Return Of Spontaneous Circulation Research Articles

Effects of Endotracheal Weight-Based Epinephrine on Pharmacokinetics and Survival in Swine With a Cardiac Arrest.

The aims of this study were to compare concentration maximum (Cmax), time to Cmax, area under the curve, mean concentration over 4 minutes, and frequency and time to return of spontaneous circulation (ROSC) by group. This was a prospective, experimental study using swine. In total, 40 pigs (n = 8 per group) were assigned as follows: 0.1 mg/kg endotracheal (ET) tube, 1 mg intravenous (IV), 2 mg ET, Cardio Pulmonary Resuscitation (CPR) + defibrillation (CPR + defib), and CPR-Only. Pigs were placed in arrest for 2 minutes, CPR was then initiated for 2 minutes, and epinephrine was then administered and repeated every 4 minutes or until ROSC. Blood samples were collected over 4 minutes. Defibrillation was initiated at 3 minutes and continued every 2 minutes for 30 minutes or until ROSC. CPR + defib and CPR-Only Groups served as controls. The CPR + defib Group had defibrillations but did not receive epinephrine. The CPR-Only Group did not receive defibrillations or epinephrine. The Cmax and area under the curve were significantly higher in the IV Group compared to the 0.1 mg/kg ET Group (P < .05). The time to Cmax was significantly longer in the 0.1 mg/kg Group than the 1 mg IV Group (P = .03). The mean concentration of the 1 mg IV Group was higher than the 0.1 mg/kg ET Group until 180 and 240 seconds. There was no significant difference between the groups relative to time to ROSC (P > .05). Return of spontaneous circulation frequencies were: 0.1 mg/kg ET Group (7 of 8); 1 mg IV Group (5 of 8); and 2 mg ET Group (1 of 8), and both CPR + defib and CPR-Only (0 out of 8). This study challenges the current guidelines relative to ET epinephrine administration. Based on our ROSC data, the 0.1 mg/kg dose of epinephrine by ET should be used as a first-line intervention.

Pre-Hospital Critical Care for Out-of-Hospital Cardiac Arrests with Return of Spontaneous Circulation: A Retrospective Observational Study

Background/Objectives: Out-of-hospital cardiac arrests (OHCAs) are common, with return of spontaneous circulation (ROSC) achieved in approximately 25% of patients. However, it remains unknown whether post-ROSC care delivered by a pre-hospital critical care team (CCT) improves patient outcomes. We therefore aimed to investigate this in OHCA patients admitted to our intensive care unit (ICU). Methods: In this retrospective observational study, consecutive adults with ROSC after non-traumatic OHCA admitted to our ICU between 1 September 2019 and 31 August 2022 were included. We compared patients who received post-ROSC care from a CCT to those who received standard care. The primary outcome was a good neurological outcome on hospital discharge (defined as Cerebral Performance Category 1–2). Descriptive statistics, Area Under the Receiver Operating Characteristic Curve (AUC) values, and adjusted Odds Ratios (ORs) are reported. We constructed multivariable logistic regression models that adjusted for the component variables of the MIRACLE2 score. Results: We included 126 OHCAs (median age 63 years, 69% male), which were largely witnessed (82%), involved bystander cardiopulmonary resuscitation (87%), and had an initial shockable rhythm (61%). The prevalence of good neurological outcomes was higher in patients who received post-ROSC care from a pre-hospital CCT (37% vs. 17%, p = 0.012). The MIRACLE2 score was a strong predictor of good neurological outcomes (AUC 0.932), and in our multivariable analysis, good neurological outcome was associated with both CCT presence post-ROSC (aOR 3.77, 95% CI 1.02–13.89) and the delivery of PHEA (aOR 4.10, 95% CI 1.10–15.27, p = 0.035). Furthermore, in patients meeting the Utstein criteria (n = 69), good neurological outcomes were also more prevalent with CCT presence post-ROSC (62% vs. 29%, p &lt; 0.001). Conclusions: We found that post-ROSC care delivered by a pre-hospital CCT was associated with good neurological outcomes on hospital discharge.

Outcomes from out-of-hospital cardiac arrest in nursing and care homes: a cohort study

BackgroundOut-of-hospital cardiac arrest (OHCA) primarily affects older adults. Individuals in nursing homes are often elderly with significant comorbidities. Nursing homes are staffed by healthcare workers, able to respond immediately to...

