Unwitnessed Cardiac Arrest Research Articles

Hypothermic cardiac arrest: prognostic factors for successful resuscitation before rewarming.

To indicate factors predicting return of spontaneous circulation in patients with hypothermic cardiac arrest in the pre-rewarming period. A multicenter retrospective study was conducted. We included patients who had suffered cardiac arrest caused by severe accidental hypothermia with a core body temperature of ≤ 28°C. Patients who had achieved return of spontaneous circulation before commencement of active rewarming at the hospital were compared to those who remained in cardiac arrest. A total of 156 patients suffering hypothermic cardiac arrest were included in the study. In 14 of them (9%) resuscitation was successful before rewarming. Factors associated with return of spontaneous circulation were as follows: witnessed onset of cardiac arrest (p = 0.04); a higher core body temperature (p = 0.005) with a prognostic threshold of 24.6°C; and a higher arterial oxygen partial pressure (p = 0.04) with a prognostic threshold of 81mmHg. One patient after successful resuscitation sustained recurrence of cardiac arrest during rewarming. Patients with core body temperature < 25°C, hypoxemia, and those who sustained unwitnessed hypothermic cardiac arrest have weak chances for successful resuscitation before rewarming. They can benefit from immediate transportation to an extracorporeal life support facility under continuous cardiopulmonary resuscitation. Effective rewarming and oxygenation during the prehospital period can increase the chances for return of spontaneous circulation. Recurrence of cardiac arrest during rewarming is uncommon.

Abstract 4136643: Automated cardiac arrest detection using a photoplethysmography wristband: Evaluation of the time to detection of the circulatory arrest event

Introduction: Out-of-hospital cardiac arrest survival depends on immediate recognition and early cardiopulmonary resuscitation. For victims of unwitnessed cardiac arrest, accounting for 30-50% of cases worldwide, survival chances are dismal as help often comes too late. Automated cardiac arrest detection and alarming would offer a solution to shorten treatment delays. Within the DETECT project, a wristband with the functionality of automated cardiac arrest detection is developed. During the DETECT-1 study, we developed a photoplethysmography (PPG) algorithm to detect circulatory arrest in patients with induced circulatory arrest. Research question: In this sub analysis of the DETECT-1 study, we aim to study the delay between the actual circulatory arrest and the algorithms’ cardiac arrest alarm. Methods: Patients undergoing circulatory arrest induction during transcatheter aortic valve implantation (TAVI), subcutaneous ICD (S-ICD) implantation or ventricular tachycardia (VT) ablation wore a PPG wristband. Continuous ECG and arterial blood pressure data were collected as reference standard. PPG data were used to develop a circulatory arrest detection algorithm in three training iterations and one validation. Time to detection was defined as the difference between the algorithm’s cardiac arrest alarm and the circulatory arrest annotated based on the arterial blood pressure data. Results: The validation set consisted of 86 patients (77 TAVI, 3 S-ICD, 6 VT ablation) with 97 induced circulatory arrest events of which 95 were correctly identified by the algorithm (sensitivity 97% [95% CI 90-100%]). The median time to circulatory arrest detection was -1 second (IQR -2 – 0). In total, 50 (53%) events were detected before the annotated time (median; -1 sec), 33 (35%) events were detected at t=0, and 12 (13%) events were detected after the annotation (median; +2 sec). A total of 65 (68%) induced circulatory arrest events were detected within one second before and after the annotated start time of the circulatory arrest. Return of PPG pulsations were detected in all patients, with a median of 4 seconds (IQR 3 – 7) after pulsations returned (Figure 1 and 2). There were no differences in detection time between the three subgroups. Conclusion: The PPG algorithm detects the induced circulatory arrest events directly when blood pressure lowers. Further research is needed to validate the circulatory arrest detection algorithm and detection interval in spontaneous cardiac arrest.

