Ventricular Fibrillation/pulseless Ventricular Tachycardia Research Articles

Machine Learning and Clinical Predictors of Mortality in Cardiac Arrest Patients: A Comprehensive Analysis.

BACKGROUND Cardiac arrest (CA) is a global public health challenge. This study explored the predictors of mortality and their interactions utilizing machine learning algorithms and their related mortality odds among patients following CA. MATERIAL AND METHODS The study retrospectively investigated 161 medical records of CA patients admitted to the Intensive Care Unit (ICU). The random forest classifier algorithm was used to assess the parameters of mortality. The best classification trees were chosen from a set of 100 trees proposed by the algorithm. Conditional mortality odds were investigated with the use of logistic regression models featuring interactions between variables. RESULTS In the logistic regression model, male sex was associated with 5.68-fold higher mortality odds. The mortality odds among the asystole/pulseless electrical activity (PEA) patients were modulated by body mass index (BMI) and among ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) patients were by serum albumin concentration (decrease by 2.85-fold with 1 g/dl increase). Procalcitonin (PCT) concentration, age, high-sensitivity C-reactive protein (hsCRP), albumin, and potassium were the most influential parameters for mortality prediction with the use of the random forest classifier. Nutritional status-associated parameters (serum albumin concentration, BMI, and Nutritional Risk Score 2002 [NRS-2002]) may be useful in predicting mortality in patients with CA, especially in patients with PCT >0.17 ng/ml, as showed by the decision tree chosen from the random forest classifier based on goodness of fit (AUC score). CONCLUSIONS Mortality in patients following CA is modulated by many co-existing factors. The conclusions refer to sets of conditions rather than universal truths. For individual factors, the 5 most important classifiers of mortality (in descending order of importance) were PCT, age, hsCRP, albumin, and potassium.

Clinical features and outcomes of patients with refractory out-of-hospital cardiac arrest and an initial shockable rhythm

Abstract Background Clinical features of patients presenting with refractory out-of-hospital cardiac arrest (OHCA) and initial shockable rhythms of ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) remain poorly described. Purpose This study evaluated clinical characteristics, angiographic findings, and short-term outcomes among patients with refractory OHCA (defined as incessant VF/pVT after ≥3 direct-current shocks) compared to those without refractory OHCA. Methods Of 761 consecutive patients hospitalized for OHCA between 2014–2018 at two large tertiary health services in Victoria, Australia, 204 (27%) had an initial shockable rhythm and were stratified by the presence (n=74, 36%) or absence (n=130, 64%) of refractory OHCA. Primary outcome was in-hospital mortality. Multivariable logistic regression was performed to evaluate independent predictors of in-hospital mortality. Results The majority of patients were male (77%) and the median age was 62 years [IQR 52–72]. Refractory OHCA patients had longer cardiopulmonary resuscitation (23 vs 15 minutes), more frequently required ≥450 mg of amiodarone (34% vs 3.8%), had cardiogenic shock (80% vs 55%) necessitating higher adrenaline dose (4.0 vs 1.0 mg) and higher rates of mechanical ventilation (92% vs 74%) (all p<0.01). A total of 167 patients (82%) underwent coronary angiography, and refractory OHCA patients were less likely to be selected (74% vs 86%, p=0.035). No difference in door-to-needle times between those with and without refractory OHCA was noted (103 vs 99 minutes, p=0.586). Significant coronary artery disease (≥1 major vessel with >70% stenosis) was present in >70% of patients. Refractory OHCA group frequently had acute coronary occlusion (64% vs 47%), especially of the left circumflex artery (20% vs 6.4%) and graft vessel (7.3% vs 0.9%), and often had complex coronary lesions (type B2 or C) (57% vs 39%) compared to those without refractory OHCA (all p<0.05). Patients with both refractory OHCA and ST-elevation on electrocardiogram had the highest prevalence of acute coronary occlusion (85%, 22/26). Refractory OHCA group had higher rates of in-hospital mortality (45% vs 30%) and new requirement for dialysis (18% vs 6.3%) (all p<0.05). After adjustment, refractory OHCA heightened the risk of in-hospital mortality by over two-fold (OR 2.28, 95% CI 1.06–4.89, p=0.034) (Figure 1). Among those with refractory OHCA, higher cumulative prehospital adrenaline dose (OR 1.38, 95% CI 1.01–1.89 per 1 mg increase), and increased number of direct-current shocks (1.13, 1.00–1.27 per 1 additional shock) were independent predictors of in-hospital mortality, whereas undergoing coronary revascularization (0.28, 0.09–0.94) diminished this risk (all p<0.05) (Figure 2). Conclusion Refractory VF/pVT OHCA was associated with more intensive resuscitation, higher rates of acute coronary occlusion and poorer in-hospital outcomes, underscoring the need for future studies in this extreme-risk subgroup.Figure 1Figure 2