Comparison of Tenecteplase Versus Alteplase for the Treatment of Pulmonary Embolism and Cardiac Arrest with Suspected Pulmonary Embolism.

High-risk pulmonary embolism (PE) is a life-threatening disease state with current guidelines recommending reperfusion therapy with systemic thrombolytics in addition to anticoagulation. This was a prospective observational cohort study with a historical control group comparing tenecteplase to alteplase for the treatment of PE or cardiac arrest with suspected PE. The primary outcome was the incidence of institutional protocol deviations defined as incorrect thrombolytic dose administered or the incorrect product compounded. Secondary outcomes included any bleeding event, major bleeding event, all-cause mortality, and for patients with a cardiac arrest, successful return of spontaneous circulation (ROSC). Fifty-four patients were included in the study. Protocol deviations occurred in one patient receiving tenecteplase and one patient receiving alteplase (4.0% vs 3.4%; P = 1.0). There was no difference in all-cause mortality (80% vs 86.2%; P = .72), any bleed (12% vs 13.8%; P = 1.0), major bleed (8.0% vs 6.9%; P = 1.0), or ROSC achievement (22.2% vs 28.6%; P = .73) when comparing tenecteplase to alteplase. Our study demonstrates that tenecteplase may be an alternative thrombolytic to alteplase for treatment of PE or cardiac arrest with suspected PE. Further studies comparing the different systemic thrombolytic agents for PE or cardiac arrest with suspected PE are needed.

Hypothermia theraphy in patients post cardiac arrest

Cardiovascular disease is the leading cause of death in several developing countries, and many of these deaths occur before reaching the hospital due to cardiac arrest. Most patients who return to spontaneous circulation (ROSC) and are brought to the hospital experience severe neurological damage during cardiac arrest, and this damage is the cause of in-hospital mortality. Improvements in survival and neurologic improvement of patients with CA have focused on two main therapy areas. The first area is improved education and skills of medical and paramedical personnel to improve perfusion post CA. The second area is a greater emphasis on post-resuscitation care which includes optimizing oxygenation and ventilation, avoiding hypotension, treating causes of CA such as acute coronary ischemia, and initiating hypothermia therapy if necessary, as in the 2020 guidelines and recommendations from the American Heart Association (AHA), International Liaison Committee of Resuscitation, and European Resuscitation Council covering the entire spectrum of post-resuscitation care. The AHA guidelines 2020 recommend optimizing hypothermia therapy for 24 hours with a target temperature between 320C - 360C in ROSC patients to improve clinical outcomes of neurological status after cardiac arrest. This is contrast to the study of Martinell et al in their research which concluded that there was no significant difference in survival rates within 30 days after cardiac arrest in patients who received either hypothermia therapy or those who did not. Hypothermia therapy, which is currently part of the post-resuscitation care recommendations, has varied variables and remains controversial in its implementation. Based on this, this referent will discuss the effects of hypothermia therapy on post-cardiac arrest patients, the stages, and the practical aspects of implementing hypothermia therapy. Keywords: Return of spontaneous circulation, cardiac arrest, hypothermia.

Lower vs. higher blood pressure targets during intensive care of comatose patients resuscitated from out-of-hospital cardiac arrest-a Bayesian analysis of the BOX trial.

The Blood Pressure and Oxygenation (BOX) targets after out-of-hospital cardiac arrest trial found no statistically significant differences in mortality or neurological outcomes with mean arterial blood pressure targets of 63 vs. 77 mmHg in patients receiving intensive care post-cardiac arrest. In this study, we aimed to evaluate the effect on 1-year mortality and assess heterogeneity in treatment effects (HTEs) using Bayesian statistics. We analyzed 1-year all-cause mortality, 1-year neurological outcomes, and plasma neuron-specific enolase (NSE) at 48 h using Bayesian logistic and linear regressions primarily with weakly informative priors. HTE was assessed according to age, plasma lactate, time to return of spontaneous circulation, primary shockable rhythm, history of hypertension, and ST-segment elevation myocardial infarction. Absolute and relative differences are presented with probabilities of any clinical benefit and harm. All 789 patients in the intention-to-treat cohort were included. The risk difference (RD) for 1-year mortality was 1.5%-points [95% credible interval (CrI): -5.1 to 8.1], with <33% probability of benefit with the higher target. There was 33% probability for a better neurological outcome (RD: 1.5%-points; 95% CrI: -5.3 to 8.3) and 35.1% for lower NSE levels (mean difference: 1.5 µg/L, 95% CrI: -6.0 to 9.1). HTE analyses suggested potential harms of the higher blood pressure target in younger patients. The effects of a higher blood pressure target on overall mortality among comatose patients resuscitated from out-of-hospital cardiac arrest were uncertain. A potential effect modification according to age warrants additional investigation. ClinicalTrials.gov ID NCT03141099.

