Resuscitation Efforts Research Articles

Hyperventilation in cardiac arrest—a systematic review and narrative synthesis

Background: Resuscitation guidelines recommend delivering ventilations at a rate of 10 per minute. However, hyperventilation is commonly reported during out-of-hospital cardiac arrest resuscitation efforts, and the impact of this on patient outcomes is unclear. This review explores the reported rates, causes and patient outcomes of hyperventilation in the management of out-of-hospital cardiac arrest. Methods: A systematic literature review with a narrative synthesis of three databases was carried out. Findings: Thirteen papers met the eligibility criteria. These showed that ventilations were consistently delivered at a higher rate and tidal volume than are internationally recommended. Hyperventilation can occur because of clinician stress, a lack of situational awareness and a focus on other clinical interventions as well as poor leadership. Conclusion: Hyperventilation is common during cardiac arrest management. Currently available human data do not produce sufficient evidence to favour any ventilation strategy; however, a harmful upper limit will exist. This review found no human randomised control studies examining how ventilation rate, tidal volume or pressure affect patient outcomes and this warrants further research.

Spiritual care support of goal concordant care in the oncologic emergency setting.

274 Background: Many patients admitted through emergency departments are near the end of life. Patients who have previously indicated that they do not wish for advanced resuscitation efforts are often admitted to the hospital with a presumption of full code status. Documentation of goals of care discussions (GOC) increases the likelihood of receiving goal concordant care during the ensuing hospitalization. In the fast-paced environment of emergency care, physicians often hesitate to introduce these critical conversations. Healthcare has evolved beyond the physician–patient dyad, it includes a variety of professions. A multi-disciplinary team including physicians, nursing, social work, and spiritual care providers (SCPs) was established to improve compliance of documenting goals of care. Methods: This quality improvement project was initiated in the institution's Acute Cancer Care Center. SCPs, a previously underutilized resource, were enlisted to assist in GOC discussions and advance care planning (ACP) documentation on patients who had previously elected do not resuscitate/do not intubate (DNR/DNI) status. The goal was to increase ACP documentation for these patients by 50% over baseline. The project employed a Plan-Do-Study-Act technique. Patients who had a history of DNR/DNI were automatically identified upon arrival to emergency care based on any of 4 criteria extracted from the electronic medical record: 1) History of DNR order within the past year; 2) advance care plan notes documenting the patient is not “full code”; 3) out of hospital DNR; and 4) previous discharge to hospice. Track boards were updated across multiple disciplines (attending physicians, SCPs, nursing and social work) to identify these patients. SCPs rounded on identified patients who were expected to be admitted based on discussions with nurses/attending physicians. They met with patients to provide support while confirming/updating their goals of care. This allowed attending providers to more easily confirm the patient’s wishes and place appropriate documentation/orders. The project took place during May 2023, using April 2023 as baseline data. Results: The goal of a 50% increase in ACP compliance was exceeded. In the month of April, 25 of 131 identified patients had ACP notes. In May 55 of 151 identified patients had ACP documentation. This represents a relative 89% increase in ACP documentation. An increase in DNR orders was also noted (table). Conclusions: SCPs can serve as a resource for establishing and documenting goals of care for patients in the emergency care setting. Collaborating with SCPs can increase compliance with local and national GOC initiatives.[Table: see text]

Maternal and Neonatal Outcomes at Periviable Gestation throughout Delivery Admission.