The impact of time to amiodarone administration on survival from out-of-hospital cardiac arrest

AimTo examine the impact of time to amiodarone administration on survival from shock-refractory Ventricular Fibrillation/pulseless Ventricular Tachycardia (VF/pVT) following out-of-hospital cardiac arrest (OHCA). MethodsA retrospective cohort study of adult (≥16 years) OHCA patients in shock-refractory VF/pVT (after 3 consecutive defibrillation attempts) of medical aetiology who arrested between January 2010 and December 2019. Time-dependent propensity score matching was used to sequentially match patients who received amiodarone at any given minute of resuscitation with patients eligible to receive amiodarone during the same minute. Log-binomial regression models were used to assess the association between time of amiodarone administration (by quartiles of time-to-matching) and survival outcomes. ResultsA total of 2,026 patients were included, 1,393 (68.8%) of whom received amiodarone with a median (interquartile range) time to administration of 22.0 (18.0–27.0) minutes. Propensity score matching yielded 1,360 matched pairs. Amiodarone administration within 28 minutes of the emergency call was associated with a higher likelihood of return of spontaneous circulation (ROSC) (≤18minutes: RR = 1.03 (95%CI 1.02, 1.04); 19-22minutes: RR = 1.02 (95%CI 1.01, 1.03); 23-27minutes: RR = 1.01 (95%CI 1.00, 1.02)) and event survival (pulse on hospital arrival) (≤18 minutes: RR = 1.05 (95%CI 1.03, 1.07); 19–22 minutes: RR = 1.03 (95%CI 1.01, 1.05); 23–27 minutes: RR = 1.02 (95%CI 1.00, 1.03). Amiodarone administration within 23 minutes of the emergency call was associated with a higher likelihood of survival to hospital discharge (≤18minutes: RR = 1.17 (95%CI 1.09, 1.24; 19–22 minutes: RR = 1.10 (95%CI 1.04, 1.17). ConclusionAmiodarone administered within 23 minutes of the emergency call is associated with improved survival outcomes in shock-refractory VF/pVT, although prospective trials are required to confirm these findings.

Out of Hospital Cardiac Arrest: A Case Report

Introduction: Sudden OHCA (Out of hospital cardiac arrest) is the third leading cause of death in industrialized nations. With more than 60% of cardiovascular deaths resulting from cardiac arrest, it remains the leading cause of death worldwide. Heart rhythms associated with cardiac arrest are divided into two groups: shockable rhythms (ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) and non-shockable rhythms (asystole and pulseless electrical activity (PEA)). VF is the most commonly identified arrhythmia in cardiac arrest patients. Urgent medical treatment includes cardiopulmonary resuscitation and early defibrillation.
 Material and Methods: Materials for this case report are data collected from the medical records of the Emergency Medical Center of Sarajevo protocol of patients.
 Case report: Our case report is presented with 59 years old man who had OHCA in his apartment. The initial rhythm was VF, and cardiopulmonary resuscitation was provided due to the Advanced life support guidelines to shockable rhythms. It was delivered 3 DC Shock-s (200J, 300J, 360 J) with the biphasic defibrillator, it was administered 1mg Adrenalin and performed endotracheal intubation. After the third DC shock, we got the return of spontaneous circulation ROSC. The patient was transferred to the University hospital, were he was stabile, and PCI of the LAD was performed as per the standard protocol. Echocardiography performed in the CCU revealed hypokinesia of RV, with preserved systolic function. On hospital day 7 he had a full neurological recovery. He was conscious, oriented, with normal breathing, blood pressure 125/79mmHg, sPO2 99, ECG: sinus rhythm, fr 87/min, without pathological signs. Echocardiography revealed the reduced systolic function of the left ventricle, with mitral regurgitation MR+2.
 Discussion: Out-of-hospital cardiac arrest (OHCA) is a major health problem in Europe and in the United States. The numbers of patients who have OHCA annually in these two parts of the world have traditionally been reported to be 275,000 and 420,000 respectively. The success of resuscitation depends on many factors: well-organized health care, organization of outpatient emergency services, but primarily when it comes to OHCA, education of the population on Basic life support, and early Cardiopulmonary resuscitation and use of AED (automated external defibrillator).