Outcomes of extracorporeal life support in hypothermic cardiac arrest: Revisiting ELSO guidelines

Aim of the studyPredictive factors for poor outcomes in hypothermic cardiac arrest (HCA) differ from those in normothermic out-of-hospital cardiac arrest (OHCA). This study aimed to evaluate the outcomes of extracorporeal life support (ECLS) in HCA patients who may not be considered eligible based on the guidelines set by the Extracorporeal Life Support Organization (ELSO). MethodsA retrospective multicentre study included 127 HCA patients, divided into two groups: those meeting the ELSO eligibility criteria for ECLS, and those with at least one of the following ELSO exclusion criteria: age over 70 years, unwitnessed cardiac arrest, or asystole. ResultsAmong the 62 patients who met the ELSO criteria, 38 (61 %) survived to hospital discharge, with 34 (89 %) achieving a favourable neurological outcomes. Of the 65 patients who received ECLS despite not meeting ELSO criteria, 24 (37 %) survived to discharge, with 20 (83 %) demonstrating a favourable neurological outcomes. In patients not meeting one or two ELSO criteria, survival rates were 18 of 47 (38 %) and 6 of 16 (38 %) respectively, with 83 % of survivors in both groups achieving favourable neurological outcomes. The two patients who failed to meet all three ELSO criteria did not survive. ConclusionQualification of patients with hypothermic cardiac arrest for ECLS rewarming should not be strictly based on guidelines for normothermic cardiac arrest, as this may result in not initiating potentially life-saving treatment for patients who could have favourable prognoses for survival with good neurological outcomes.

Automated cardiac arrest detection using a photoplethysmography wristband: algorithm performance in relation to sex, skin color type and arm hair density

Abstract Background While survival from witnessed out-of-hospital cardiac arrest (OHCA) has improved, this is not the case for unwitnessed cardiac arrest as the event goes unnoticed. Automated cardiac arrest detection and alerting through a wristband is considered a promising technique also facilitating early assistance for this large group. In the DETECT-1 study, a photoplethysmography(PPG) algorithm for circulatory arrest detection was developed in patients with induced circulatory arrest. However, patient characteristics, such as skin color and arm hair density, can influence the accuracy of the PPG signal. Thus, we performed further analyses to study the effect of patient characteristics on the algorithm’s performance. Purpose To assess the performance of the developed PPG algorithm for cardiac arrest detection in relation to sex, skin color type and arm hair density. Methods Patients who underwent short-lasting circulatory arrest induction during transcatheter aortic valve implantation, ventricular tachycardia ablation or subcutaneous ICD implantation wore a PPG wristband during the procedure. Continuous ECG and invasive blood pressure recordings served as reference standards. A PPG algorithm for circulatory arrest detection was developed. The algorithm’s performance was assessed in subgroups based on sex, skin color type (according to the Fitzpatrick scale), and arm hair density. The sensitivity for the detection of circulatory arrest and false positive alarms were compared between the different subgroups. Results In total, 151 patients were included in the current analysis. Analyzed data consisted of 159 hours of PPG data including 176 induced circulatory arrest events. The population consisted of 57 (38%) females and 94 (62%) males. The sensitivity for circulatory arrest detection was 100% in the female group vs. 98% in the male group (p=ns); false positive alarms occurred in 4 females and 9 males, resulting in a positive predictive value (PPV) of 94% and 92% (p=ns), respectively. Within the skin color subgroup analysis, 114 (75%) patients had skin color type I or II, and 37 (25%) patients had a skin color type III, IV, V or VI. There were no differences in sensitivity (p=ns) and PPV (p=ns) in the skin color subgroup (table 1). The population consisted of 106 (71%) patients with nil or sparse arm hair density, 43 (29%) patients with moderate or dense arm hair density, and 2 not reported. There were no differences in sensitivity (p=ns) and PPV (p=ns) within the arm hair density subgroup (table 1). Conclusions Automated cardiac arrest detection using a smartwatch is feasible and its accuracy is not affected by sex, skin color type or arm hair density in this study. Further study is needed to assess performance of the algorithm in a larger sample size and a more diverse study population. If proven to be effective, automated cardiac arrest detection has the potential to improve survival from OHCA.Sensitivity/PPV for arrest detection

High-sensitivity troponin T for detection of culprit lesions in patients with out-of-hospital cardiac arrest.