The threshold of viability, as well as cutoffs for delivery interventions and neonatal resuscitation, vary by hospital and involve complex counseling. With improvements in neonatal resuscitation and intensive care, the threshold of viability has been decreasing. Decisions regarding delivery planning and neonatal resuscitation efforts should be based on the best available evidence. Our objective was to characterize survival rates and neonatal outcomes following periviable birth at different milestones beginning with prenatal admission through 1 year of life in a contemporary cohort. We performed a retrospective cohort study of all inborn infants without major congenital anomalies who delivered at the University of Alabama at Birmingham from 2013 to 2019 at gestational ages 22+0/7 to 25+6/7. Our primary outcome was to compared survival milestones throughout the pre- and postdelivery periods and neonatal complications in surviving newborns through 1 year of life at each gestational age. The survival rate to 1 year of life was 49% (48-56%, 95% confidence interval [CI]) for the entire cohort and varied according to gestational age at delivery (22 weeks 15% [10-23%, 95% CI], 23 weeks 48% [43-58%, 95% CI], 24 weeks 57% [52-67%, 95% CI], 25 weeks 71% [67-82%, 95% CI]). Overall for the entire cohort, the rate of lung disease requiring respiratory support at discharge was 51%, intraventricular hemorrhage was 42%, retinopathy of prematurity was 74%, pulmonary hypertension was 30%, and concerns for cerebral palsy at 1 year of life was 25%. All outcomes improved with advancing gestational age at delivery. Of infants who delivered during the 22nd week of gestation, 50% received antenatal corticosteroids. Infants exposed to antenatal corticosteroids had more interventions, less pulmonary hypertension, and improved survival to 1 year of life. Knowledge of maternal complications, longitudinal survival rates, and neonatal outcomes of periviable deliveries according to gestational age throughout the admission enhances obstetric and perinatal counseling after hospital admission. · Periviable birth outcomes at different delivery milestones is important for counseling.. · Providing contemporary outcomes for periviable deliveries is critical for accurate counseling.. · Administration of antenatal corticosteroids at 22 weeks' gestation appears beneficial overall..

Resuscitation of people with a do-not-resuscitate order: When does it happen and what are the outcomes?

BackgroundDo-not-resuscitate (DNR) orders allow competent individuals to state their wishes to not receive resuscitation. Despite the existence of a DNR order, resuscitative efforts may still occur. MethodsThe statewide out-of-hospital cardiac arrest (OHCA) registry in Victoria, Australia (population 6.5 million) identified rates of DNR orders and resuscitative efforts in ≥60-year-olds from 2006-2021. ResultsOf 47,322 patients ≥60 years old with OHCA, 2,688 (5.7%) had a DNR order. DNR order was communicated to emergency call-takers in only 332 (12.4%) cases. Bystander resuscitation was commenced in 1,074 (40.0%) patients, with EMS terminating efforts in 346 (32.2%) patients on arrival but commencing resuscitation in 189 others. Strongest predictors of bystander resuscitation were shockable rhythm (OR 7.75, 95% CI 5.04–11.9) and OHCA in public location (OR 4.8, 95% CI 2.0–11.3). Predictors of EMS terminating resuscitation efforts were OHCA in residential aged care facility (OR 1.93, 95% CI 1.47–2.5) and older age (OR 1.02, 95% CI 1.00–1.04). Transfer to hospital was undertaken in 107 patients, with strongest predictors being return of spontaneous circulation (OR 91.1, 95% CI 51.7–160.7) and witnessed OHCA (OR 7.5, 95% CI 3.9–14.5). Only 7 (0.3%) transported patients survived to discharge, with 5 deceased at 12-month follow-up. ConclusionApproximately 5% of EMS-attended OHCAs in ≥60-year-olds involve a patient with a DNR order, with low rates of awareness of DNR orders. Resuscitation is commenced in 47% of patients, and 4% are transported to hospital with very poor outcomes. Strategies to communicate DNR status and respect patients’ autonomy are extremely important.

Do we need standardized management after termination-of-resuscitation attempts? Autoresuscitation in a 67-year-old woman

BackgroundAutoresuscitation is the phenomenon of spontaneous return of circulation after cessation of CPR, also known as the Lazarus phenomenon. Most of the evidence is based on case reports and a few systematic reviews. The occurrence of autoresuscitation may lead to self-reproach and dismay in affected emergency personnel and may rise questions about the correct procedure after terminating resuscitative efforts. In contrast to existing cardiac arrest guidelines there is no standardized approach to terminating resuscitative attempts.CaseWe report a case of out of hospital autoresuscitation in a 67-year-old female after 60 min of advanced cardiac life support. After shock refractory shockable rhythm, we recorded pulseless electrical activity and fixed pupils, consequently resuscitation was terminated. About 50 min later the patient surprisingly showed signs of life. Due to the suggestive history a coronary angiography was performed, showing severe coronary heart disease which necessitated surgical intervention. After ACBP surgery and intensive care followed by treatment on the cardiological ward, she was finally discharged to neurological rehabilitation.ConclusionAs already proposed by existing literature, there should be at least a 10-min interval of close monitoring after abandoning CPR. Transport of a deceased patient should only take place after secure signs of death can be detected. Further investigation is needed to determine which patients are most likely to benefit from an extended observation period. Our case reports highlights the difficulties in death declaration and the importance of close monitoring after abandoning CPR.