Cost-effectiveness of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A multi-centre prospective cohort study

AimExtracorporeal cardiopulmonary resuscitation (ECPR) is an evolving resuscitative method for refractory cardiopulmonary arrests. However, considering the substantial healthcare costs and resources involved, there is an urgent need for a full economic evaluation. We therefore assessed the cost-effectiveness of ECPR for refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT). MethodsWe developed a decision model to estimate lifetime costs and outcomes for out-of-hospital cardiac arrest patients with VF/pVT who received either ECPR or conventional cardiopulmonary resuscitation. Quality-adjusted life-years (QALY) was used as the main outcome measure. This model was a combination of a decision tree model for the acute phase based on a prospective observational study (SAVE-J study), together with a Markov model for long-term follow-up periods extrapolated from published data.To evaluate the robustness of this model, we conducted a comprehensive deterministic sensitivity analysis (DSA) and a probabilistic sensitivity analysis (PSA). ResultsECPR was cost-effective, with an incremental cost of ¥3,521,189 (Є30,227), an incremental effectiveness of 1.34 QALY, and an incremental cost-effectiveness ratio of ¥2,619,692 (Є22,489) per QALY gained. DSA revealed that the present model was most sensitive to probability of Cerebral Performance Category 1 after ECPR (¥2,153,977/QALY to ¥3,186,475/QALY), patient age (¥2,170,112/QALY to ¥3,334,252/QALY), and long-term medical cost for modified Rankin Scale 0 (¥2,280,352/QALY to ¥2,855,330/QALY). PSA indicated ECPR to be cost-effective and below the willingness-to-pay threshold of ¥5,000,000 with an 86.7 % possibility. ConclusionsECPR was an economically acceptable resuscitative strategy, and the results of the present study were robust even when considering the uncertainty of all parameters.

Prehospital Double Defibrillation for Refractory Ventricular Fibrillation: A Scoping Review Protocol.

Double defibrillation (DD) has been proposed as an alternative treatment for patients with refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) out-of-hospital cardiac arrest (OHCA) nonresponsive to the best current standard of care. Treatment results are promising, but the efficacy and safety of the procedure remain unclear. Currently, there is a paucity of evidence in the literature on DD suggesting the optimal strategy for treating this challenging patient population. Thus, we aim to perform a scoping review to explore the current literature addressing resuscitative parameters, survival rates, and neurological outcomes in refractory VF/pVT OHCA patients treated with DD as well as to identify gaps in the literature that may require further research. Here, we discuss the anticipated study protocol.