Patients with an out-of-hospital cardiac arrest (OHCA) often undergo coronary angiography, although a culprit lesion is found in only 30%-40% of patients. The aim of this study was to investigate high-sensitivity troponin T (hsTnT) levels in post cardiac arrest patients with and without coronary culprit lesions; factors affecting hsTnT levels after return of spontaneous circulation (ROSC); and the diagnostic ability of hsTnT in identifying patients with culprit lesions. We hypothesized that peak hsTnT levels were higher during the initial 48 h after cardiac arrest in patients with a coronary culprit lesion. This was a retrospective observational study, which included patients admitted to the Intensive Care Unit after an OHCA and who received a coronary angiography. Peak values and dynamic changes in hsTnT were analyzed in relation to the presence of a culprit lesion at coronary angiography. A total of 238 patients were studied, of whom 140 had a culprit lesion. HsTnT levels during the initial 48 h were higher in patients with culprit lesions, longer time to ROSC and an unwitnessed cardiac arrest. At 6 to 12 h after ROSC, a hsTnT cut-off level of 1690 ng/L had a sensitivity of 64% and specificity of 84% to identify a culprit lesion. In patients without ST-elevations, hsTnT measured between 6 and 12 h after ROSC had a specificity above 90%, with a sensitivity of 46%. HsTnT levels after cardiac arrest are higher in patients with coronary culprit lesions. Presence of a culprit lesion, witnessed status and the duration of CPR are important factors affecting hsTnT levels. Repeated measurement of hsTnT within the first 12 h after admission improved diagnostic accuracy but the value of hsTnT as a predictor of culprit lesions early after OHCA is limited.

Can Biomarkers Correctly Predict Ventilator-associated Pneumonia in Patients Treated With Targeted Temperature Management After Cardiac Arrest? An Exploratory Study of the Multicenter Randomized Antibiotic (ANTHARTIC) Study.

Ventilator-associated pneumonia (VAP) frequently occurs in patients with cardiac arrest. Diagnosis of VAP after cardiac arrest remains challenging, while the use of current biomarkers such as C-reactive protein (CRP) or procalcitonin (PCT) is debated. To evaluate biomarkers' impact in helping VAP diagnosis after cardiac arrest. This is a prospective ancillary study of the randomized, multicenter, double-blind placebo-controlled ANtibiotherapy during Therapeutic HypothermiA to pRevenT Infectious Complications (ANTHARTIC) trial evaluating the impact of antibiotic prophylaxis to prevent VAP in out-of-hospital patients with cardiac arrest secondary to shockable rhythm and treated with therapeutic hypothermia. An adjudication committee blindly evaluated VAP according to predefined clinical, radiologic, and microbiological criteria. All patients with available biomarker(s), sample(s), and consent approval were included. The main endpoint was to evaluate the ability of biomarkers to correctly diagnose and predict VAP within 48 hours after sampling. The secondary endpoint was to study the combination of two biomarkers in discriminating VAP. Blood samples were collected at baseline on day 3. Routine and exploratory panel of inflammatory biomarkers measurements were blindly performed. Analyses were adjusted on the randomization group. Among 161 patients of the ANTHARTIC trial with available biological sample(s), patients with VAP (n = 33) had higher body mass index and Acute Physiology and Chronic Health Evaluation II score, more unwitnessed cardiac arrest, more catecholamines, and experienced more prolonged therapeutic hypothermia duration than patients without VAP (n = 121). In univariate analyses, biomarkers significantly associated with VAP and showing an area under the curve (AUC) greater than 0.70 were CRP (AUC = 0.76), interleukin (IL) 17A and 17C (IL17C) (0.74), macrophage colony-stimulating factor 1 (0.73), PCT (0.72), and vascular endothelial growth factor A (VEGF-A) (0.71). Multivariate analysis combining novel biomarkers revealed several pairs with p value of less than 0.001 and odds ratio greater than 1: VEGF-A + IL12 subunit beta (IL12B), Fms-related tyrosine kinase 3 ligands (Flt3L) + C-C chemokine 20 (CCL20), Flt3L + IL17A, Flt3L + IL6, STAM-binding protein (STAMBP) + CCL20, STAMBP + IL6, CCL20 + 4EBP1, CCL20 + caspase-8 (CASP8), IL6 + 4EBP1, and IL6 + CASP8. Best AUCs were observed for CRP + IL6 (0.79), CRP + CCL20 (0.78), CRP + IL17A, and CRP + IL17C. Our exploratory study shows that specific biomarkers, especially CRP combined with IL6, could help to better diagnose or predict early VAP occurrence in cardiac arrest patients.