Critical systolic blood pressure threshold for endovascular aortic occlusion-A multinational analysis to determine when to place a REBOA.

Systolic blood pressure (SBP) is a potential indicator that could guide when to use a resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma patients with life-threatening injuries. This study aims to determine the optimal SBP threshold for REBOA placement by analyzing the association between SBP pre-REBOA and 24-hour mortality in severely injured hemodynamically unstable trauma patients. We performed a pooled analysis of the aortic balloon occlusion (ABO) trauma and AORTA registries. These databases record the details related to the use of REBOA and include data from 14 countries worldwide. We included patients who had suffered penetrating and/or blunt trauma. Patients who arrived at the hospital with a SBP pre-REBOA of 0 mm Hg and remained at 0 mm Hg after balloon inflation were excluded. We evaluated the impact that SBP pre-REBOA had on the probability of death in the first 24 hours. A total of 1,107 patients underwent endovascular aortic occlusion, of these, 848 met inclusion criteria. The median age was 44 years (interquartile range [IQR], 27-59 years) and 643 (76%) were male. The median injury severity score was 34 (IQR, 25-45). The median SBP pre-REBOA was 65 mm Hg (IQR, 49-88 mm Hg). Mortality at 24 hours was reported in 279 (32%) patients. Math modeling shows that predicted probabilities of the primary outcome increased steadily in SBP pre-REBOA below 100 mm Hg. Multivariable mixed-effects analysis shows that when SBP pre-REBOA was lower than 60 mm Hg, the risk of death was more than 50% (relative risk, 1.5; 95% confidence interval, 1.17-1.92; p = 0.001). In patients who do not respond to initial resuscitation, the use of REBOA in SBPs between 60 mm Hg and 80 mm Hg may be a useful tool in resuscitation efforts before further decompensation or complete cardiovascular collapse. The findings from our study are clinically important as a first step in identifying candidates for REBOA. Prognostic and Epidemiological; Level IV.

Clinicopathological profile & outcome of critically ill patients suffering from Dengue: Single Centre Experience during COVID Pandemic

Introduction: Dengue is endemic in our country contributing significantly in morbidity & mortality. This study was conducted to observe the clinic-pathological profile, presentation & outcome of critically ill dengue patients who required Intensive Care Unit admission. Methods: This observational study was conducted in ICU of a tertiary care hospital in Dhaka city from July 2021 to September 2021. Laboratory confirmed cases of Dengue patients admitted in ICU were included in the study. Results: Total patients were 40 with equal male-female distribution. Mean age of the patients was 39.17 ± 13.83 years with most of them (70%) in age group of 18-40 years. Direct admission through Emergency Room (42.5%) was more than transfer-in from indoor of same hospital & other hospitals (35% & 22.5% respectively). There were multiple reasons for ICU admission including hypotension (commonest reason), breathlessness, diarrhoea, abdominal distension, altered level of consciousness etc. Only 13 (32.5%) patients had co-morbidities like DM, HTN etc, and mean age of them was significantly higher than patients without co-morbidities (50.3 ± 13.31, vs 32.23 ± 6.88). Biochemical parameters showed that TWBC count was normal in most patients (n=27, 67.5%), thrombocytopenia was present in 35 (87.5%) patients during admission, hypocalcaemia was present in most patients (90%), liver enzymes were raised in most patients (87.5% & 95% respectively for AST & ALT) and three patients had AKI. Twenty percent patients needed vasopressor support for shock & 5% needed mechanical ventilator support for respiratory failure. Clinical condition was improved in 38 patients & most of them (82.5%) were transferred out from ICU within 6 days. Only two among forty patients expired despite resuscitative efforts. There was no significant difference in the biochemical parameters between survivors & non-survivors. Conclusion: As dengue specific treatment is not yet available, early recognition of the critically ill patients and immediate supportive treatment along with close monitoring in Intensive Care Unit is life-saving for the patients. Bangladesh Crit Care J September 2023; 11 (2): 68-74

Evaluating a Novel Infant Heart Rate Detector for Neonatal Resuscitation Efforts: Protocol for a Proof-of-Concept Study.

