after CA, in the plasma have not been evaluated. In this study, we assessed the equilibrium between pro- and anti-oxidants within the plasma to assess the oxidative status of plasma post-CA.MethodsIn male Sprague–Dawley rats, 10 min asphyxial-CA was induced followed by cardiopulmonary resuscitation (CPR). Plasma was drawn immediately after achieving return of spontaneous circulation (ROSC) and after 2 h post-ROSC. Plasma was isolated and analyzed for prooxidant capacity (Amplex Red and dihydroethidium oxidation, total nitrate and nitrite concentration, xanthine oxidase activity, and iron concentration) and antioxidant capacity (catalase and superoxide dismutase activities, Total Antioxidant Capacity, and Iron Reducing Antioxidant Power Assay). The consequent oxidative products, such as 4-Hydroxyl-2-noneal, malondialdehyde, protein carbonyl, and nitrotyrosine were evaluated to determine the degree of oxidative damage.ResultsAfter CA and resuscitation, two trends were observed: (1) plasma prooxidant capacity was lower during ischemia, but rapidly increased post-ROSC as compared to control, and (2) plasma antioxidant capacity was increased during ischemia, but either decreased or did not increase substantially post-ROSC as compared to control. Consequently, oxidation products were increased post-ROSC.ConclusionOur study evaluated the disbalance of pro- and anti-oxidants after CA in the plasma during the early phase after resuscitation. This disequilibrium favors the prooxidants and is associated with increased levels of downstream oxidative stress-induced end-products, which the body’s antioxidant capacity is unable to directly mitigate. Here, we suggest that circulating plasma is a major contributor to oxidative stress post-CA and its management requires substantial early intervention for favorable outcomes.

Effect of Temporal Difference on Clinical Outcomes of Patients with Out-of-Hospital Cardiac Arrest: A Retrospective Study from an Urban City of Taiwan.

Circadian pattern influence on the incidence of out-of-hospital cardiac arrest (OHCA) has been demonstrated. However, the effect of temporal difference on the clinical outcomes of OHCA remains inconclusive. Therefore, we conducted a retrospective study in an urban city of Taiwan between January 2018 and December 2020 in order to investigate the relationship between temporal differences and the return of spontaneous circulation (ROSC), sustained (≥24 h) ROSC, and survival to discharge in patients with OHCA. Of the 842 patients with OHCA, 371 occurred in the daytime, 250 in the evening, and 221 at night. During nighttime, there was a decreased incidence of OHCA, but the outcomes of OHCA were significant poor compared to the incidents during the daytime and evening. After multivariate adjustment for influencing factors, OHCAs occurring at night were independently associated with lower probabilities of achieving sustained ROSC (aOR = 0.489, 95% CI: 0.285–0.840, p = 0.009) and survival to discharge (aOR = 0.147, 95% CI: 0.03–0.714, p = 0.017). Subgroup analyses revealed significant temporal differences in male patients, older adult patients, those with longer response times (≥5 min), and witnessed OHCA. The effects of temporal difference on the outcome of OHCA may be a result of physiological factors, underlying etiology of arrest, resuscitative efforts in prehospital and in-hospital stages, or a combination of factors.

Duration of resuscitation efforts and long-term prognosis following in-hospital cardiac arrest (IHCA)