Cardiac arrest, stony heart, and cardiopulmonary resuscitation: An updated revisit.

The post-resuscitation period is recognized as the main predictor of cardiopulmonary resuscitation (CPR) outcomes. The first description of post-resuscitation syndrome and stony heart was published over 50 years ago. Major manifestations may include but are not limited to, persistent precipitating pathology, systemic ischemia/reperfusion response, post-cardiac arrest brain injury, and finally, post-cardiac arrest myocardial dysfunction (PAMD) after successful resuscitation. Why do some patients initially survive successful resuscitation, and others do not? Also, why does the myocardium response vary after resuscitation? These questions have kept scientists busy for several decades since the first successful resuscitation was described. By modifying the conventional modalities of resuscitation together with new promising agents, rescuers will be able to salvage the jeopardized post-resuscitation myocardium and prevent its progression to a dismal, stony heart. Community awareness and staff education are crucial for shortening the resuscitation time and improving short- and long-term outcomes. Awareness of these components before and early after the restoration of circulation will enhance the resuscitation outcomes. This review extensively addresses the underlying pathophysiology, management, and outcomes of post-resuscitation syndrome. The pattern, management, and outcome of PAMD and post-cardiac arrest shock are different based on many factors, including in-hospital cardiac arrest vs out-of-hospital cardiac arrest (OHCA), witnessed vs unwitnessed cardiac arrest, the underlying cause of arrest, the duration, and protocol used for CPR. Although restoring spontaneous circulation is a vital sign, it should not be the end of the game or lone primary outcome; it calls for better understanding and aggressive multi-disciplinary interventions and care. The development of stony heart post-CPR and OHCA remain the main challenges in emergency and critical care medicine.

Sudden cardiac death in people with schizophrenia: higher risk, poorer resuscitation profiles and differing pathologies

Abstract Background People with schizophrenia account for approximately 1.0% of the population and appear to experience increased rates of sudden cardiac death (SCD). This study determined characteristics of increased SCD in people with schizophrenia. Methods A prospective state-wide registry compared people aged 15-50 years with and without schizophrenia who experienced SCD within a two-year time-period and were referred for forensic evaluation. Results 579 individuals were identified, of whom 65 (11.2%) had schizophrenia. Patients with schizophrenia were more commonly smokers (46.2% vs 23.0%, p&amp;lt;0.0001), consumed excess alcohol (32.3% vs 21.4%, p=0.05), and used QTc-prolonging medications (69.2% vs 17.9%, p&amp;lt;0.0001). They were less likely to arrest while exercising (0.0% vs 6.4%, p=0.04). Unfavourable arrest-related factors included lower rates of witnessed arrest (6.2% vs 23.5%, p&amp;lt;0.0001), more likely to be found in asystole (92.3% vs 73.3%, p&amp;lt;0.0001), and being more likely to be found as part of a welfare check after a prolonged period of time (median 42 vs 12 hours, p=0.003). There was more frequent evidence of decomposition, and they more commonly underwent autopsy (41.2% vs 26.4%, p=0.04 and 93.8% vs 82.5%, p=0.05), with diagnosis of non-ischaemic cardiomyopathy being more common (29.2% vs 18.1%, p=0.04). Conclusion People with schizophrenia account for 11% of young SCD patients referred for forensic investigations, exceeding population rates eleven-fold. They have higher pre-existing cardiac risk factor burden, unfavourable resuscitation profiles and higher rates of non-ischaemic cardiomyopathy. Strategies targeting biopsychosocial support may deliver not only psychological benefits but also help reduce unwitnessed cardiac arrest.