Over 10 million newborns worldwide undergo resuscitation at birth each year. Pediatricians may use electrocardiogram (ECG), pulse oximetry (PO), and stethoscope in determining heart rate (HR), as HR guides the need for and steps of resuscitation. HR must be obtained quickly and accurately. Unfortunately, the current diagnostic modalities are either too slow, obtaining HR in more than a minute, or inaccurate. With time constraints, a reliable robust heart rate detector (HRD) modality is required. This paper discusses a protocol for conducting a methods-based comparison study to determine the HR accuracy of a novel real-time HRD based on 3D-printed dry-electrode single-lead ECG signals for cost-effective and quick HR determination. The HRD's HR results are compared to either clinical-grade ECG or PO monitors to ensure robustness and accuracy. The purpose of this study is to design and examine the feasibility of a proof-of-concept HRD that quickly obtains HR using biocompatible 3D-printed dry electrodes for single-lead neonatal ECG acquisition. This study uses a novel HRD and compares it to the gold-standard 3-lead clinical ECG or PO in a hospital setting. A cross-sectional study is planned to be conducted in the neonatal intensive care unit or postpartum unit of a large community teaching hospital in Toronto, Canada, from June 2023 to June 2024. In total, 50 newborns will be recruited for this study. The HRD and an ECG or PO monitor will be video recorded using a digital camera concurrently for 3 minutes for each newborn. Hardware-based signal processing and patent-pending embedded algorithm-based HR estimation techniques are applied directly to the raw collected single-lead ECG and displayed on the HRD in real time during video recordings. These data will be annotated and compared to the ECG or PO readings at the same points in time. Accuracy, F1-score, and other statistical metrics will be produced to determine the HRD's feasibility in providing reliable HR. The study is ongoing. The projected end date for data collection is around July 2024. The study will compare the novel patent-pending 3D-printed dry electrode-based HRD's real-time HR estimation techniques with the state-of-the-art clinical-grade ECG or PO monitors for HR accuracy and examines how fast the HRD provides reliable HR. The study will further provide recommendations and important improvements that can be made to implement the HRD for clinical applications, especially in neonatal resuscitation efforts. This work can be seen as a stepping stone in the development of robust dry-electrode single-lead ECG devices for HR estimations in the pediatric population. DERR1-10.2196/45512.

Public Out-of-Hospital Cardiac Arrest in Residential Neighborhoods

BackgroundAlthough one-half of all public out-of-hospital cardiac arrests (OHCAs) occur outside private homes in residential neighborhoods, their characteristics and outcomes remain unexplored. ObjectivesThe authors assessed interventions before ambulance arrival and survival for public OHCA patients in residential neighborhoods. MethodsPublic OHCAs from Vienna (2018-2021) and Copenhagen (2016-2020) were designated residential neighborhoods or nonresidential areas. Interventions (cardiopulmonary resuscitation [CPR], automated external defibrillator [AED] attached, and defibrillation) and 30-day survival were compared using a generalized estimation equation model adjusted for age and time of day and presented as ORs. ResultsWe included 1,052 and 654 public OHCAs from Vienna and Copenhagen, respectively, and 68% and 55% occurred in residential neighborhoods, respectively. The likelihood of CPR, defibrillation, and survival in residential neighborhoods vs nonresidential areas (reference) were as follows: CPR Vienna, 73% vs 78%, OR: 0.78 (95% CI: 0.57-1.06), CPR Copenhagen, 83% vs 90%, OR: 0.54 (95% CI: 0.34-0.88), and CPR combined, 76% vs 84%, OR: 0.70 (95% CI: 0.53-0.90); AED attached Vienna, 36% vs 44%, OR: 0.69 (95% CI: 0.53-0.90), AED attached Copenhagen, 21% vs 43%, OR: 0.33 (95% CI: 0.24-0.48), and AED attached combined, 31% vs 44%, OR: 0.53 (95% CI: 0.42-0.65); defibrillation Vienna, 14% vs 20%, OR: 0.61 (95% CI: 0.43-0.87), defibrillation Copenhagen, 16% vs 36%, OR: 0.35 (95% CI: 0.24-0.51), and defibrillation combined, 15% vs 27%, OR: 0.46 (95% CI: 0.36-0.61); and 30-day survival rate Vienna, 21% vs 26%, OR: 0.84 (95% CI: 0.58-1.20), 30-day survival rate Copenhagen, 33% vs 44%, OR: 0.65 (95% CI: 0.47-0.90), and 30-day survival rate combined, 25% vs 36%, OR: 0.73 (95% CI: 0.58-0.93). ConclusionsTwo-thirds of public OHCAs occurred in residential neighborhoods with fewer resuscitative efforts before ambulance arrival and lower survival than in nonresidential areas. Targeted efforts to improve early CPR and defibrillation for public OHCA patients in residential neighborhoods are needed.