Using a Neural Network Architecture for the Prediction of Neurologic Outcome for Out-of-Hospital Cardiac Arrests Using Hospital Level Variables and Novel Physiologic Markers

Out-of-hospital cardiac arrest (OHCA) is a major public health burden due to its high mortality rate, sudden nature, and long-term impact on survivors. Consequently, there is a crucial need to create prediction models to better understand patient trajectories and assist clinicians and families in making informed decisions. We studied 107 adult OHCA patients admitted at an academic Emergency Department (ED) from 2018–2023. Blood samples and ocular ultrasounds were acquired at 1, 6, and 24 h after return of spontaneous circulation (ROSC). Six classes of clinical and novel variables were used: (1) Vital signs after ROSC, (2) pre-hospital and ED data, (3) hospital admission data, (4) ocular ultrasound parameters, (5) plasma protein biomarkers and (6) sex steroid hormones. A base model was built using 1 h variables in classes 1–3, reasoning these are available in most EDs. Extending from the base model, we evaluated 26 distinct neural network models for prediction of neurological outcome by the cerebral performance category (CPC) score. The top-performing model consisted of all variables at 1 h resulting in an AUROC score of 0.946. We determined a parsimonious set of variables that optimally predicts CPC score. Our research emphasizes the added value of incorporating ocular ultrasound, plasma biomarkers, sex hormones in the development of more robust predictive models for neurological outcome after OHCA.

Prevalence and Prognostic Impact of ST Segment Elevation in Lead aVR Among Patients with Cardiac Arrest.

In acute coronary syndrome, ST-segment elevation in lead aVR (STE-aVR) indicates global myocardial ischemia, often related to multivessel or severe left main disease, and correlates with increased mortality. The prevalence and prognostic significance of STE-aVR in cardiac arrest (CA) patients is unknown. We identified patients (≥18 years) with CA between 2011 to 2022 who achieved return of spontaneous circulation (ROSC). The first electrocardiogram (ECG) post-ROSC was assessed for STE-aVR, defined as ≥1 mm ST-segment elevation at the J point, measured by two trained assessors. Multivariable logistic regression was used to analyze the association between STE-aVR and outcomes (in-hospital mortality and poor neurologic outcome), adjusted for patient and arrest characteristics. Including 443 CA patients, the median (IQR) age was 61 years (50-72 years), with 60.5% (n=268) male, 65.7% (n=291) presenting with out-of-hospital cardiac arrest (OHCA) and 29.8% (n=132) with shockable rhythms. STE-aVR was observed in 18.3% (n=81) of patients. Those with STE-aVR were more likely to present with OHCA and less likely to have a shockable rhythm (both, P<0.05). STE-aVR was associated with higher in-hospital mortality (86.4% vs 65.8%, P<0.001) and poor neurologic outcomes (90.1% vs 72.9%, P=0.001). After multivariable adjustment, STE-aVR remained associated with higher in-hospital mortality (odds ratio [OR] 2.23; 95% confidence interval [CI]: 1.02-4.84, P=0.04), but not a poor neurologic outcome (OR 2.12; 95% CI: 0.90-4.98, P=0.09). STE-aVR was present in 1 in 5 CA survivors and was independently associated with higher in-hospital mortality.

