Rhythm Of Pulseless Electrical Activity Research Articles

Association Between QRS Characteristics in Pulseless Electrical Activity and Survival Outcome in Cardiac Arrest Patients: A Systematic Review and Meta-Analysis

Objective Recent studies have shown inconsistent results regarding the association between QRS characteristics and survival outcomes in patients with cardiac arrest and pulseless electrical activity (PEA) rhythms. This meta-analysis aimed to identify the usefulness of QRS width and frequency as prognostic tools for outcomes in patients with cardiac arrest and PEA rhythm. Methods Extensive searches were conducted using Medline, Embase, and the Cochrane Library to find articles published from database inception to 4 June 2023. Studies that assessed the association between the QRS characteristics of cardiac arrest patients with PEA rhythm and survival outcomes were included. The Newcastle-Ottawa Scale was used to assess the methodological quality of the included studies. Results A total of 9727 patients from seven observational studies were included in this systematic review and meta-analysis. The wide QRS group (QRS ≥ 120 ms) was associated with significantly higher odds of mortality than the narrow QRS group (QRS < 120 ms) (odds ratio (OR) = 1.86, 95% confidence interval (CI) = 1.11–3.11, I 2 = 58%). The pooled OR for mortality was significantly higher in patients with a QRS frequency of < 60/min than in those with a QRS frequency of ≥ 60/min (OR = 1.90, 95% CI = 1.19–3.02, I 2 = 65%). Conclusions Wide QRS width or low QRS frequency is associated with increased odds of mortality in patients with PEA cardiac arrest. These findings may be beneficial to guide the disposition of cardiac arrest patients with PEA during resuscitation.

Cardiac arrest after severe epistaxis

Nasal bleeding frequently leads to admissions to the Emergency Department (ED), with anterior nasal packing being a common treatment approach. Our patient was transferred to the ED from a nursing home due to epistaxis, which was already initially managed by nasal packing. Upon arrival at the ED he suffered Cardiopulmonary Arrest (CA) with an initial CA rhythm of Pulseless Electrical Activity (PEA). Advanced Life Support (ALS) was initiated immediately according to the ERC guidelines. Upon intubation, a nasal gauze was aspirated from the endotracheal tube, and approximately ten minutes later, Return of Spontaneous Circulation (ROSC) was achieved. Subsequently, the patient was transferred to the Intensive Care Unit (ICU). Unfortunately, despite medical intervention, the patient succumbed to complications days later. The dislodgement of nasal packing leading to asphyxiation represents a rare but potentially fatal complication of this procedure. Healthcare providers should be vigilant and prepared to promptly address such complications as they arise.

Identifying individuals satisfying the termination of resuscitation rule but having potential to achieve favourable neurological outcome following out-of-hospital cardiac arrest

AimTo develop a simple scoring model that identifies individuals satisfying the termination of resuscitation (TOR) rule but having potential to achieve favourable neurological outcome following out-of-hospital cardiac arrest (OHCA). MethodsThis study analysed the All-Japan Utstein Registry from 1 January 2010 to 31 December 2019. We identified patients satisfying basic life support (BLS) and advanced life support (ALS) TOR rules and determined factors associated with favourable neurological outcome (cerebral performance category scale of 1 or 2) for each cohort using multivariable logistic regression analysis. Scoring models were derived and validated to identify patient subgroups that might benefit from continued resuscitation efforts. ResultsAmong 1,695,005 eligible patients, 1,086,092 (64.1%) and 409,498 (24.2%) satisfied BLS and ALS TOR rules, respectively. One month post-arrest, 2038 (0.2%) and 590 (0.1%) patients in the BLS and ALS cohorts, respectively, achieved favourable neurological outcome. A scoring model derived for the BLS cohort (2 points for age <17 years or ventricular fibrillation/ventricular tachycardia rhythm; 1 point for age <80 years, pulseless electrical activity rhythm, or transport time <25 min) effectively stratified the probability of achieving 1-month favourable neurological outcome, with patients scoring <4 having a probability of <1%, whereas those scoring 4, 5, and 6 having probabilities of 1.1%, 7.1%, and 11.1%, respectively. In the ALS cohort, the probability increased with scores; however, it remained <1%. ConclusionA simple scoring model comprising age, first documented cardiac rhythm, and transport time effectively stratified the likelihood of achieving favourable neurological outcome in patients satisfying the BLS TOR rule.