Needs Assessment for a Resuscitative Thoracotomy Curriculum for General Surgery Residents in the Northeast Region

Resuscitative thoracotomy (RT) is a high-acuity low occurrence (HALO) procedure with which general surgical resident (GSR) experience and confidence are unknown. We sought to identify and describe this educational gap by conducting a targeted needs assessment for an RT curriculum for GSRs. An online regional needs assessment survey was conducted for an RT curriculum for GSRs. The survey was developed by a group of trauma stakeholders and revised after being piloted on a small, representative group of GSRs. We surveyed GSRs in the Northeast region regarding their experience and confidence with RT; interest in an RT curriculum; and content, format, and scope for an RT curriculum. The survey response rate was 43%, reflecting the viewpoints of GSRs at 8 major training centers across the Northeast. Only 13% of respondents were interested in pursuing a career in Trauma and Critical Care despite 97% of them training at a Level I Trauma Center. Twenty-nine percent and 33% of GSRs had ever assisted with or performed RT, respectively. Twenty-one percent of GSRs reported feeling confident performing RT. Most respondents (98%) agreed or strongly agreed that an RT curriculum would add value to their general surgery education. The most positively rated content topics were resuscitative maneuvers (100% positive responses [PR]), when to cease resuscitative efforts (100% PR), and morbidity and mortality associated with RT (98% PR). The most highly rated learning methods were individual RT simulation time (97% PR) and a tour of the trauma bay equipment (97% PR). This needs assessment demonstrates a lack of experience and confidence with RT, a strong learner interest in an RT curriculum, and a desire for experiential learning methods. Learning objectives are defined herein, and the next steps involve developing educational materials for an RT curriculum for GSRs.

Use of pediatric trauma simulations to facilitate exposure to pediatric trauma resuscitations during training

BackgroundPediatric traumas are often high-acuity but are low-frequency compared to adult trauma activations. This is reflected in the relatively limited experience with these events during training. Although some principles of trauma resuscitation are similar between adults and children, there are also important differences in physiology, injury patterns, and presentation. Therefore, simulation can be used to supplement trainee exposure and enhance their ability to respond to these high-stakes events. MethodsWe developed a multidisciplinary pediatric trauma resuscitation simulation curriculum to increase exposure to pediatric traumas at our institution. The intervention includes monthly sessions in the pediatric resuscitation bays, during which multidisciplinary teams complete 2 full pediatric trauma resuscitation simulations. This is supplemented with formal debriefing, simulation-specific teaching, and standardized trauma cognitive aids. The comprehensiveness of trauma evaluations and resuscitation efforts are evaluated using our institutional structured trauma resuscitation observation tool, and post-simulation surveys are used to assess the impact of the teaching interventions. ResultsNine simulation sessions were conducted with more than 100 participants, including surgical residents, emergency medicine residents, nursing staff, respiratory therapists, and medical students. Completeness of resuscitation efforts improved from 55% to 82% (P < .01) between initial and repeat simulations. Surveyed participants reported improvement in overall team performance on the Team Emergency Assessment Measure (P < .01). ConclusionImplementing a multidisciplinary pediatric trauma simulation curriculum with structured teaching interventions and standardized trauma scripts promotes teamwork and strengthens trainees’ ability to conduct comprehensive evaluations required for high-acuity pediatric traumas.