Comparison of out-of-hospital cardiac arrests during the COVID-19 pandemic with those before the pandemic: an updated systematic review and meta-analysis.

The coronavirus disease of 2019 (COVID-19) pandemic, directly and indirectly, affected the emergency medical care system and resulted in worse out-of-hospital cardiac arrest (OHCA) outcomes and epidemiological features compared with those before the pandemic. This review compares the regional and temporal features of OHCA prognosis and epidemiological characteristics. Various databases were searched to compare the OHCA outcomes and epidemiological characteristics during the COVID-19 pandemic with before the pandemic. During the COVID-19 pandemic, survival and favorable neurological outcome rates were significantly lower than before. Survival to hospitalization, return of spontaneous circulation, endotracheal intubation, and use of an automated external defibrillator (AED) decreased significantly, whereas the use of a supraglottic airway device, the incidence of cardiac arrest at home, and response time of emergency medical service (EMS) increased significantly. Bystander CPR, unwitnessed cardiac arrest, EMS transfer time, use of mechanical CPR, and in-hospital target temperature management did not differ significantly. A subgroup analysis of the studies that included only the first wave with those that included the subsequent waves revealed the overall outcomes in which the epidemiological features of OHCA exhibited similar patterns. No significant regional differences between the OHCA survival rates in Asia before and during the pandemic were observed, although other variables varied by region. The COVID-19 pandemic altered the epidemiologic characteristics, survival rates, and neurological prognosis of OHCA patients. Review registration: PROSPERO (CRD42022339435).

Sudden Cardiac Death in People With Schizophrenia: Higher Risk, Poorer Resuscitation Profiles, and Differing Pathologies

BackgroundPeople with schizophrenia account for approximately 1.0% of the population and seem to experience increased rates of sudden cardiac death (SCD). ObjectivesThis study sought to determine characteristics of increased SCD in people with schizophrenia. MethodsThe End Unexplained Cardiac Death (EndUCD) prospective state-wide registry compared people aged 15 to 50 years with and without schizophrenia who experienced SCD within a 2-year time period and were referred for forensic evaluation. ResultsWe identified 579 individuals, of whom 65 (11.2%) had schizophrenia. Patients with schizophrenia were more commonly smokers (46.2% vs 23.0%; P < 0.0001), consumed excess alcohol (32.3% vs 21.4%; P = 0.05), and used QTc-prolonging medications (69.2% vs 17.9%; P < 0.0001). They were less likely to arrest while exercising (0.0% vs 6.4%; P = 0.04). Unfavorable arrest-related factors included lower rates of witnessed arrest (6.2% vs 23.5%; P < 0.0001), more likely to be found in asystole (92.3% vs 73.3%; P < 0.0001), and being more likely to be found as part of a welfare check after a prolonged period of time (median 42 hours vs 12 hours; P = 0.003). There was more frequent evidence of decomposition, and they more commonly underwent autopsy (41.2% vs 26.4%; P = 0.04 and 93.8% vs 82.5%; P = 0.05), with a diagnosis of nonischemic cardiomyopathy being more common (29.2% vs 18.1%; P = 0.04). ConclusionsPeople with schizophrenia account for 11% of young SCD patients referred for forensic investigations, exceeding population rates by 11-fold. They have a higher preexisting cardiac risk factor burden, unfavorable resuscitation profiles, and higher rates of nonischemic cardiomyopathy. Strategies targeting biopsychosocial support may deliver not only psychological benefits, but also help to decrease unwitnessed cardiac arrest.