PO-05-137 ECG MORPHOLOGY IS A DETERMINANT OF SURVIVAL IN PULSELESS ELECTRICAL ACTIVITY

Sudden cardiac arrest (SCA) due to pulseless electrical activity (PEA) has a poor prognosis and identification of cases with a higher likelihood of survival could facilitate the resuscitation process. In PEA, QRS frequency and morphology can vary significantly. To investigate if the frequency and morphology of the QRS can predict survival outcomes in PEA. The study population is drawn from two prospective, community-based studies of out-of-hospital SCA in the U.S.: Oregon SUDS from the Portland, OR metro area (Pop. approx. 1 million; since 2002) and Ventura PRESTO from Ventura County CA (Pop. approx. 850,000, since 2015). In the present study, we included SCA cases resuscitated by EMS that had EMS recording of the ECG available, and PEA was the presenting rhythm. We analyzed QRS frequency, regularity, and width of the presenting PEA rhythm in a subset of 347 PEA-SCA cases (34 survivors and 313 non-survivors). The mean age of the subjects was 70.3±15.5 years and 60.2% were male. The prevalence of QRS frequency >60 bpm was 23.1% and QRS width <120 ms was 32.6%. Females were more likely to have a narrow QRS complex than males (39.9% vs. 27.8%; p=0.02) but there was no sex difference in the QRS frequency. Those with QRS frequency >60 bpm had a higher survival rate than those with QRS frequency <60 bpm (17.5% vs. 7.5%: p=0.02). In addition, cases with QRS width <120 ms had a higher survival rate in comparison to cases with QRS width >120 ms (17.7% vs. 6.0%; p=0.001). Cases with both narrow QRS complex (<120 ms) and fast frequency (>60 bpm) had the highest survival rate (10/38, 26.3%). There was no difference in the survival rate between regular and irregular rhythms. PEAs with electrical activity >60 bpm and narrow QRS complex were associated with higher survival. These results suggest that resuscitation efforts are most likely to be beneficial in PEA-SCA cases that present with a narrow and fast QRS pattern.

Delayed administration of epinephrine is associated with worse neurological outcomes in patients with out-of-hospital cardiac arrest and initial pulseless electrical activity: insight from the nationwide multicentre observational JAAM-OHCA (Japan Association for Acute Medicine) registry.

AimsThe delayed administration of epinephrine has been proven to worsen the neurological outcomes of patients with out-of-hospital cardiac arrest (OHCA) and shockable rhythm or asystole. We aimed to investigate whether the delayed administration of epinephrine might also worsen the neurological outcomes of patients with witnessed OHCA and initial pulseless electrical activity (PEA).Methods and resultsThe JAAM-OHCA Registry is a multicentre registry including OHCA patients between 2014 and 2017. Patients with emergency medical services (EMS)-treated OHCA and initial PEA rhythm were included. The primary exposure was the time from the EMS call to the administration of epinephrine. The secondary exposure was the time to epinephrine dichotomized as early (≤15 min) or delayed (>15 min). The primary outcome was the achievement of a favourable neurological outcome, defined as Cerebral Performance Categories Scale 1–2 at 30 days after OHCA. Out of 34 754 patients with OHCA, 3050 patients were included in the present study. After adjusting for potential confounders, the delayed administration of the epinephrine was associated with a lower likelihood of achieving a favourable neurological outcome [adjusted odds ratio (OR) 0.96; 95% confidence interval (CI) 0.93–0.99; P = 0.016]. The percentage of patients who achieved a favourable neurological outcome in the delayed epinephrine group was lower than that in the early epinephrine group (1.3% vs. 4.7%; adjusted OR 0.33; 95% CI 0.15–0.72; P = 0.005). A restricted cubic spline analysis demonstrated that delayed epinephrine administration could decrease the likelihood of achieving a favourable neurological outcome; this was significant within the first 10 min.ConclusionsThe delayed administration of epinephrine was associated with worse neurological outcomes in patients with witnessed OHCA patients with initial PEA.

Outcomes for in-hospital cardiac arrest for COVID-19 patients at a rural hospital in Southern California.