Factors affecting the course of resuscitation from cardiac arrest with pulseless electrical activity in children and adolescents

BackgroundAlthough in-hospital pediatric cardiac arrests and cardiopulmonary resuscitation occur >15,000/year in the US, few studies have assessed which factors affect the course of resuscitation in these patients. We investigated transitions from Pulseless Electrical Activity (PEA) to Ventricular Fibrillation/pulseless Ventricular Tachycardia (VF/pVT), Return of Spontaneous Circulation (ROSC) and recurrences from ROSC to PEA in children and adolescents with in-hospital cardiac arrest. MethodsEpisodes of cardiac arrest at the Children's Hospital of Philadelphia were prospectively registered. Defibrillators that recorded chest compression depth/rate and ventilation rate were applied. CPR variables, patient characteristics and etiology, and dynamic factors (e.g. the proportion of time spent in PEA or ROSC) were entered as time-varying covariates for the transition intensities under study. ResultsIn 67 episodes of CPR in 59 patients (median age 15 years) with cardiac arrest, there were 52 transitions from PEA to ROSC, 22 transitions from PEA to VF/pVT, and 23 recurrences of PEA from ROSC. Except for a nearly significant effect of mean compression depth beyond a threshold of 5.7 cm, only dynamic factors that evolved during CPR favored a transition from PEA to ROSC. The latter included a lower proportion of PEA over the last 5 min and a higher proportion of ROSC over the last 5 min. Factors associated with PEA to VF/pVT development were age, weight, the proportion spent in VF/pVT or PEA the last 5 min, and the general transition intensity, while PEA recurrence from ROSC only depended on the general transition intensity. ConclusionThe clinical course during pediatric cardiac arrest was mainly influenced by dynamic factors associated with time in PEA and ROSC. Transitions from PEA to ROSC seemed to be favored by deeper compressions.

The Evolving Role of Esmolol in Management of Pre-Hospital Refractory Ventricular Fibrillation; a Scoping Review.

Few studies have described their experience using esmolol, an ultra-short acting β-adrenergic antagonist, in the emergency department (ED) as a feasible adjuvant therapy for the treatment of refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) out-of-hospital cardiac arrest. However, there is currently insufficient evidence to support the widespread implementation of this therapy. The aim of this scoping review was to summarize the current available evidence on the use of esmolol as an adjuvant therapy for refractory VF/pVT out-of-hospital cardiac arrest, as well as to identify gaps within the literature that may require further research. We conducted a comprehensive literature search of MEDLINE via PubMed, Embase, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) on July 5, 2019. The search was restricted to articles that were published from January 2000 to July 2019. Google Scholar was searched and reference lists of relevant papers were examined to identify additional studies. We included any controlled clinical study design (randomized controlled trials and non-randomized controlled trials) and observational studies (cohort studies and case-control studies) in adults providing information on the use of esmolol as an adjuvant therapy for refractory VF/pVT out-of-hospital cardiac arrest. The search yielded 2817 unique records, out of which 2 peer-reviewed articles were found relating to the research purpose totaling 66 patients 33.3% (n = 22) of which received esmolol. These studies found that sustained return of spontaneous circulation (ROSC) was significantly more common in the patients that received esmolol compared to the control group. However, no statistically significant outcomes were found regarding survival to discharge and favorable neurological outcome. No randomized controlled trials were identified. To date, it is difficult to conclude the real benefit of esmolol as an adjuvant therapy for refractory VF/pVT out-of-hospital cardiac arrest based on the available evidence. The findings of this scoping review suggest that there is a paucity of research and limited evidence to support this therapy.

The Evolving Role of the Cardiac Catheterization Laboratory in the Management of Patients With Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association.