Abstract Background The decision to terminate resuscitation efforts can be challenging. Notably, the association between duration of resuscitation and long-term survival and functional outcomes after in-hospital cardiac arrest (IHCA) is unknown. Purpose To examine 30-day and 1-year survival stratified by duration of resuscitation efforts. Further, to report long term outcome (1-year survival) without anoxic brain damage or nursing home admission among 30-day IHCA survivors. Methods We included all patients with IHCA from 13 Danish hospitals between January 1st, 2013 to December 31st, 2015. Patients were only included if there was clinical indication for a resuscitation attempt. Data on IHCA was obtained from the DANARREST database, which was linked to national registries to retrieve information on patient characteristics, survival, anoxic brain damage and nursing home admission. Patients were stratified into four groups (A-D) according to quartiles of duration of resuscitation efforts: Group A (<5 minutes), group B (5–11 minutes), group C (12–20 minutes) and group D (≥21 minutes). Using multivariable regression analysis, outcomes were standardized for patient age, sex, Charlson Comorbidity Index, witnessed arrest, monitored arrest, cardiopulmonary resuscitation (CPR) prior to arrival of the in-hospital cardiac arrest team and defibrillation. Results The study population comprised of 1868 patients, median age was 74 (1st-3rd quartile [Q1-Q3] 65–81 years) and 65.0% were men. In total, 52.1% (n=973) of the patients achieved return of spontaneous circulation (ROSC). The overall median duration of resuscitation was 12 min (Q1-Q3 5–21 min). The standardized absolute chance of 30-day survival was 63.6% (95% CI 58.0%-69.0%) for group A, 34.0% (95% CI 29.7%-38.2%) for group B, 14.1% (95% CI 10.7%-17.5%) for group C and 9.0% (95% CI 6.8%-11.8%) for group D. Similarly, the chance of 1-year survival was highest for group A (51.5%; 95% CI 46.3%-56.7%) gradually decreasing to 7.0% (95% CI 4.5%-9.5%) in group D (Fig. 1). Among 30-day survivors of an IHCA, the standardized absolute chance of survival without anoxic brain damage or nursing home admission within one-year post-arrest was highest for patients resuscitated in group A (83.2%; 95% CI 78.4%-88.1%), decreasing to 72.3% (95% CI 64.5%-80.0%) in group B, 68.3% (95% CI 55.3%-81.2%) in group C and 71.1% (95% CI 54.2%-88.0%) in group D (Fig. 2). Conclusion Short time to ROSC after in-hospital cardiac arrest is associated with better long-term prognosis. However, the majority of 30-day survivors are alive 1-year post-arrest without anoxic brain damage and without need for nursing home admission despite prolonged resuscitation. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

Racial disparities in out-of-hospital cardiac arrest in Denmark

Abstract Introduction American studies have pointed out racial disparities regarding sudden cardiac death occurrence and outcomes. Black individuals have higher sudden cardiac death rates and lower survival compared with white subjects (1). Although income and social status partly explain differences in outcomes (2), sudden cardiac death is 2-fold higher in black individuals after adjustment on these characteristics (3,4). In Denmark, immigrants account for 9.1% of the population (5) but to date, no data exists regarding Out-of-Hospital Cardiac Arrest (OHCA) incidence. Purpose The main objective of this study was to compare the incidence of OHCA among native and immigrant individuals between 2001 and 2014 in Denmark. Methods This nationwide study included all patients identified from the Danish Cardiac Arrest Registry with OHCA of presumed cardiac cause between 18 and 80 years from 2001 to 2014 (6). The primary outcome was OHCA occurrence defined as a clinical condition of cardiac arrest resulting in resuscitation efforts either by bystanders or by EMS personnel. The immigrant status was defined as native or immigrant according to the national database from Statistics Denmark. An immigrant was defined as a person born abroad whose both parents were either foreign citizens or born abroad. The odds ratio of OHCA between immigrants and native Danes were adjusted according to age, sex, income, and education level. Results A total of 33,730 OHCA were recorded between 2001 and 2014. Among them, 1,684 occurred in immigrants and 32,046 in natives. Compared to natives, immigrant victims of OHCA were younger (62.0 [51.0, 71.0] vs. 66.0 [56.0, 74.0], p<0.001), and more often had a history of diabetes (20.5% vs. 14.0; p<0.001), myocardial infarction (11.9% vs. 8.7%; p<0.001) and chronic heart failure (17.0% vs. 14.7%; p<0.01). Female proportion was not statistically different between the two groups (30.2% vs. 31.3% of immigrants and natives respectively; p=0.32). The incidence of OHCA was 61.0/100,000 person-years in natives and 35.0/100,000 person-years in immigrants (OR=0.57; 95% CI 0.54–0.60; p<0.001). Between 2001 and 2014, the OHCA incidence decreased from 71.4 [67.9–75.0] to 70.9 [68.2–73.6]/100 000 person-years in natives (p=0.99) and from 40.2 [30.8–51.5] to 36.5 [31.1–42.6] /100,000 person-years in immigrants (p=0.91) (Figure). After logistic regression, compared to natives, the immigrant status was associated with 0.61-fold odds of OHCA when adjusting on age and sex (OR=0.61; 95% CI 0.59–0.65; p<0.001), and 0.65-fold odds of OHCA when adjusting on age, sex, income, and education level (OR=0.66; 95% CI 0.63–0.70; p<0.001). Conclusion This is the first study assessing the incidence of OHCA in immigrants versus natives in a European country. Despite higher cardiovascular burden, the incidence of OHCA was lower in immigrants even when adjusted on sex, age, income, and education reflecting a selection of individuals migrating to Denmark. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Fédération Française de Cardiologie