BackgroundIn-hospital cardiac arrest (IHCA) carries a high mortality and providing resuscitation to COVID-19 patients presents additional challenges for emergency physicians. Our objective was to describe outcomes of COVID-19 patients suffering IHCA at a rural hospital in Southern California.MethodsSingle-center retrospective observational study. A hospital registry of COVID-19 patients was queried for all patients who suffered IHCA and received cardiopulmonary resuscitation (CPR) between May 1st and July 31st, 2020. A manual chart review was performed to obtain patient demographics, oxygen requirement prior to cardiac arrest (CA), details of the resuscitation including presence of an emergency physician, and final disposition.ResultsTwenty-one patients were identified, most of whom were Hispanic, male, and aged 50–70. The most common medical comorbidities were diabetes and hypertension. Most patients suffered respiratory arrest, with an initial rhythm of pulseless electrical activity or asystole. Return of spontaneous circulation (ROSC) was achieved in 3/9 patients already receiving mechanical ventilation, but all 3 expired within the following 24 h. ROSC was achieved in 10/12 patients not already intubated, though most also expired within a few days. The only 2 patients who survived to discharge suffered respiratory arrest after their oxygen delivery device dislodged.ConclusionAt a small rural hospital with limited resources and a predominantly Hispanic population, cardiac arrest in a COVID-19 patient portends an extremely poor prognosis. A better appreciation of these outcomes should help inform emergency providers and patients when discussing code status and attempts at resuscitation, particularly in resource limited settings.

Usefulness of thrombolysis in cardiac arrest secondary to suspected or confirmed pulmonary embolism

Acute pulmonary embolism (PE) is a form of venous thromboembolism associated with significant morbidity and mortality. Massive PE, characterized by hemodynamic instability, has been reported as a common cause of cardiac arrest. Thrombolytic agents have therefore been identified as a potential rescue therapy to restore circulatory perfusion. This study describes use patterns of systemic thrombolysis in cardiac arrest and corresponding patient outcomes. A multicenter retrospective chart review was conducted to evaluate adult patients who received rescue thrombolysis during cardiac arrest for suspected or confirmed PE. A total of 27 patients were included. PE was confirmed in 4 patients (15%). Pulseless electrical activity was the initial rhythm in 21 patients (78%), with a median cardiac arrest duration of 23 minutes in patients with return of spontaneous circulation (ROSC) vs 42.5 minutes in patients without ROSC. Among the 11 patients (41%) with ROSC, two (7%) survived to hospital discharge. Notable characteristics of the two survivors included a confirmed PE, an initial presenting rhythm of pulseless electrical activity, and administration of alteplase within 5 minutes of cardiac arrest. We recommend early administration of rescue thrombolysis when there is a high clinical index of suspicion that PE is the cause of the arrest.

Reduction of in-hospital cardiac arrest with sequential deployment of rapid response team and medical emergency team to the emergency department and acute care wards.

PurposeThis study aimed to determine if sequential deployment of a nurse-led Rapid Response Team (RRT) and an intensivist-led Medical Emergency Team (MET) for critically ill patients in the Emergency Department (ED) and acute care wards improved hospital-wide cardiac arrest rates.MethodsIn this single-center, retrospective observational cohort study, we compared the cardiac arrest rates per 1000 patient-days during two time periods. Our hospital instituted a nurse-led RRT in 2012 and added an intensivist-led MET in 2014. We compared the cardiac arrest rates during the nurse-led RRT period and the combined RRT-MET period. With the sequential approach, nurse-led RRT evaluated and managed rapid response calls in acute care wards and if required escalated care and co-managed with an intensivist-led MET. We specifically compared the rates of pulseless electrical activity (PEA) in the two periods. We also looked at the cardiac arrest rates in the ED as RRT-MET co-managed patients with the ED team.ResultsHospital-wide cardiac arrests decreased from 2.2 events per 1000 patient-days in the nurse-led RRT period to 0.8 events per 1000 patient-days in the combined RRT and MET period (p-value = 0.001). Hospital-wide PEA arrests and shockable rhythms both decreased significantly. PEA rhythms significantly decreased in acute care wards and the ED.ConclusionImplementing an intensivist-led MET-RRT significantly decreased the overall cardiac arrest rate relative to the rate under a nurse-led RRT model. Additional MET capabilities and early initiation of advanced, time-sensitive therapies likely had the most impact.