Coronary artery disease is prevalent in different causes of out-of-hospital cardiac arrest (OHCA), especially in individuals presenting with shockable rhythms of ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT). The purpose of this report is to review the known prevalence and potential importance of coronary artery disease in patients with OHCA and to describe the emerging paradigm of treatment with advanced perfusion/reperfusion techniques and their potential benefits on the basis of available evidence. Although randomized clinical trials are planned or ongoing, current scientific evidence rests principally on observational case series with their potential confounding selection bias. Among patients resuscitated from VF/pVT OHCA with ST-segment elevation on their postresuscitation ECG, the prevalence of coronary artery disease has been shown to be 70% to 85%. More than 90% of these patients have had successful percutaneous coronary intervention. Conversely, among patients resuscitated from VF/pVT OHCA without ST-segment elevation on their postresuscitation ECG, the prevalence of coronary artery disease has been shown to be 25% to 50%. For these patients, early access to the cardiac catheterization laboratory is associated with a 10% to 15% absolute higher functionally favorable survival rate compared with more conservative approaches of late or no access to the cardiac catheterization laboratory. In patients with VF/pVT OHCA refractory to standard treatment, a new treatment paradigm is also emerging that uses venoarterial extracorporeal membrane oxygenation to facilitate return of normal perfusion and to support further resuscitation efforts, including coronary angiography and percutaneous coronary intervention. The burden of coronary artery disease is high in this patient population, presumably causative in most patients. The strategy of venoarterial extracorporeal membrane oxygenation, coronary angiography, and percutaneous coronary intervention has resulted in functionally favorable survival rates ranging from 9% to 45% in observational studies in this patient population. Patients with VF/pVT should be considered at the highest severity in the continuum of acute coronary syndromes. These patients have a significant burden of coronary artery disease and acute coronary thrombotic events. Evidence from randomized trials will further define optimal clinical practice.

Prehospital Double Sequential Defibrillation: A Matched Case-Control Study.

The goal of our study was to determine whether prehospital double sequential defibrillation (DSD) is associated with improved survival to hospital admission in the setting of refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT). This project is a matched case-control study derived from prospectively collected quality assurance/quality improvement data obtained from the San Antonio Fire Department out-of-hospital cardiac arrest (OHCA) database between January 2013 and December 2015. The cases were defined as OHCA patients with refractory VF/pVT who survived to hospital admission. The control group was defined as OHCA patients with refractory VF/pVT who did not survive to hospital admission. The primary variable in our study was prehospital DSD. The primary outcome of our study was survival to hospital admission. Of 3,469 consecutive OHCA patients during the study period, 205 OHCA patients met the inclusion criterion of refractory VF/pVT. Using a predefined algorithm, two blinded researchers identified 64 unique cases and matched them with 64 unique controls. Survival to hospital admission occurred in 48.0% of DSD patients and 50.5% of the conventional therapy patients (p>0.99; odds ratio= 0.91, 95% confidence interval= 0.40-2.1). Our matched case-control study on the prehospital use of DSD for refractory VF/pVT found no evidence of associated improvement in survival to hospital admission. Our current protocol of considering prehospital DSD after the third conventional defibrillation in OHCA is ineffective.

Antiarrhythmic drug therapy during cardiopulmonary resuscitation: should we use it?

The optimal antiarrhythmic drug therapy (amiodarone or lidocaine) in the treatment of ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) cardiac arrest that is refractory to defibrillation is uncertain. This article reviews the evidence for and against these drugs, alternatives treatments for refractory VF/pVT and aims to define the role of antiarrhythmic drugs during cardiopulmonary resuscitation (CPR). A large randomized controlled trial that compared amiodarone, lidocaine and saline 0.9% sodium chloride for the treatment of refractory VF/pVT out-of-hospital cardiac arrest reported no difference in survival to hospital discharge or neurological outcome. In patients with witnessed arrest, survival was improved with antiarrhythmic drugs compared to saline. The benefit of antiarrhythmic drugs appears to be for those patients in whom initial early CPR and defibrillation attempts fail and the antiarrhythmic drug is given early. There does not appear to be any clear survival benefit for any one particular drug and other factors such as availability and cost should be considered when deciding which drug to use. Furthermore, other interventions (e.g. percutaneous coronary intervention and extra-corporeal CPR) may provide additional survival benefit when defibrillation attempts and antiarrhythmic drugs are not effective.