Development and validation of a prediction model of hospital mortality for patients with cardiac arrest survived 24 hours after cardiopulmonary resuscitation

ObjectiveResearch on predictive models for hospital mortality in patients who have survived 24 h following cardiopulmonary resuscitation (CPR) is limited. We aim to explore the factors associated with hospital mortality in these patients and develop a predictive model to aid clinical decision-making and enhance the survival rates of patients post-resuscitation.MethodsWe sourced the data from a retrospective study within the Dryad dataset, dividing patients who suffered cardiac arrest following CPR into a training set and a validation set at a 7:3 ratio. We identified variables linked to hospital mortality in the training set using Least Absolute Shrinkage and Selection Operator (LASSO) regression, as well as univariate and multivariate logistic analyses. Utilizing these variables, we developed a prognostic nomogram for predicting mortality post-CPR. Calibration curves, the area under receiver operating curves (ROC), decision curve analysis (DCA), and clinical impact curve were used to assess the discriminability, accuracy, and clinical utility of the nomogram.ResultsThe study population comprised 374 patients, with 262 allocated to the training group and 112 to the validation group. Of these, 213 patients were dead in the hospital. Multivariate logistic analysis revealed age (OR 1.05, 95% CI: 1.03–1.08), witnessed arrest (OR 0.28, 95% CI: 0.11–0.73), time to return of spontaneous circulation (ROSC) (OR 1.05, 95% CI: 1.02–1.08), non-shockable rhythm (OR 3.41, 95% CI: 1.61–7.18), alkaline phosphatase (OR 1.01, 95% CI: 1–1.01), and sequential organ failure assessment (SOFA) (OR 1.27, 95% CI: 1.15–1.4) were independent risk factors for hospital mortality for patients who survived 24 h after CPR. ROC of the nomogram showed the AUC in the training and validation group was 0.827 and 0.817, respectively. Calibration curves, DCA, and clinical impact curve demonstrated the nomogram with good accuracy and clinical utility.ConclusionOur prediction model had accurate predictive value for hospital mortality in patients who survived 24 h after CPR, which will be beneficial for assisting in identifying high-risk patients and intervention. Further confirmation of the model's accuracy required external validation data.

A retrospective 'target trial emulation' comparing amiodarone and lidocaine for adult out-of-hospital cardiac arrest resuscitation.

The administration of amiodarone or lidocaine is recommended during the resuscitation of out-of-hospital cardiac arrest (OHCA) patients presenting with defibrillation-refractory or recurrent ventricular fibrillation or ventricular tachycardia. Our objective was to use 'target trial emulation' methodology to compare the outcomes of patients who received amiodarone or lidocaine during resuscitation. Adult, non-traumatic OHCA patients in the ESO Data Collaborative 2018-2023 datasets who experienced OHCA prior to EMS arrival, presented with a shockable rhythm, and received amiodarone or lidocaine during resuscitation were evaluated for inclusion. We used propensity score matching (PSM) to investigate the association between antiarrhythmic and outcomes. Return of spontaneous circulation (ROSC) was the primary outcome. Secondary outcomes included the number of post-drug defibrillations and survival to hospital discharge. After application of exclusion criteria, 23,263 patients from 1,707 EMS agencies were eligible for analysis. Prior to PSM, 6,010/20,284 (29.6%) of the patients who received amiodarone and 1,071/2,979 (35.9%) of the patients who received lidocaine achieved prehospital ROSC. Following PSM, lidocaine administration was associated with greater odds of prehospital ROSC (36.0 vs. 30.4%; aOR: 1.29 [1.16, 1.44], n=2,976 matched pairs). Lidocaine administration was also associated with fewer post-drug defibrillations (median: 2 [0-4] vs. 2 [0-6], mean: 3.3 vs. 3.9, p<0.01, n=2,976 pairs), and greater odds of survival to discharge (35.1 vs. 25.7%; OR: 1.54 [1.19, 2.00], n=538 pairs). Our 'target trial emulation' suggested that lidocaine was associated with greater odds of prehospital ROSC in comparison to amiodarone when administered during resuscitation from shock refractory or recurrent VF/VT.