Abstract 370: Electrical Features Of Pulseless Electrical Activity Associated With Cardiac Arrest Outcomes

Introduction: The cardiac arrest rhythm of pulseless electrical activity (PEA) poses various diagnostic and therapeutic challenges. PEA may represent a spectrum of arrest conditions with variable responses to resuscitation care. Aim: We analyzed PEA rhythms to identify diagnostic patterns associated with survival in cardiac arrest. Methods: In this retrospective cohort study, we utilized the Portland Resuscitation Outcomes Consortium database of out-of-hospital cardiac arrests compiled by the Tualatin Valley Fire and Rescue from 2006-2016. Recordings from defibrillation pads included compression waveforms, electrocardiogram, and transthoracic impedance signals. For each patient, we analyzed the first two pauses in chest compressions, characterized by flat compression and impedance signals. Features extracted from raw ECG signals included contraction frequency and variability. Signal Fourier transformation and 0-100 Hz band pass filtering yielded signals’ distribution across a frequency spectrum from which signal power was extracted. Extraction of the three most prominent frequencies was performed from the Gaussian filtered frequency spectrum. Non-parametric tests (Mann-Whitney, Fisher) and logistic regression methods were used for analysis. Results: Fifty-nine ECG recordings were analyzed corresponding to 7 (11.9%) survivors and 52 (88.1%) non-survivors. Median age was 72 (IQR 20), and 28.8% (17/59) were female. No significant differences were noted in sex or median age between survivors and non-survivors. Analysis of the first ECG pause showed a higher first peak median frequency among survivors (2.15 vs 0.06 Hz, p=0.049). We did not find a significant association between the second peak median frequency of the first ECG segment (6.46 vs 1.49 Hz, p=0.882) or the signal power of the second ECG segment (108.04 vs 100.77 Hz, p=0.647) with survival. Regression analysis did not provide reliable outcome prediction models for survival in this preliminary cohort. Conclusion: Computerized analysis of PEA ECG waveforms offers alternate approaches to bedside signal interpretation that may correlate with survival. Our preliminary work offers a potential approach to PEA analysis that will require application to a larger PEA arrest cohort.

Abstract 232: Delayed Administration of Epinephrine is Associated with Worse Neurological Outcomes in Patients with Out-of-hospital Cardiac Arrest and Initial Pulseless Electrical Activity

Background: Delayed administration of epinephrine has been proven to worsen the neurological outcomes of patients with out-of-hospital cardiac arrest (OHCA) and initial shockable rhythm. We aimed to investigate whether delayed administration of epinephrine might also worsen the neurological outcomes of patients with witnessed OHCA and initial pulseless electrical activity (PEA). Methods: The Japanese Association for Acute Medicine - out-of-hospital cardiac arrest (JAAM-OHCA) Registry is a multicenter, prospective, observational registry including 34,754 OHCA patients between 2014 and 2017. The present study assessed the impact of the time to epinephrine administration on neurological outcomes in patients with witnessed non-traumatic OHCA with initial rhythm of PEA. The primary outcome was defined as Cerebral Performance Categories (CPC) Scale 1-2 at 30 days after OHCA. The association between the odds ratio for the primary outcome and the time from witnessed OHCA to epinephrine administration was assessed with a restricted cubic spline analysis. Results: Out of 34,754 patients with OHCA, 3,050 patients with OHCA and initial PEA who received epinephrine were included in the present study. Mean age was 73.7 years and 1836 (60.2%) was male. After adjusting for potential confounders, the time from witnessed OHCA to epinephrine administration was associated with lower likelihood of favorable neurological outcomes (odds ratio [OR] 0.92; 95% confidence interval [CI] 0.89-0.96; P&amp;lt;0.001). The restricted cubic spline analysis demonstrated that delayed epinephrine administration could decrease the likelihood of a favorable neurological outcome; this was significant within the first 10 minutes. Conclusions: Delayed administration of epinephrine was associated with worse neurological outcomes in patients with witnessed OHCA patients with initial PEA.