Practice Preferences using Resuscitative Endovascular Balloon Occlusion of the Aorta for Traumatic Injury Before and After the 2017 EndoVascular and Hybrid Trauma and Bleeding Management Symposium

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique to aid in resuscitative eff orts for hemorrhagic shock. The use of REBOA is not yet commonplace and there is little understanding of real-world practice patterns. The Endovascular and Hybrid Trauma and Bleeding Management Symposium is a large international conference specifically developed to discuss multidisciplinary, endovascular and hybrid approaches to hemorrhage management. We sought to evaluate provider opinions and practice patterns using REBOA for traumatic vascular injury before and after attending this conference. Methods: A detailed survey was completed by a variety of providers before and after the conference. The survey was composed of demographic information, and focused on practice patterns and opinions regarding the implementation of REBOA.Results: We received 186 survey responses (99 pre, 87 post). There was increased perception of feasibility for REBOA in all settings, with the largest increase for pre-hospital and austere military environments (53.5% pre, 67.8% post and 59.6% pre, 73.6% post respectively). While there was no consensus on tolerable occlusion times and indications for utilization, most participants felt that partial REBOA was the most viable technique for prolonging the benefi ts of REBOA, and more participants came to this conclusion after attending the conference (62.2% pre, 81.6% post, p = 0.006). Conclusions: REBOA is an exciting and important advancement in the management of life threatening hemorrhage; however, its implementation has not been codifi ed and there is much variation in practitioners’ understanding of its use. Continued investigation is needed to determine the appropriate indications, methods, and practical limitations of REBOA as a new hemorrhage management paradigm.

Vasopressin versus epinephrine during cardiopulmonary resuscitation of asphyxiated newborns: A study protocol for a prospective, cluster, open label, single-center, randomized controlled phase 2 trial – The VERSE-Trial

IntroductionCurrent neonatal resuscitation guidelines recommend the use of epinephrine during neonatal cardiopulmonary resuscitation (CPR). However, newborns receiving epinephrine continue to have high rates of mortality and neurodevelopmental disability. The infrequent need for neonatal CPR, coupled with an inability to consistently anticipate which newborn infants are at risk of requiring CPR, explains the lack of high-quality evidence (i.e., large randomized clinical trials) to better guide healthcare providers in their resuscitative effort. Therefore, we need neonatal data to determine the optimal vasopressor therapy during neonatal CPR. The current pilot trial will examine the efficacy of vasopressin versus epinephrine during CPR of asphyxiated newborn infants. Methods and analysisThe trial will be a prospective, cluster, open label, single-center, randomized controlled trial on two alternative cardiovascular supportive medications. This study will assess the primary outcome of time to return of spontaneous circulation (ROSC) in newborns requiring CPR in the delivery room who were treated with either vasopressin (intervention) or epinephrine (control). Secondary outcomes such as infant mortality and other clinical outcome measures will also be collected. An estimated 20 newborns will be recruited, and comparisons will be made between asphyxiated infants treated with either drugs. Ethics and disseminationThis study has been approved by the Research Ethics Board at the University of Alberta (June 16, 2023). Study findings will be published in peer-reviewed journals, presented at conferences, and communicated to relevant participants and stakeholders.Trial registration: ClinicalTrial.gov Identifier: NCT05738148. Registered February 21, 2023.

Outcomes of Neonatal Resuscitation With and Without an Intact Umbilical Cord: A Meta-Analysis.

Around the world, very few babies require a more intensive resuscitative effort for stabilization. The optimal timing of an intact umbilical cord to help with resuscitation is controversial. Our objective in the review is to compare the outcomes of neonatal resuscitation with and without an intact umbilical cord. A search of six electronic database libraries was explored for data released between 2014 and 2023. A manual search of secondary references in relevant studies was also performed.Studies focusedonly on randomized controlled trials comparing the outcomes of neonatal resuscitation with and without an intact umbilical cord at any gestational age. Two reviewers retrieved data for relevant outcomes and independently evaluated trial quality and eligibility. Mortality rate and APGAR (appearance, pulse, grimace, activity, and respiration) scores were noted as common in the two studies. Four randomized control trials were assessed for the impact of delayed cord clamping on neonates. One study focused on neurodevelopmental outcomes and noted significant improvement. Other studies noted delayed clamping as beneficial for improvingoxygen saturation, APGAR score, and mortality rate.The meta-analysis included three controlled trials with a total of 528 babies and tested the effects of clamping the umbilical cord either late (n = 264) or early (n = 264). The heterogeneity of mortality and APGAR score at 5 minutes were not significant, which may be because only two studies of each case were available to compare. We concluded that veryfew studies are available to identify a significant impact of delayed cord clamping in neonates. However, delayed clamping for up to 5 minutes is noted as beneficial to the newborn.