201 Effect of Gender, Race, and Ethnicity on Duration of Resuscitative Efforts Following Out-of-Hospital Cardiac Arrest

The duration of unsuccessful resuscitation attempts in the emergency department (ED) following out-of- hospital cardiac arrest (OHCA) may be influenced by many factors. Factors known to be associated with a decreased likelihood of survival may influence providers to consider resuscitative efforts futile sooner, and may include: whether the arrest was witnessed, if bystander CPR was performed, duration of CPR in the pre-hospital setting, and the presence of a shockable rhythm. More subtle, and potentially sub-conscious factors may also influence the duration of unsuccessful resuscitation efforts, as well.

DESCENDING NECROTIZING MEDIASTINITIS (DNM) DISGUISING AS A MEDIASTINAL MASS

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: DNM is an uncommon infection arising in the head or neck which tracks between the cervical fascial planes into the mediastinum. We report a case of DNM with a challenging presentation. CASE PRESENTATION: A 56-year-old male on chronic hemodialysis recovering from COVID pneumonia, presented to the emergency department with 2 days of shortness of breath. He was hypertensive, tachycardic and hypoxic, in respiratory distress, requiring immediate initiation of noninvasive ventilation. Shortly after arrival, he went into cardiac arrest. Resuscitation efforts were successful. Intensive management included mechanical ventilation, broad spectrum antibiotics, vasopressors and continuous renal replacement therapy for suspected septic shock. Chest x-ray showed mediastinal widening, confirmed by CT, to be due to a 7.5 cm lobulated, soft tissue density in the mediastinum impinging on the trachea. Bronchoscopy via endotracheal tube showed no obstruction except for some dynamic airway collapse. Trans-bronchial needle aspiration of the mediastinal mass was non-diagnostic. In 2 days, he improved, was extubated but then emergently re-intubated due to acute upper airway obstruction. Repeat imaging revealed a large retropharyngeal abscess extending from C1 level to the thyroid gland. It wrapped around anteriorly and communicated with a large collection in the superior mediastinum surrounding the trachea. Also noted was an enlarging pleural effusion. Urgent surgical drainage of the retropharyngeal space, superior mediastinum and pleural fluid was performed. Cultures grew Staphylococcus aureus. Mediastinal exploration and tracheostomy followed. He steadily improved and was discharged. DISCUSSION: DNM is a life-threatening infection that originates in the neck;retropharyngeal abscess in this case. It spreads caudally through cervical fascial planes facilitated by gravity and negative intrathoracic pressures (1). Oral flora are the usual pathogens (2). Diagnosis needs a high index of suspicion to obtain necessary imaging. Favorable outcomes are seen with early diagnosis, airway protection, antibiotics and timely surgical drainage (3).Our patient had narrowing of the proximal trachea due to compression from the fluid collection requiring emergent re-intubation. His initial chest CT reported a soft tissue density concerning for malignancy. It was the second CT that suggested an abscess. Looking back, prior chest x-rays showed progressive mediastinal widening over 10 days, making malignancy less likely. Review of old imaging remains invaluable. CONCLUSIONS: Deep neck infection leading to mediastinitis requires early diagnosis, antibiotic administration as well as operative management for source control. REFERENCE #1: Benedetto C, et al. Catastrophic descending necrotizing mediastinitis of the anterior and posterior compartments: A case report. Radiol Case Rep. 2020;15(10):1832-1836 REFERENCE #2: Brook I, Frazier EH. Microbiology of mediastinitis. Arch Intern Med. 1996 Feb 12;156(3):333-6. Erratum in: Arch Intern Med 1996 May 27;156(10):1112. PMID: 8572845. REFERENCE #3: Ridder GJ, Maier W, Kinzer S, Teszler CB, Boedeker CC, Pfeiffer J. Descending necrotizing mediastinitis: contemporary trends in etiology, diagnosis, management, and outcome. Ann Surg. 2010 Mar;251(3):528-34. doi: 10.1097/SLA.0b013e3181c1b0d1. PMID: 19858699. DISCLOSURES: No relevant relationships by Rana Hejal, source=Web Response No relevant relationships by Willie McClure, source=Web Response No relevant relationships by Tanmay Panchabhai, source=Web Response No relevant relationships by Layla Sankari, source=Web Response No relevant relationships by Apoorwa Thati, source=Web Response