A BRIDGE INTO TROUBLED MYOCARDIUM

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Myocardial bridging refers to the anomalous intra-myocardial course of a segment of a major coronary artery. Though usually benign, it may manifest in peculiar situations. CASE PRESENTATION: A 47-year-old male with a history of moderate persistent asthma presented with a severe acute exacerbation. On arrival to the emergency department, there was a witnessed cardiopulmonary arrest requiring intubation and advanced cardiac life support for an initial rhythm of pulseless electrical activity. Sustained return of spontaneous circulation was achieved after the administration of 1mg of intravenous epinephrine. Subsequent 12 lead electrocardiogram (ECG) demonstrated 3mm ST-segment elevations in leads aVR and V1, with widespread ST-segment depressions (figure 1a). An emergent left heart catheterization revealed hyper-dynamic contractility and a rhythmic occlusion of the proximal left anterior descending with near total occlusion during systole (figure 2b) that became non-obstructed during diastole (figure 2a). On ECG thirty minutes later, at a notably slower heart rate, there was resolution of the ST segment abnormalities (figure 1b). DISCUSSION: The myocardial bridge of an epicardial coronary artery is usually an incidental finding on autopsy. However, scant observational data have revealed potential clinical manifestations including dysrhythmias, acute coronary syndromes and sudden cardiac death.[1] The hemodynamic implications of this phenomenon may depend on certain aspects of the intra-myocardial course such as the depth, length and orientation of fibers. Physiologic stressors have been shown to unmask an otherwise clinically irrelevant bridge by reducing coronary blood flow during both phases of the cardiac cycle; tachycardia results in shortened diastolic filling time, and hyper-contractility augments the dynamic compression of the bridged segment during systole. Ostensibly, exogenous epinephrine may exaggerate these mechanisms resulting in potentially catastrophic consequences, as seen in our case.[2] Therapeutic strategies are primarily aimed at reduction in the hemodynamic disturbance of the bridge. Despite a paucity of randomized clinical trials, beta blockers and calcium channel blockers have proven beneficial. Per contra, pure vasodilators such as nitrates have been shown to worsen the pressure gradient across the bridge leading to poorer clinical outcomes. Stenting, myotomy and bypass grafting may also be considered in refractory cases.[1] CONCLUSIONS: In critically ill patients, especially those in hyper-adrenergic states, fluctuating myocardial ischemia may be a sign of myocardial bridging. Reference #1: Corban MT, Hung OY, Eshtehardi P, Rasoul-Arzrumly E, McDaniel M, Mekonnen G, Timmins LH, Lutz J, Guyton RA, Samady H. Myocardial Bridging. J Am Coll Cardiol. 2014 Jun, 63 (22) 2346-2355. Reference #2: Ge J, Jeremias A, Rupp A, et al. New signs characteristic of myocardial bridging demonstrated by intracoronary ultrasound and Doppler. Eur Heart J. 1995;20:1707–16. Reference #3: Ripa C, Melatini MC, Olivieri F, Antonicelli R. Myocardial bridging: A 'forgotten’ cause of acute coronary syndrome - a case report. Int J Angiol. 2007;16(3):115–118. doi:10.1055/s-0031-1278262. DISCLOSURES: No relevant relationships by William Kogler, source=Web Response No relevant relationships by Michael Omar, source=Web Response No relevant relationships by Pujan Patel, source=Web Response No relevant relationships by Patrisha Shelley, source=Web Response

Prevalence and Outcomes of Pediatric In-Hospital Cardiac Arrest Associated With Pulmonary Hypertension.