Venoarterial extracorporeal membrane oxygenation in acute myocardial infarction

Venoarterial extracorporeal membrane oxygenation in acute myocardial infarction

In the Limelight: December 2022

In the Limelight: December 2022

Risk factors for development of cerebral edema following cardiac arrest

BackgroundCerebral edema following cardiac arrest is a well-known complication of resuscitation and portends a poor outcome. We identified predictors of post-cardiac arrest cerebral edema and tested the association of cerebral edema with discharge outcome. MethodsWe performed a retrospective chart review including patients admitted at a single center between January 2015–March 2020 following resuscitation from in-hospital and out-of-hospital cardiac arrest who had head computed tomography imaging. Our primary outcome was moderate-to-severe cerebral edema, which we defined as loss of grey-white differentiation with effacement of the basal and ambient cisterns and radiographic evidence of uncal herniation. We used logistic regression to test associations of demographic information, clinical predictors and comorbidities with moderate-severe cerebral edema. ResultsWe identified 727 patients who met the inclusion criteria, of whom 102 had moderate-to-severe cerebral edema. We identified six independent predictors of moderate-to-severe cerebral edema: younger age, prolonged arrest duration, pulseless electrical activity/asystole as initial rhythm, unwitnessed cardiac arrest, hyperglycemia on admission, and lower Glasgow coma score on presentation. Of patients with moderate-to-severe cerebral edema, 2% survived to discharge, 56% had withdrawal of life-sustaining therapies and 42% progressed to death by neurological criteria. ConclusionsOur study identified several risk factors associated with the development of cerebral edema following cardiac arrest. Further studies are needed to determine the benefits of early interventions in these high-risk patients.

Rewarming from unwitnessed hypothermic cardiac arrest with good neurological recovery using extracorporeal membrane oxygenation.

A 26-year-old man, who was training in bad weather for a mountain ultramarathon, became hypothermic after running for 4h. He deteriorated and was unable to continue. His running partner went for help. The man suffered an unwitnessed hypothermic cardiac arrest. The on-site management and evacuation are described and included the use of intermittent cardiopulmonary resuscitation and a mechanical device during transport. The patient was successfully resuscitated and rewarmed by Extracorporeal Membrane Oxygenation (ECMO) after more than 2h of cardiopulmonary resuscitation. After 14h of ECMO support and five days of ventilation, the patient subsequently made a good neurological recovery. At hospital discharge, he had normal cerebral function, and an improving peripheral polyneuropathy affecting distal limbs, with paraesthesia in both feet and reduced coordination and fine motor skills in both hands.

Does the presence of physician-staffed emergency medical services improve the prognosis in out-of-hospital cardiac arrest? A propensity score matching analysis.

Substantial differences in survival after out-of-hospital cardiac arrest (OHCA) have been observed between countries. These might be attributed to the organization of emergency medical service (EMS) systems, including prehospital physician involvement. However, limited data exist on the physician's role in improving survival after OHCA. To compare prehospital and in-hospital outcomes of OHCA patients attended by physician-staffed EMS vs. paramedic-staffed EMS units. Among all patients enrolled in the regional, prospective registry of OHCA in southern Poland, we excluded those aged <18 years, with unwitnessed or EMS-witnessed cardiac arrest, without attempted cardiopulmonary resuscitation (CPR), attended by more than one EMS, or with traumatic cardiac arrest. The groups were matched 1:1 using propensity scores for baseline characteristic variables that might influence physician-staffed EMS dispatch. A total of 812 OHCA cases were included in the current analysis. Among them, 351 patients were attended by physician-staffed EMS. There were no differences in baseline characteristics in the propensity-score matched cohort consisting of 351 pairs. The return of spontaneous circulation (ROSC) was more often achieved in the physician-staffed EMS group (42.7% vs. 33.3%; P = 0.01). The prehospital survival rate was also higher in this group (34.1% vs. 19.2%; P <0.01). However, there were no significant differences in survival rate to discharge between cases treated by physician-staffed and paramedic-staffed EMS (9.7% vs. 7.0%; P = 0.22). OHCA patients attended by physician-staffed EMS were more likely to have ROSC and survive till hospital admission. However, better prehospital outcomes might not translate into improved in-hospital prognosis in these patients.