"LEADING TO DANGER": A CASE OF INFECTIVE ENDOCARDITIS INVOLVING AN AUTOMATIC IMPLANTABLE CARDIAC DEFIBRILLATOR LEAD

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Patients with presence of intracardiac devices are at an increased risk of developing endocarditis. In this report we present a patient with an automatic implantable cardiac defibrillator (AICD) who presented with atypical symptoms found to have a significant vegetation involving the AICD lead who required emergent removal of the cardiac device and ultimately expired. CASE PRESENTATION: A 58-year-old male with history of lung cancer and ischemic cardiomyopathy status post AICD placement presented to the emergency department with low back pain. Physical exam was remarkable for tenderness to palpation of his lumbar region. The patient was found to have a leukocytosis, but was afebrile and without other signs of infection. Imaging of his spine did not reveal any apparent etiology for his back pain. Blood cultures obtained at presentation grew gram positive cocci in four of four bottles and ultimately speciated as MSSA. A transthoracic echocardiogram was performed and revealed a large vegetation on the tricuspid valve with concern for involvement of the AICD lead. Given these findings he underwent emergent surgery for lead and device extraction. During the procedure the patient became bradycardic and hypotensive and went into cardiac arrest. Despite maximum resuscitative efforts the patient expired. DISCUSSION: Infective endocarditis (IE) is a highly morbid and deadly infection involving the endocardium, the lining of the inside of the heart and heart valves. Right-sided endocarditis is less common, making up approximately 5% to 10% of all cases. It is most commonly associated with intravenous drug use, central venous catheters, and the presence of intracardiac devices. The prevalence of right-sided endocarditis has increased over the past several decades due to the increase in the aforementioned risk factors. Unique complications of right-sided endocarditis include the risk of septic pulmonary emboli, pneumonia, and the formation of a pulmonary abscess. In cases where implantable cardiac devices are present the mainstay of treatment includes not only antibiotics, but also the complete extraction of the device and leads. Studies have shown that early diagnosis and lead extraction of infected cardiac devices are associated with lower in-hospital mortality. CONCLUSIONS: Patients with intracardiac devices are at increased risk of developing infective endocarditis and their clinical presentation maybe atypical, such as back pain in our patient. It is of paramount importance to perform early diagnostic tests and prompt device removal in such cases. Clinicians must be aware of the increased risk in such a population in order to facilitate early detection and appropriate intervention. REFERENCE #1: Cahill TJ, Prendergast BD. Infective endocarditis. Lancet. 2016;387(10021):882-893. doi:10.1016/S0140-6736(15)00067-7 REFERENCE #2: Hubers SA, DeSimone DC, Gersh BJ, Anavekar NS. Infective Endocarditis: A Contemporary Review. Mayo Clin Proc. 2020;95(5):982-997. doi:10.1016/j.mayocp.2019.12.008 REFERENCE #3: Shmueli H, Thomas F, Flint N, Setia G, Janjic A, Siegel RJ. Right-Sided Infective Endocarditis 2020: Challenges and Updates in Diagnosis and Treatment. J Am Heart Assoc. 2020;9(15):e017293. doi:10.1161/JAHA.120.017293 DISCLOSURES: No relevant relationships by Ahmed Aladham, source=Web Response No relevant relationships by Kyle Brockman, source=Web Response No relevant relationships by Navitha Ramesh, source=Web Response