In adult in-hospital cardiac arrest, pulmonary hypertension is associated with worse outcomes, but pulmonary hypertension-associated in-hospital cardiac arrest has not been well studied in children. The objective of this study was to determine the prevalence of pulmonary hypertension among children with in-hospital cardiac arrest and its impact on outcomes. Retrospective single-center cohort study. PICU of a quaternary care, academic children's hospital. Children (<18 yr old) receiving greater than or equal to 1 minute of cardiopulmonary resuscitation (cardiopulmonary resuscitation) for an index in-hospital cardiac arrest with an echocardiogram in the 48 hours preceding in-hospital cardiac arrest, excluding those with cyanotic congenital heart disease. None. Of 284 in-hospital cardiac arrest subjects, 57 (20%) had evaluable echocardiograms, which were analyzed by a cardiologist blinded to patient characteristics. Pulmonary hypertension was present in 20 of 57 (35%); nine of 20 (45%) had no prior pulmonary hypertension history. Children with pulmonary hypertension had worse right ventricular systolic function, measured by fractional area change (p = 0.005) and right ventricular global longitudinal strain (p = 0.046); more right ventricular dilation (p = 0.010); and better left ventricular systolic function (p = 0.001). Children with pulmonary hypertension were more likely to have abnormal baseline functional status and a history of chronic lung disease or acyanotic congenital heart disease and less likely to have sepsis or acute kidney injury. Children with pulmonary hypertension were more likely to have an initial rhythm of pulseless electrical activity or asystole and were more frequently treated with inhaled nitric oxide (80% vs 32%; p < 0.001) at the time of cardiopulmonary resuscitation. On multivariable analysis, pulmonary hypertension was not associated with event survival (14/20 [70%] vs 24/37 [65%]; adjusted odds ratio, 1.30 [CI95, 0.25-6.69]; p = 0.77) or survival to discharge (8/20 [40%] vs 10/37 [27%]; adjusted odds ratio, 1.17 [CI95, 0.22-6.44]; p = 0.85). Pulmonary hypertension physiology preceding pediatric in-hospital cardiac arrest may be more common than previously described. Among this cohort with a high frequency of inhaled nitric oxide treatment during cardiopulmonary resuscitation, pulmonary hypertension was not associated with survival outcomes.

P083: Innovative use of AED by RNs and RTs during in-hospital cardiac arrest (Phase III)

Introduction: In-hospital cardiac arrest (IHCA) most commonly occurs in non-monitored areas, where we observed a 10min delay before defibrillation (Phase I). Nurses (RNs) and respiratory therapists (RTs) cannot legally use Automated External Defibrillators (AEDs) during IHCA without a medical directive. We sought to evaluate IHCA outcomes following usual implementation (Phase II) vs. a Theory-Based educational program (Phase III) allowing RNs and RTs to use AEDs during IHCA. Methods: We completed a pragmatic before-after study of consecutive IHCA. We used ICD-10 codes to identify potentially eligible cases and included IHCA cases for which resuscitation was attempted. We obtained consensus on all data definitions before initiation of standardized-piloted data extraction by trained investigators. Phase I (Jan.2012-Aug.2013) consisted of baseline data. We implemented the AED medical directive in Phase II (Sept.2013-Aug.2016) using usual implementation strategies. In Phase III (Sept.2016-Dec.2017) we added an educational video informed by key constructs from a Theory of Planned Behavior survey. We report univariate comparisons of Utstein IHCA outcomes using 95% confidence intervals (CI). Results: There were 753 IHCA for which resuscitation was attempted with the following similar characteristics (Phase I n = 195; II n = 372; III n = 186): median age 68, 60.0% male, 79.3% witnessed, 29.7% non-monitored medical ward, 23.9% cardiac cause, 47.9% initial rhythm of pulseless electrical activity and 27.2% ventricular fibrillation/tachycardia (VF/VT). Comparing Phases I, II and III: an AED was used 0 times (0.0%), 21 times (5.6%), 15 times (8.1%); time to 1st rhythm analysis was 6min, 3min, 1min; and time to 1st shock was 10min, 10min and 7min. Comparing Phases I and III: time to 1st shock decreased by 3min (95%CI -7; 1), sustained ROSC increased from 29.7% to 33.3% (AD3.6%; 95%CI -10.8; 17.8), and survival to discharge increased from 24.6% to 25.8% (AD1.2%; 95%CI -7.5; 9.9). In the VF/VT subgroup, time to first shock decreased from 9 to 3 min (AD-6min; 95%CI -12; 0) and survival increased from 23.1% to 38.7% (AD15.6%; 95%CI -4.3; 35.4). Conclusion: The implementation of a medical directive allowing for AED use by RNs and RRTs successfully improved key outcomes for IHCA victims, particularly following the Theory-Based education video. The expansion of this project to other hospitals and health care professionals could significantly impact survival for VF/VT patients.