The association of capillary refill time and return of spontaneous circulation during out-of-hospital cardiac arrest: an observational study

IntroductionMicrocirculatory alterations are predictive of poor outcomes in patients with shock and after cardiac arrest in animal models. However, microcirculatory alterations during human cardiac arrest have not yet been studied.MethodsWe prospectively included adult patients receiving resuscitation after witnessed out-of-hospital cardiac arrest. Exclusion criteria were hypovolemia, hypo- or hyperthermia (< 34.0 °C, > 37.5 °C), peripheral arterial disease, Raynaud’s disease, and logistical issues (e.g., shortage of space). Capillary refill time was measured on the finger (CRT-F) and the earlobe (CRT-E) every other minute until return of spontaneous circulation (any ROSC) or termination of resuscitation. The primary endpoint was any ROSC, secondary endpoints were 30-day-mortality and good neurological outcome (defined as cerebral performance category 1–2). Based on the data structure, CRT-F and CRT-E values were grouped post-hoc into quartiles and tertiles. A cluster-robust standard error logistic regression was performed for the primary outcome. Trend analyses were made for each individual.ResultsAfter screening of 141 patients, 50 were included in the analysis (median age 75 years, 28% female, any ROSC 32%). The median CRT-F was > 10 [7–> 10] seconds; the median CRT-E was 3 [3–4] seconds. The any ROSC rate for patients in CRT-F quartile 1 (3–5 s) was 71.4%, 31.7% in quartile 2 (6–8 s), 23.1% in quartile 3 (9–10 s), and 10% in quartile 4 (> 10 s). The odds ratio of 0.39 (95% CI 0.20–0.73, p = 0.004) indicated, that with an increase of CRT-F by a quartile, the chance of achieving any ROSC decreased by 61%. Patients with a decreasing CRT-F achieved any ROSC in 70%, whereas patients with constant or increasing CRT-F had any ROSC in only 21% (p = 0.008). In contrast, CRT-E showed no association with any ROSC (T1 [1–2 s.]: 16.7%, T2 [3 s.]: 27.5%, T3 [4—> 10 s.]: 22.4%, OR by tertiles: 1.18, 95% CI 0.58–2.44, p = 0.646).ConclusionDuring out-of-hospital cardiac arrest, shorter CRT-F, but not CRT-E, is associated with a higher chance of any ROSC.Trial registration: This trial was pre-registered on clinicaltrials.gov with the number: NCT04791995 on March 2nd, 2021.

Cardiac arrest after hanging: A scoping review.

Hanging is a common cause of suicide and asphyxial cardiac arrest. There are few data to inform the treatment of cardiac arrest after hanging. We designed a scoping review to describe evidence relating to interventions and outcomes in patients with and without cardiac arrest after hanging. Medline, Embase and Cochrane were searched from inception to 05/12/2024. Titles and abstracts were screened, and duplicates were removed. Articles were eligible for inclusion if they studied non-judicial hanging in adults or children, included cardiac arrest patients and provided functional or survival outcomes. The search retrieved 855 articles. One hundred and nineteen references underwent full-text review. Forty-five studies were included in the review. Studies were mainly from high-income countries and were all observational. There was variation in the terminology for hanging and in the outcomes reported. Survival with favourable functional outcome was rare in patients with cardiac arrest after hanging but was very common in patients without cardiac arrest. Cervical spine, airway and vascular injuries were rare. No studies identified interventions that were associated with improved survival following return of spontaneous circulation. There are few data to inform treatment of patients with cardiac arrest after hanging. The available data suggest that cardiac arrest is a critical determinant of poor outcome following hanging. Further research should uniformly report outcomes of patients with cardiac arrest after hanging based on the Utstein template.

An exploratory study on the effect of rescuer team size on basic and advanced life support technical skills in a high-fidelity simulation of canine cardiopulmonary arrest.