Evaluation of outcomes after EMS-witnessed traumatic out-of-hospital cardiac arrest caused by traffic collisions

AimThe survival rate of patients with traumatic cardiac arrest is 3% or lower. Cardiac arrest witnessed by emergency medical services (EMS) accounts for approximately 16% of prehospital traumatic cardiac arrests, but the prognosis is unknown. We aimed to compare the 1-month survival rate of cardiac arrest witnessed by EMS with that of cardiac arrest witnessed by bystanders and unwitnessed cardiac arrest in traffic trauma victims; further, the time from injury to cardiac arrest was assessed. MethodsThis analysis used the Utstein Registry in Japan and included data of 3883 patients with traumatic cardiac arrest caused by traffic collisions registered between 2014 and 2019 in Japan. ResultsThe 1-month survival rate was 10.9% in the EMS-witnessed cardiac arrest group; this was significantly higher than that in the bystander-witnessed (7.2%) and unwitnessed (5.6%) cardiac arrest groups (P < 0.01). The median time from injury to cardiac arrest was 18 min (25% quartile: 12, 75% quartile: 26). ConclusionThe 1-month survival rate was significantly higher in the EMS-witnessed cardiac arrest group than in the bystander-witnessed and unwitnessed cardiac arrest groups. It is important to prevent progression to cardiac arrest in trauma patients with intact respiratory function and pulse rate at the time of contact with EMS. A system for early recognition of severe trauma is needed, and a doctor’s car or helicopter can be requested as needed. We believe that early recognition and prompt intervention will improve the prognosis of prehospital traumatic cardiac arrest.

Patterns of retinal hemorrhage associated with cardiac arrest and cardiopulmonary resuscitation

Hypoxia and cardiopulmonary resuscitation (CPR) have been proposed as causes of retinal hemorrhage (RH) in children evaluated for abusive head trauma (AHT). We sought to determine the prevalence and characteristics of RH in children who underwent CPR after cardiac arrest. This was a prospective, single-center, consecutive observational study of 38 children (<18 years of age). Indirect ophthalmoscopic examination was completed by an ophthalmologist within 48 hours of CPR. Extensive medical records data were collected to assess for potential confounding factors. Outcomes included the presence and pattern of RH. Of the 38 children, 20 had in-hospital arrest; 18 had out-of-hospital arrest. The median duration of CPR was 10 minutes. Seven children had RH, of whom 6 had an RH pattern consistent with coexistent medical conditions: 4 AHT diagnosable with nonocular findings, including subdural and subarachnoid hemorrhage, rib fractures, abdominal injury (RH pattern: diffuse, numerous, intraretinal and/or multilayered RH); 1 septic shock (RH pattern: 1-2 posterior pole RH); 1 ruptured arteriovenous malformation (RH pattern: 4-8 peripapillary RH). The seventh child had unwitnessed cardiac arrest due to nonfatal drowning and a single superficial intraretinal peripapillary hemorrhage. CPR for cardiac arrest is rarely associated with RH, which, absent coexisting conditions causing retinal hemorrhage, are intraretinal, few in number, and located in the posterior pole. In children who have undergone CPR, when RH are multilayered, or are more than a few in number, or extend outside the posterior pole, another etiology for the RH should be sought.

Extracorporeal Life Support in Accidental Hypothermia with Cardiac Arrest-A Narrative Review.