Cardiac arrest with pulseless electrical activity rhythm in newborn infants: a case series

The 2015 neonatal resuscitation guidelines added ECG to assess an infant’s heart rate when determining the need for resuscitation at birth. However, a recent case report raised concerns about this...

Electrocardiography vs. Auscultation to Assess Heart Rate During Cardiac Arrest With Pulseless Electrical Activity in Newborn Infants.

Background: In 2015, the neonatal resuscitation guidelines incorporated the use of electrocardiography (ECG) to monitor heart rate of newborns. However, previous studies have indicated that cardiac arrest with pulseless electrical activity rhythm (PEA) may occur in the delivery room, rendering this method problematic.Objective: To evaluate the accuracy of ECG and auscultation to assess heart rate during PEA.Methods: A total of 45 piglets (age 1–3 days, weight 1.7–2.3 kg) were exposed to 30 min normocapnic alveolar hypoxia followed by asphyxia until asystole, achieved by disconnecting the ventilator and clamping the endotracheal tube. During asphyxia, heart rate (HR) was assess using auscultation, ECG, and carotid blood flow (CBF). At the time of asystole (defined as zero CBF) HR auscultated using a neonatal/infant stethoscope was compared to ECG traces.Results: The median (IQR) duration of asphyxia was 325 (200–491) s. In 8 (18%) piglets, CBF, ECG, and auscultation identified asystole. In 22 (49%) piglets no CBF and no audible heart sounds, were observed, while ECG displayed a HR ranging from 17 to 75/min. Fifteen (33%) piglets remained bradycardic (defined as HR of < 100/min) after 10 min of asphyxia, which was identified by CBF, ECG, and auscultation. The overall accuracy of ECG and auscultation in the detection of HR were 51 and 80%, respectively (p = 0.004).Conclusion: In cases with PEA ECG is not superior in correctly identifying HR in newborn piglets.

Abstract 284: Association of Neurological Outcome and Survival With Interventions by Bystander and Emergency Medical Service for Unwitnessed Out-of-Hospital Cardiac Arrest Patient; Results From the JCS-ReSS Study

Introduction: Although studies have shown that bystander cardiopulmonary resuscitation (CPR) in witnessed out-of-hospital cardiac arrest (OHCA) is associated with better neurological prognosis, whether bystander and Emergency Medical Service (EMS) interventions are associated with prognosis in unwitnessed OHCA patients is not fully elucidated. We aimed to investigate the prognostic importance of bystander and EMS interventions among unwitnessed OHCA patients in Japan. Methods and Results: This study was a nation-wide population-based observational study of OHCA in Japan from 2011 to 2015 based on data from the All-Japan Utstein Registry. The outcome measures were neurological outcome and survival at 30-day. The neurologically favorable outcome was defined as Glasgow-Pittsburgh cerebral performance category score 1 or 2. First, to investigate the effectiveness of bystander interventions, we included 105,655 unwitnessed cardiogenic OHCA patients (aged 18-80 years). Of these, 1,614 (1.5%) showed neurologically favorable outcome and 3,273 (3.1%) survived at 30-day. Multivariate logistic regression analysis adjusting for age, sex, geographical region, year and EMS response time showed that bystander CPR was associated with neurologically favorable outcome (adjusted odds ratio [aOR] 1.49, 95% CI 1.35-1.65, P&lt;0.001). Additionally, to investigate the effectiveness of EMS interventions for patients with non-shockable rhythm, we examined 43,342 patients who were performed public CPR and had the initial rhythm of pulseless electrical activity (PEA) or asystole. Of these, 101 (0.2%) showed neurologically favorable outcome and 453 (1.0%) were survival at 30-day. Advanced airway management by EMS was negatively associated with neurologically favorable outcome (aOR 0.55, 95% CI 0.37-0.81, P=0.003) and administration of epinephrine by EMS was associated with survival (aOR 2.35, 95% CI 1.89-2.92, P&lt;0.001). Conclusions: Among unwitnessed OHCA patients, bystander CPR was associated with neurologically favorable prognosis. For unwitnessed OHCA patients with non-shockable rhythm, epinephrine administration was associated with survival, but advanced airway management was negatively associated with neurological outcome.