To evaluate the effect of rescuer team size on objective skill measures of basic life support (BLS) and advanced life support (ALS) using high-fidelity canine CPR simulation. Prospective, experimental study. Veterinary clinical simulation center. Forty-eight Reassessment Campaign on Veterinary Resuscitation CPR-certified veterinary students. Five groups of participants each conducted 3 CPR simulations in configurations of 4, 6, and 8 rescuers. Simulations represented a shock patient declining into asystole, followed by ventricular fibrillation and return of spontaneous circulation. Resuscitation efforts were video-recorded to evaluate BLS and ALS tasks. Mean (±SD) was derived and data were compared among team sizes using ANOVA and Tukey's post hoc analysis. Significance was set at P<0.05. Among teams of 4, 6, and 8 rescuers, time to first chest compression (13s [±6], 9s [±2], 8s [±4]; P=0.24) and positive-pressure breath (101s [±37], 56s [±15], 67s [±24]; P=0.05) were not significantly different. Chest compression (100/min [±5], 108/min [±6], 107/min [±6]; P=0.12) and ventilatory rates (9/min [±1], respectively, P=0.52) were not significantly different. Time without chest compressions/total length of CPR was not significantly different (72s [±16], 61s [±16], 54s [±8]; P=0.15). Capnography and ECG monitoring were used by all teams. Time to first vasopressor administration was significantly different among team sizes (268s [±70], 164s [±65], 174s [±34]; P=0.04), with vasopressors being most quickly administered by teams of 6 rescuers. Time to electrical defibrillation was not significantly different (486s [±45], 424s [±22], 488s [±181]; P=0.57). Incorrect ALS interventions occurred in 60%, 0%, and 40% of CPR events in 4, 6, and 8 rescuer teams, respectively. Although the achievement of BLS tasks was comparable in teams of 4 rescuers, teams of 6 rescuers may be preferable based on differences in the rate of guideline-incompliant treatments and ALS task efficiency. Teams of 8 rescuers were neither more efficient nor more accurate at conducting BLS and ALS tasks.

Epidemiology and outcomes of patients with cardiac arrest in the emergency department of a lower middle-income country

BackgroundAdvanced cardiovascular life support (ACLS) for cardiac arrest is a cornerstone of emergency care and yet remains poorly studied in low- and middle-income countries. We characterised the clinical epidemiology and...

Sudden Cardiac Arrest Associated with Hemodialysis: A Community-Based Study.

Individuals with end-stage renal disease may be at increased risk of sudden cardiac arrest (SCA) associated with dialysis therapy. However, community-based studies with comprehensive adjudication of SCA are lacking. We conducted a community-based study using a case-case study design in a US population of ≈1 million. All SCA cases with chronic kidney disease (CKD) were ascertained prospectively (2002-2020). We reviewed EMS narratives and archived medical records from regional hospitals to capture patients dialysis history, schedules, and the timing of SCA events in relation to dialysis sessions. Among those on regular hemodialysis, individuals who suffered SCA during hemodialysis or within an hour after completing hemodialysis (Intradialytic/immediate post-HD [IIHD]) were compared to cases with SCA at other times (non-IIHD). Non-compliant individuals or those intolerant of dialysis were excluded. Out of 1,023 SCA cases with CKD, 195 (19.1%) were undergoing regular scheduled hemodialysis. Among these cases, 24.1% were IIHD SCA, while 75.9% occurred non-IIHD. The incidence of SCA during dialysis was 2.9 times higher than expected by chance. SCA events were more likely to occur on dialysis days (65.3% of events) vs. 34.7% events on the 4 off dialysis days (p<0.001). IIHD SCA had higher serum sodium (138.9±4.8 vs. 135.5±5.5 mmol/L, p=0.005), lower serum potassium (3.6±0.7 vs. 5.6±1.6 mmol/L, p<0.001), and higher bicarbonate levels (25.9±6.6 vs. 20.2±5.5 mmol/L, p<0.001) compared to their non-IIHD SCA counterparts. Regarding resuscitation details, IIHD SCA had a higher percentage of shockable rhythm (46.5 vs. 32.4%, p=0.09), witnessed collapse (85.1 vs. 53.4%, p<0.001), bystander CPR (72.3 vs. 37.9%, p<0.001), return of spontaneous circulation (66.0 vs. 42.5%, p=0.005), and survival to hospital discharge (30.4 vs. 5.4%, p<0.001) compared to non-IIHD SCA. In patients undergoing dialysis, SCA events were significantly more common on dialysis days, and 3-fold higher than expected by chance. We identified potential risk factors and survival outcome differences between IIHD vs. non-IIHD SCA groups that warrant future investigation.