Abdominal and thoracic wall closure: damage control surgery's cinderella.

Damage control surgery principles allow delayed management of traumatic lesions and early metabolic resuscitation by performing abbreviated procedures and prompt resuscitation maneuvers in severely injured trauma patients. However, the initial physiological response to trauma and surgery, along with the hemostatic resuscitation efforts, causes important side effects on intracavitary organs such as tissue edema, increased cavity pressure, and hemodynamic collapse. Consequently, different techniques have been developed over the years for a delayed cavity closure. Nonetheless, the optimal management of abdominal and thoracic surgical closure remains controversial. This article aims to describe the indications and surgical techniques for delayed abdominal or thoracic closure following damage control surgery in severely injured trauma patients, based on the experience obtained by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia. We recommend negative pressure dressing as the gold standard technique for delayed cavity closure, associated with higher wall closure success rates and lower complication and mortality rates.

Integrated Multiorgan Bedside Ultrasound for the Diagnosis and Management of Sepsis and Septic Shock.

Despite decades of research, the mortality rate of sepsis and septic shock remains unacceptably high. Delays in diagnosis, identification of an infectious source, and the challenge of providing patient-tailored resuscitation measures routinely result in suboptimal patient outcomes. Bedside ultrasound improves a clinician's ability to both diagnose and manage the patient with sepsis. Indeed, multiple point-of-care ultrasound (POCUS) protocols have been developed to evaluate and treat various subsets of critically ill patients. These protocols mostly target patients with undifferentiated shock and have been shown to improve clinical outcomes. Other studies have shown that POCUS can improve a clinician's ability to identify a source of infection. Once a diagnosis of septic shock has been made, serial POCUS exams can be used to continuously guide resuscitative efforts. In this review, we advocate that the patient with suspected sepsis or septic shock undergo a comprehensive POCUS exam in which sonographic information across organ systems is synthesized and used in conjunction with traditional data gleaned from the patient's history, physical exam, and laboratory studies. This harmonization of information will hasten an accurate diagnosis and assist with hemodynamic management.

Predictors to forgo resuscitative effort during Covid-19 critical illness at the height of the pandemic : A retrospective cohort study