The Case Files

The Case Files

P003: Which factors predict resuscitation outcomes in patients arriving to the emergency department in cardiac arrest? A SHoC series study

Introduction: The decision as to whether to end resuscitation for pre-hospital cardiac arrest (CA) patients in the field or in the emergency department (ED) is commonly made based upon standard criteria. We studied the reliability of several easily determined criteria as predictors of resuscitation outcomes in a population of adults in CA transported to the ED. Methods: A retrospective database and chart analysis was completed for patients arriving to a tertiary ED in cardiac arrest, between 2010 and 2014. Patients were excluded if aged under 19. Multiple data were abstracted from charts using a standardized form. Regression analysis was used to compare criteria that predicted return of spontaneous circulation (ROSC) and survival to hospital admission (SHA). Results: 264 patients met the study inclusion criteria. Logistic regression was used to identify predictors of ROSC and SHA. The criteria that emerged as significant predictors for ROSC included; longer ED resuscitation time (Odds ratio 1.11 (1.06- 1.18)), witnessed arrest (Odds ratio 9.43 (2.58- 53.0)) and having an initial cardiac rhythm of Pulseless Electrical Activity (Odds Ratio 3.23 (1.07-9.811)) over Asystole. Receiving point of care ultrasound (PoCUS; Odds ratio 0.22 (0.07-0.69)); and having an initial cardiac rhythm of Pulseless Electrical Activity (Odds Ratio 4.10 (1.43-11.88)) were the significant predictors for SHA. Longer times for ED resuscitation was close to reaching significance for predicting SHA Conclusion: Our results suggest that both fixed and adaptable factors, including increasing resuscitation time, and PoCUS use in the ED were important independent predictors of successful resuscitation. Several commonly used criteria were unreliable predictors.

Utility of prehospital electrocardiogram characteristics as prognostic markers in out-of-hospital pulseless electrical activity arrests

BackgroundIt is unclear if there are predictors of survival, including ECG characteristics, that can guide resuscitative efforts in pulseless electrical activity (PEA) cardiac arrests. We studied the predictive potential of...

Improvements in Out-of-Hospital Cardiac Arrest Survival from 1998 to 2013

Objectives: Out-of-hospital cardiac arrest (OHCA) remains a major public health burden. Aggregate OHCA survival to hospital discharge has reportedly remained unchanged at 7.6% for almost 30 years from 1970 to 2008. We examined the trends in adult OHCA survival over a 16-year period from 1998 to 2013 within a single EMS agency. Methods: Observational cohort study of adult OHCA patients treated by Tualatin Valley Fire & Rescue (TVF&R) from 1998 to 2013. This is an ALS first response fire agency that maintains an active Utstein style cardiac arrest registry and serves a population of approximately 450,000 in 9 incorporated cities in Oregon. Primary outcomes were survival to hospital discharge in all patients and in the subgroup with witnessed ventricular fibrillation/pulseless ventricular tachycardia (VF/VT). The impact of key covariates on survival was assessed using univariate logistic regression. These included patient factors (age and sex), event factors (location of arrest, witnessed status, and first recorded cardiac arrest rhythm), and EMS system factors (response time interval, bystander CPR, and non-EMS AED shock). We used multivariate logistic regression to examine the impact of year increment on survival after multiple imputation for missing data. Sensitivity analysis was performed with complete cases. Results: During the study period, 2,528 adult OHCA had attempted field resuscitation. The survival rate for treated cases increased from 6.7% to 18.2%, with witnessed VF/VT cases increasing from 14.3% to 31.4% from 1998 to 2013. Univariate analysis showed that younger age, male sex, public location of arrest, bystander or EMS witnessed event, initial rhythm of pulseless electrical activity (PEA) or VF/VT, bystander CPR, non-EMS AED shock, and a shorter EMS response time were independently associated with survival. After adjustment for covariates, the odds of survival increased by 9% (OR 1.09, 95%CI: 1.05–1.12) per year in all treated cases, and by 6% (OR 1.06, 95% 1.01–1.10) per year in witnessed VF/VT subgroups. Findings remained consistent on sensitivity analysis. Conclusions: Overall survival from treated OHCA has increased over the last 16 years in this community. These survival increases demonstrate that OHCA is a treatable condition that warrants further investigation and investment of resources.