Manual Chest Compression versus Automated Chest Compression Device during Day-Time and Night-Time Resuscitation Following Out-of-Hospital Cardiac Arrest: A Retrospective Historical Control Study.

We assessed the effectiveness of automated chest compression devices depending on the time of admission based on the frequency of iatrogenic chest injuries, the duration of in-hospital resuscitation efforts, and clinical outcomes among out-of-hospital cardiac arrest (OHCA) patients. We conducted a retrospective historical control study of OHCA patients in Japan between 2015-2022. The patients were divided according to time of admission, where day-time was considered 07:00-22:59 and night-time 23:00-06:59. These patients were then divided into two categories based on the in-hospital cardiopulmonary resuscitation (IHCPR) device: manual chest compression (mCC) group and automatic chest compression devices (ACCD) group. We used univariate and multivariate ordered logistic regression models adjusted for pre-hospital confounders to evaluate the impact of ACCD use during IHCPR on outcomes (IHCPR duration, CPR-related chest injuries, and clinical outcomes) in the day-time and night-time groups. Among 1101 patients with OHCA (day-time, 809; night-time, 292), including 215 patients who underwent ACCD during IHCPR in day-time (26.6%) and 104 patients in night-time group (35.6%), the multivariate model showed a significant association of ACCD use with the outcomes of in-hospital resuscitation and higher rates of return in spontaneous circulation, lower incidence of CPR-related chest injuries, longer in-hospital resuscitation durations, greater survival to Emergency Department and hospital discharge, and greater survival with good neurological outcome to hospital discharge, though only in the night-time group. Patients who underwent ACCD during in-hospital resuscitation at night had a significantly longer duration of in-hospital resuscitation, a lower incidence of CPR-related chest injuries, and better outcomes.

A simple scoring rule to predict survival to discharge after out of hospital cardiac arrest at the time of ED arrival

BackgroundIt is important to be able to predict the chance of survival to hospital discharge upon ED arrival in order to determine whether to continue or terminate resuscitation efforts after out of hospital cardiac arrest. This study was conducted to develop and validate a simple scoring rule that could predict survival to hospital discharge at the time of ED arrival. MethodsThis was a multicenter retrospective cohort study based on a nationwide registry (Korean Cardiac Arrest Research Consortium) of out of hospital cardiac arrest (OHCA). The study included adult OHCA patients older than 18 years old, who visited one of 33 tertiary hospitals in South Korea from September 1st, 2015 to June 30th, 2020. Among 12,321 screened, 5471 patients were deemed suitable for analysis after exclusion. Pre-hospital ROSC, pre-hospital witness, shockable rhythm, initial pH, and age were selected as the independent variables. The dependent variable was set to be the survival to hospital discharge. Multivariable logistic regression (LR) was performed, and the beta-coefficients were rounded to the nearest integer to formulate the scoring rule. Several machine learning algorithms including the random forest classifier (RF), support vector machine (SVM), and K-nearest neighbor classifier (K−NN) were also trained via 5-fold cross-validation over a pre-specified grid, and validated on the test data. The prediction performances and the calibration curves of each model were obtained. Pre-processing of the registry was done using R, model training & optimization using Python. ResultsA total of 5471 patients were included in the analysis. The AUROC of the scoring rule over the test data was 0.7620 (0.7311–0.7929). The AUROCs of the machine learning classifiers (LR, SVM, k-NN, RF) were 0.8126 (0.7748–0.8505), 0.7920 (0.7512–0.8329), 0.6783 (0.6236–0.7329), and 0.7879 (0.7465–0.8294), respectively. ConclusionA simple scoring rule consisting of five, binary variables could aid in the prediction of the survival to hospital discharge at the time of ED arrival, showing comparable results to conventional machine learning classifiers.