Severely hypothermic patients, especially suffering cardiac arrest, require highly specialized treatment. The most common problems affecting the recognition and treatment seem to be awareness, logistics, and proper planning. In severe hypothermia, pathophysiologic changes occur in the cardiovascular system leading to dysrhythmias, decreased cardiac output, decreased central nervous system electrical activity, cold diuresis, and noncardiogenic pulmonary edema. Cardiac arrest, multiple organ dysfunction, and refractory vasoplegia are indicative of profound hypothermia. The aim of these narrative reviews is to describe the peculiar pathophysiology of patients suffering cardiac arrest from accidental hypothermia. We describe the good chances of neurologic recovery in certain circumstances, even in patients presenting with unwitnessed cardiac arrest, asystole, and the absence of bystander cardiopulmonary resuscitation. Guidance on patient selection, prognostication, and treatment, including extracorporeal life support, is given.

Epidemiological characteristics and factors associated with out-of-hospital cardiac arrest attended by bystanders before ambulance arrival.

The aim of this study is to analyze the characteristics of out-of-hospital cardiac arrests based on whether patients received bystander resuscitation before ambulance arrival, and to describe the factors associated with resuscita-tion attempts by bystanders. A retrospective observational study was performed. Clinical data from cardiac arrest patients in the Basque Country (Spain) were collected over a period of five years. Epidemiological characteristics compared resuscitation started by bystanders with resuscitation carried out by ambulance caregivers. The relation between no resuscitation started by bystander and different exposure factors was explored by multiple logistic regression analysis. We analyzed 3,278 cardiac arrests. Of them, 61.9?% were not attended by bystanders and this was associated with the absence of instructions from Emergency Centre (OR: 6.25, 95%CI: 5.15-7.58, p?<?0.001), home location (OR: 2.94, 95%CI: 2.48-3.48, p?<?0.001), unwitnessed cardiac arrest (OR: 1.56, 95%CI 1.28-1.89, p?<?0.001), victims of 65 years or older (OR: 1.48, 95%CI: 1.26-1.74, p?<?0.001) and suburban locations (OR: 1.29, 95%CI: 1.04-1.62, p?=?0.023). There are differences in cardiac arrests depending on whether they have been resuscitated by bystanders. These characteristics may influence the bystander's decision to initiate resuscitation maneuvers (or not) and evolution.

Factors Associated With Initiation of Extracorporeal Cardiopulmonary Resuscitation in the Pediatric Population: An International Survey.

Although extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly utilized in the pediatric critical care environment, our understanding regarding pediatric candidacy for ECPR remains unknown. Our objective is to explore current practice and indications for pediatric ECPR. Scenario-based, self-administered, online survey, evaluating clinical determinants that may impact pediatric ECPR initiation with respect to four scenarios: postoperative cardiac surgery, cardiac failure secondary to myocarditis, septic shock, and chronic respiratory failure in a former preterm child. Responders are pediatric critical care physicians from four societies. 249 physicians, mostly from North America, answered the survey. In cardiac scenarios, 40% of the responders would initiate ECPR, irrespective of CPR duration, compared with less than 20% in noncardiac scenarios. Nearly 33% of responders would consider ECPR if CPR duration was less than 60 minutes in noncardiac scenarios. Factors strongly decreasing the likelihood to initiate ECPR were out-of-hospital unwitnessed cardiac arrest and blood pH <6.60. Additional factors reducing this likelihood were multiple organ failure, pre-existing neurologic delay, >10 doses of adrenaline, poor CPR quality, and lactate >18 mmol/l. Pediatric intensive care unit location for cardiac arrest, good CPR quality, 24/7 in-house extracorporeal membrane oxygenation (ECMO) team moderately increase the likelihood of initiating ECPR. This international survey of pediatric ECPR initiation practices reveals significant differences regarding ECPR candidacy based on patient category, location of arrest, duration of CPR, witness status, and last blood pH. Further research identifying prognostic factors measurable before ECMO initiation should help define the optimal ECPR initiation strategy.