A CASE OF INTRAOPERATIVE ARREST &amp; MOBILE ECMO

Over the past two decades, extracorporeal membrane oxygenation (ECMO) has been increasingly used to support critical patients with cardiac and respiratory failure who fail to respond to conventional management. In refractory cardiac arrest, ECMO can restore perfusion in patients who meet specific criteria designed to maximize survival benefit and good neurological outcomes. In recent literature, there is no report of mobile ECMO in a case of prolonged cardiac arrest with direct cardiac massage. We describe our experience with a 34-year-old man with multiple traumatic injuries following a motor vehicle collision. He was treated in a trauma center hospital in the same city as our center. He was initially in stable condition (spontaneous ventilation with FiO2 0.21, no vasoactive drugs, Glasgow 15, no acute kidney injury or other organ dysfunction). One week after admission, a retained left hemopneumothorax required surgical intervention, as previous drainage was ineffective. Computed tomography imaging was also concerning for parencyhmal injury by the thoracotomy tube. Intraoperatively, when the patient was placed in lateral position, he experienced cardiac arrest, presumed to be secondary to pulmonary embolism. After 18 minutes we were asked to rescue this patient with ECMO, as he had no contraindications to support. After 81 minutes of advanced life support, including direct cardiac massage, return of spontaneous circulation was achieved seconds after ECMO was initiated. He was then transported to our hospital. The patient achieved a favorable neurological outcome (Glasgow Coma Scale score of 15 at 24 h) and was discharged after a 2 month stay. This case highlights the potential benefits of prolonged cardiopulmonary resuscitation and ECMO in patients with refractory in-hospital cardiac arrest. In this case, proper ACLS and CPR allowed time for mobile ECMO support to be initiated from a remote center.

Considering veno-venous extracorporeal membrane oxygenation as a first-line strategy for rewarming in accidental hypothermia complicated by cardiac arrest - a case series.

Severe accidental hypothermia can lead to cardiac arrest. The most efficient method of resuscitating and warming is by ECMO (Extracorporeal Membrane Oxygenation). While the convention is to use VA ECMO (Veno Arterial ECMO), using VV ECMO (Veno Venous ECMO) in which the blood is returned directly into the right ventricle could be an alternative and lead to conversion to life sustaining cardiac rhythm. In this article we present our case series of ECMO for resuscitation of accidental hypothermia complicated by cardiac arrest. We used VV ECMO for 4 patients; in 3 of them ROSC (Return of Spontaneous Circulation) was successfully achieved. We also discuss the potential advantages of VV ECMO and VA ECMO in this setting and present our algorithm for management.

Video versus Direct Laryngoscopy for Tracheal Intubation Following Cardiac Arrest: a Secondary Analysis of the DEVICE Trial.

Airway management is a critical component of the care of patients experiencing cardiac arrest, but data from randomized trials on the use of video vs direct laryngoscopy for intubation in the setting of cardiac arrest are limited. Current AHA guidelines recommend placement of an endotracheal tube either during CPR or shortly after return of spontaneous circulation but do not provide guidance around intubation methods, including the choice of laryngoscope. Does use of video laryngoscopy improve the incidence of successful intubation on the first attempt, compared to use of direct laryngoscopy, among adults undergoing tracheal intubation after experiencing cardiac arrest? This secondary analysis of the Direct versus Video Laryngoscope (DEVICE) trial compared video laryngoscopy versus direct laryngoscopy in the subgroup of patients who were intubated following cardiac arrest. The primary outcome was the incidence of successful intubation on the first attempt. Additional outcomes included the duration of laryngoscopy. Among the 1,417 patients in the DEVICE trial, 113 (7.9%) had experienced cardiac arrest prior to intubation, of whom 48 were randomized to the video laryngoscopy group and 65 to the direct laryngoscopy group. Successful intubation on the first attempt occurred in 40 of 48 patients (83.3%) in the video laryngoscopy group and 42 of 65 patients (64.6%) in the direct laryngoscopy group (absolute risk difference, 18.7 percentage points; 95% confidence interval [CI], 1.2 to 36.2; P = 0.03). The mean duration of laryngoscopy was 48.0 seconds (standard deviation [SD], 37.3 seconds) in the video laryngoscope group and 98.0 seconds (SD, 122.4) in the direct laryngoscopy group (mean difference, -50.0; 95% CI, -86.8 to -13.3, P = 0.004). Among adults undergoing tracheal intubation after experiencing cardiac arrest, use of video laryngoscopy was associated with increased incidence of successful intubation on the first attempt and shortened duration of laryngoscopy, compared to use of direct laryngoscopy.