Background: Early in the Covid-19 pandemic, there was uncertainty regarding critical illness prognosis and challenges to traditional face-to-face family meetings. Ethnic minority populations have suffered disproportionately worse outcomes during the pandemic, which may in part relate to differences in end-of-life decision-making. Aim: Characterize patterns of and factors associated with decisions to forgo resuscitative efforts, as measured by do-not-resuscitate orders, during critical illness with Covid-19. Design: Retrospective cohort with medical record abstraction. Setting/participants: Adult patients diagnosed with SARS-Cov-2 virus via polymerase chain reaction and admitted to the intensive care unit at an academic hospital, which cares for the city’s underserved communities, between March 1 and June 7, 2020 who underwent invasive mechanical ventilation for at least 48 hours. Results: In this cohort (n = 155), 45% were black people, and 51% spoke English as their primary language. Median time to first goals-of-care conversation was 3.9 days (IQR 1.9–7.6) after intensive care unit admission. Overall 61/155 patients (39%) transitioned to do-not-resuscitate status, and 50/62 (82%) patients who died had do-not-resuscitate orders. Multivariate analysis shows age and palliative care involvement as the strongest predictors of decision to instate do-not-resuscitate order. There was no association between race, ethnicity, or language and decisions to forego resuscitation. Conclusions: During this time of crisis and uncertainty with limited resources and strained communication, time to first goals of care conversation was shorter than in pre-pandemic studies, but rates of foregoing resuscitation remained similar, with no differences observed by race, ethnicity, or language. This study suggests that early palliative care involvement and non-traditional communications, including videoconferencing, to facilitate goals of care conversations could have mitigated potential disparities in end-of-life decision making patterns during the pandemic.

Out of Hospital Cardiac Arrest: Saudi Red Crescent Experience Throughout COVID-19 Era.

PurposeThe quality of resuscitation for out hospital cardiac arrest (OHCA) during the COVID-19 era could be affected. We aim to describe prehospital healthcare providers’ resuscitative efforts for OHCA cases and their definitive outcomes.Patients and MethodsThis retrospective cross-sectional study included all OHCA cases between April and June 2021 across all regions in the Kingdom of Saudi Arabia (KSA). Demographic variables, response times, CPR providers, initial rhythm, use of AED/Defibrillator, medical interventions, ROSC data, and dispatch codes were extracted from a central electronic platform.ResultsA total of 1307 OHCA cases were included in this study, males constituted 65% and 42% were ≥65 years. Although the median response time to initiate CPR was 13 min, 11% of OHCA cases had a response time between 0 and 6 min. About 75% of CPR was provided on scene by BLS units, 78% of OHCA cases had asystole as their initial rhythm, an AED/Defibrillator was used more than 90% of the time for pulseless VT/VF rhythm, and ROSC was achieved in 8% of OHCA patients.ConclusionDuring the COVID-19 pandemic, maintaining resuscitative efforts for OHCA continues in KSA. Closing knowledge gaps in the community and a better description of OHCA for the dispatcher could guide dispatch-assisted CPR and minimize OHCA response times.

Chest compression release and recoil dynamics in prolonged manual cardiopulmonary resuscitation

Aim of the studyCharacterize release and recoil dynamics in chest compressions during prolonged cardiopulmonary resuscitation (CPR) efforts, which are increasingly prevalent. MethodsForce and depth of chest compressions, and their rates of change, were calculated from records extracted from CPR monitors used during prolonged resuscitation efforts for out-of-hospital cardiac arrest and tracked over time. Metrics were normalized to the median of the first 100 compressions.Kruskal-Wallis ANOVA and Jonckheere-Terpstra trend analyses were used for differences and trends. Averages are reported as median (interquartile range). Correlations among metrics are reported as coefficients of determination. ResultsIn 471 cases of adult subjects receiving at least 1000 compressions, peak depths varied modestly over the course of extended resuscitation efforts, staying within a narrow range without a trend over the course of resuscitation efforts. Increases in recoil velocity and decreases in recoil interval also remained within limited ranges (5%, 6% variation respectively). By contrast, force waveforms changed substantially. Peak force decreased monotonically reaching a 38% decrease for compression numbers > 3500, similar to a decrease in release rate (39%) and an increase in release interval (39%). ConclusionDepth waveforms change markedly less than do force waveforms over the course of prolonged CPR. With the benefit of feedback, CPR providers effectively adjust the application of force to compensate for changes in chest stiffness, documented previously. Despite slowing release and quickening recoil, interference between release of force and recoil of depth appears limited. Spontaneous chest recoil is well preserved in prolonged duration manual CPR.