COVID-19 Testing Among Out-of-Hospital Cardiac Arrest Patients: Implications for Public Health

Objective The objective of this study was to compare COVID-19 test positivity among out-of-hospital cardiac arrest patients whose resuscitative efforts were terminated in the field with the surrounding community. Methods This was a retrospective cohort study of out-of-hospital cardiac arrest patients for whom unsuccessful resuscitative efforts were terminated in the field. Emergency medical services (EMS) personnel obtained postmortem COVID-19 nasal swab specimens from these patients between July 1, 2020 and February 28, 2022 to facilitate patient contact tracing and awareness of potential occupational exposure. A chi-square (n-1) was used to compare test result proportions between cardiac arrest patients and the community at large. A Pearson correlation was used to correlate test positivity among the two groups. Results EMS personnel obtained postmortem specimens from 648 cardiac arrest patients; 20 (3.1%) were inconclusive. Of the 628 specimens successfully tested, 69 (11.0%) were positive, and 559 (89.0%) were negative. Monthly positivity ranged from 0.0% to 34.0%. For the community at large, overall test positivity during the same period was 5.1%, with a monthly range from 0.4% to 15.2%. Overall, expired and tested cardiac arrest patients had 5.9% (95%CI 3.68 − 8.59) greater COVID-19 test positivity than the general community. There was significant correlation in monthly positivity rates between the groups (r = 0.778, p < .001, 95%CI0.51 − 0.91). Conclusions Compared to the general population, COVID-19 was over-represented among EMS cardiac arrest patients who died in the field. Postmortem testing by EMS personnel, not typical practice, identified infectious disease cases that would have otherwise gone undetected, indicating potential for future surveillance applications.

Survival following Prehospital Traumatic Cardiac Arrest Resuscitation in the Israel Defense Forces: A Retrospective Study

Background Prehospital traumatic cardiac arrest (TCA) is associated with a poor prognosis and requires urgent interventions to address its potentially reversible causes. Resuscitative efforts of TCA in the prehospital setting may entail significant resource allocation and impose added tolls on caregivers. The Israel Defense Forces Medical Corps (IDF-MC) instructs clinicians to perform a set protocol in the case of TCA, providing prompt oxygenation, chest decompression and volume resuscitation. This study investigates the settings, interventions, and outcomes of TCA resuscitation by IDF-MC teams over 25 years in both combat and civilian settings. Methods Retrospective study of the IDF-MC Trauma Registry between 1997–2022. Search criteria were applied to identify cases where the TCA protocol was initiated. A manual review of cases matching the search criteria was performed by two curators to determine the indications, interventions, and outcomes of casualties with prehospital TCA. Patients for whom interventions were performed outside of the TCA protocol, such as with measurable vital signs, were excluded. The primary outcome was survival to hospital admission, with the secondary outcome being return of vital signs in the prehospital setting. Results Following case review, 149 patients with prehospital TCA were included, with a median age of 21 (interquartile range 19–27). Eighty-four (56.4%) presented with TCA in military or combat settings, with gunshot wounds and blast injuries being the most common mechanisms in this group. For 56 casualties (37.8%), all components of the protocol were performed (oxygenation, chest decompression, and volume resuscitation). Five (3.4%) casualties had return of vital signs in the prehospital setting, but none survived to hospital admission. Conclusion The prognosis of prehospital TCA is poor, and efforts to address its potentially reversible causes may often be futile. These notions may be further emphasized in military settings, where resources are limited, and extensive penetrating injuries are more common.

The Beginning of an ECLS Center: First Successful ECPR in an Emergency Department in Romania-Case-Based Review.

According to the latest international resuscitation guidelines, extracorporeal cardiopulmonary resuscitation (ECPR) involves the utilization of extracorporeal membrane oxygenation (ECMO) in specific patients experiencing cardiac arrest, and it can be considered in situations where standard cardiopulmonary resuscitation efforts fail if they have a potentially reversible underlying cause, among which we can also find hypothermia. In cases of cardiac arrest, both witnessed and unwitnessed, hypothermic patients have higher chances of survival and favorable neurological outcomes compared to normothermic patients. ECPR is a multifaceted procedure that requires a proficient team, specialized equipment, and comprehensive multidisciplinary support within a healthcare system. However, it also carries the risk of severe, life-threatening complications. With the increasing use of ECPR in recent years and the growing number of centers implementing this technique outside the intensive care units, significant uncertainties persist in both prehospital and emergency department (ED) settings. Proper organization is crucial for an ECPR program in emergency settings, especially given the challenges and complexities of these treatments, which were previously not commonly used in ED. Therefore, within a narrative review, we have incorporated the initial case of ECPR in an ED in Romania, featuring a successful resuscitation in the context of severe hypothermia (20 °C) and a favorable neurological outcome (CPC score of 1).

Hypothermia-related resuscitation efforts

Hypothermia-related resuscitation efforts