Modelling emergency response times for Out-of-Hospital Cardiac Arrest (OHCA) patients in rural areas of the North of England using routinely collected data

BackgroundNational response time targets for ambulance services are known to be more strongly maintained in urban areas compared to rural. That may mean that responses in rural areas could be less immediate which can in turn affect survival of those experiencing cardiac arrest. Thus, analysis of variation in response times using routinely collected data can be used to understand which rural areas have the highest need for emergency intervention. In this study we have focused, given the heterogeneity of demographic make up, on a specific area of the North of England. Some areas in North England have shown to have a large proportion of cardiac arrests occurring in a rural setting, specifically, in the anonymised study region this was almost half of the cases at 46.3%. Response times to these areas were found to be over 3.5 minutes slower than for urban areas making it worthy of further exploration.MethodsA retrospective observation analysis was conducted on routinely collected data from regional ambulance services for areas within the North of England from April 2016 to March 2021. Information was collected on service and geographic characteristics for 1915 incidents. A multivariable linear mixed effect regression model was used to understand the association between geographical, service factors and response times to cardiac arrest patients. To advance previous research which up to now only used visualisations to analyse ambulance response times, the study used a mixed effects model with a variety of predictors, capturing geographical variation alongside service characteristics.ResultsFrom the cases analysed it was found that the mean response time to scene was 9.1 minutes, with a standard deviation of 6.4 minutes. After adjustment for geographic variation and incorporating robust standard errors into the model: distance to the nearest ambulance station (coefficient = 0.61, 95% confidence interval [CI]: 0.56-0.66), urgency of the call (Category 2, second most urgent, compared to the most urgent coefficient = 1.66, 95% CI: 1.13 - 2.18), location of the nearest ambulance station to the incident and the type of crew who attended the incident (Advanced Paramedic when compared to just Paramedic, coefficient = -0.70, 95% CI: -1.24 - -0.16) were all factors which affected response times to scene.ConclusionFor each extra km the incident was away from an ambulance station, the response time to scene increased by 37 seconds. The ambulance station which displayed the largest increase in response time, Station L was 170 seconds (95% CI: 79, 261) longer than Station N, which had a median performance across all stations, as measured by median survival rate to return of spontaneous circulation (ROSC). The rural geography of the North of England means that lots of cardiac arrest incidents occur a considerable distance away from the stations, emphasising the need to use alternative emergency services technologies within these rural areas to attend to patients sooner.

Radiomics for Predicting the Development of Brain Edema from Normal-Appearing Early Brain-CT After Cardiac Arrest and Return of Spontaneous Circulation.

Background: Hypoxic-ischemic brain injury (HIBI) is a feared complication post-cardiac arrest (CA). The timing of brain imaging remains a topic of ongoing debate. Early computed tomography (CT) scans can reveal acute intracranial pathologies but may have limited predictive value due to delayed manifestation of HIBI-related changes. Radiomics analyses present a promising approach to identifying subtle imaging markers, potentially aiding early HIBI detection. Methods: This study retrospectively assessed post-CA patients between 2016 and 2023 who received immediate brain CTs. Patients without acute intracranial pathology on initial scans and who underwent follow-up brain CTs within 14 days post-return of spontaneous circulation (ROSC) were included. Image segmentation involved manual basalganglia segmentation and automated whole-brain segmentation. Radiomics features were calculated using Pyradiomics (v3.0.1) in 3DSlicer (v5.2.2). Feature selection involved reproducibility analysis via ICC and LASSO regression, retaining five features per segmentation method. A logistic regression model for each segmentation method underwent 5-fold cross-validation. Results were summarized with ROC analyses and average sensitivity and specificity. Results: A total of 83 patients (average age: 65 ± 13.3 years, 19 women) with CA and ROSC were included. Follow-up CT scans after 5.2 ± 2.9 days revealed brain edema in 47 patients. The model using manual segmentation achieved an average AUC of 0.76, sensitivity of 0.59, and specificity of 0.78. The automated segmentation model showed an average AUC of 0.66, sensitivity of 0.49, and specificity of 0.68. Conclusions: Radiomics, particularly focused on the basalganglia area in normal-appearing brain CTs after CA and ROSC, may enhance predictive insights for HIBI and the development of brain edema.