Improving trend in ventricular fibrillation/pulseless ventricular tachycardia out-of-hospital cardiac arrest in Rochester, Minnesota: A 26-year observational study from 1991 to 2016

BackgroundMortality from out-of-hospital cardiac arrest (OHCA) is characterized by substantial regional variation. The Institute of Medicine (IOM) recently recommended enhancing the capabilities of EMS systems to improve outcome. In this study, we analyzed the trend in outcome from ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) OHCA in Rochester, MN. Survival from these forms of arrest is commonly employed as a benchmark of Emergency Medical Services (EMS) system performance. MethodsUsing a population-based Utstein-style registry in Rochester, MN where a first responder early defibrillation system is utilized, we evaluated outcome from all EMS-treated VF/pVT arrests and the subgroup of bystander-witnessed VF/pVT from 1991 to 2016. Outcome measurement was neurologically intact survival to discharge, defined as Cerebral Performance Category (CPC) 1 or 2. We divided the 26-year study into three periods: 1991–1997, 1998–2008, and 2009–2016, based on initiation of the first responder system of police officers in 1991 and fire-rescue personnel in 1998, and the latter period for comparison with our previous report in 2009. ResultsWe observed 355 all VF/pVT arrests and 292 bystander-witnessed VF/pVT arrests between 1991 and 2016. In 2009–2016, neurologically intact survival to discharge from overall VF/pVT and bystander-witnessed VF/pVT increased to 53.7% and 65.2%, respectively, compared with 39.5% and 43.4% in 1991–1997. Using multivariable analysis, survival significantly increased in 2009–2016 among all VF/pVT arrests (adjusted OR, 3.10; 95% CI, 1.54–6.40) and bystander-witnessed VF/pVT (adjusted OR, 4.28; 95% CI, 2.01–9.50), compared with those in 1991–1997. ConclusionsWe observed a significant improving secular trend in neurologically intact survival from VF/pVT cardiac arrests with a relatively high recent survival rate in this EMS System.

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.

Development and Implementation of a Comprehensive, Multidisciplinary Emergency Department Extracorporeal Membrane Oxygenation Program

Despite advances in the medical and surgical management of cardiovascular disease, greater than 350,000 patients experience out-of-hospital cardiac arrest in the United States annually, with only a 12% neurologically favorable survival rate. Of these patients, 23% have an initial shockable rhythm of ventricular fibrillation/pulseless ventricular tachycardia (VF/VT), a marker of high probability of acute coronary ischemia (80%) as the precipitating factor. However, few patients (22%) will experience return of spontaneous circulation and sufficient hemodynamic stability to undergo cardiac catheterization and revascularization. Previous case series and observational studies have demonstrated the successful application of intra-arrest extracorporeal life support, including to out-of-hospital cardiac arrest victims, with a neurologically favorable survival rate of up to 53%. For patients with refractory cardiac arrest, strategies are needed to bridge them from out-of-hospital cardiac arrest to the catheterization laboratory and revascularization. To address this gap, we expanded our ICU and perioperative extracorporeal membrane oxygenation (ECMO) program to the emergency department (ED) to reach this cohort of patients to improve survival. In this report, we illustrate our process and initial experience of developing a multidisciplinary team for rapid deployment of ED ECMO as a template for institutions interested in building their own ED ECMO programs.

The dynamic pattern of end-tidal carbon dioxide during cardiopulmonary resuscitation: difference between asphyxial cardiac arrest and ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest

IntroductionPartial pressure of end-tidal carbon dioxide (PetCO2) during cardiopulmonary resuscitation (CPR) correlates with cardiac output and consequently has a prognostic value in CPR. In our previous study we confirmed that initial PetCO2 value was significantly higher in asphyxial arrest than in ventricular fibrillation/pulseless ventricular tachycardia (VF/VT) cardiac arrest. In this study we sought to evaluate the pattern of PetCO2 changes in cardiac arrest caused by VF/VT and asphyxial cardiac arrest in patients who were resuscitated according to new 2005 guidelines.MethodsThe study included two cohorts of patients: cardiac arrest due to asphyxia with initial rhythm asystole or pulseless electrical activity (PEA), and cardiac arrest due to arrhythmia with initial rhythm VF or pulseless VT. PetCO2 was measured for both groups immediately after intubation and repeatedly every minute, both for patients with or without return of spontaneous circulation (ROSC). We compared the dynamic pattern of PetCO2 between groups.ResultsBetween June 2006 and June 2009 resuscitation was attempted in 325 patients and in this study we included 51 patients with asphyxial cardiac arrest and 63 patients with VF/VT cardiac arrest. The initial values of PetCO2 were significantly higher in the group with asphyxial cardiac arrest (6.74 ± 4.22 kilopascals (kPa) versus 4.51 ± 2.47 kPa; P = 0.004). In the group with asphyxial cardiac arrest, the initial values of PetCO2 did not show a significant difference when we compared patients with and without ROSC (6.96 ± 3.63 kPa versus 5.77 ± 4.64 kPa; P = 0.313). We confirmed significantly higher initial PetCO2 values for those with ROSC in the group with primary cardiac arrest (4.62 ± 2.46 kPa versus 3.29 ± 1.76 kPa; P = 0.041). A significant difference in PetCO2 values for those with and without ROSC was achieved after five minutes of CPR in both groups. In all patients with ROSC the initial PetCO2 was again higher than 1.33 kPa.ConclusionsThe dynamic pattern of PetCO2 values during out-of-hospital CPR showed higher values of PetCO2 in the first two minutes of CPR in asphyxia, and a prognostic value of initial PetCO2 only in primary VF/VT cardiac arrest. A prognostic value of PetCO2 for ROSC was achieved after the fifth minute of CPR in both groups and remained present until final values. This difference seems to be a useful criterion in pre-hospital diagnostic procedures and attendance of cardiac arrest.

European Resuscitation Council Guidelines for Resuscitation 2010 Section 3. Electrical therapies: Automated external defibrillators, defibrillation, cardioversion and pacing

The importance of early, uninterrupted chest compressions is emphasised throughout these guidelines. Much greater emphasis on minimising the duration of the preshock and post-shock pauses. The continuation of compressions during charging of the defibrillator is recommended. Immediate resumption of chest compressions following defibrillation is also emphasised; in combination with continuation of compressions during defibrillator charging, the delivery of defibrillation should be achievable with an interruption in chest compressions of no more than 5 s. Safety of the rescuer remains paramount, but there is recognition in these guidelines that the risk of harm to a rescuer from a defibrillator is very small, particularly if the rescuer is wearing gloves. The focus is now on a rapid safety check to minimise the pre-shock pause. When treating out-of-hospital cardiac arrest, emergency medical services (EMS) personnel should provide good-quality CPR while a defibrillator is retrieved, applied and charged, but routine delivery of a pre-specified period of CPR (e.g., 2 or 3min) before rhythm analysis and a shock is delivered is no longer recommended. For some emergency medical services that have already fully implemented a pre-specified period of chest compressions before defibrillation, given the lack of convincing data either supporting or refuting this strategy, it is reasonable for them to continue this practice. The use of up to three-stacked shocks may be considered if ventricular fibrillation/pulseless ventricular tachycardia (VF/VT)

The first documented cardiac arrest rhythm in hospitalized patients with heart failure

Background Patients with heart failure (HF) have abnormal cellular anatomy and myocardial mechanics that may impact the initial rhythm and subsequent outcomes in cardiac arrest (CA). Hypothesis Patients with pre-existing HF are less likely to have ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) as the first documented rhythm in CA and have poorer survival than patients without pre-existing HF. Purpose Identify the first documented cardiac arrest rhythm (FDR) in hospitalized patients with and without a pre-existing history of HF. Methods We evaluated 60,389 consecutive, adult, index, pulseless CA events with documented initial rhythm in the National Registry of Cardiopulmonary Resuscitation. The primary endpoint was the FDR in patients with and without a history of pre-existing HF. Secondary endpoints were return of spontaneous circulation (ROSC), survival to discharge, and neurological outcome. Results Thirty three percent of patients had a pre-existing diagnosis of HF. HF patients were more likely to have VF/pVT (25.9 vs. 23.2%) and less likely to have asystole (34.4 vs. 35.3%, p = <.0001) than non-HF. There was no difference in survival to discharge (18.3 vs. 18.2%, p = .66), or good neurological outcomes (82.2 vs. 83.2%, p = .23) between the groups. Women were less likely to have VF/pVT as the first documented rhythm in both HF and non-HF groups. Conclusions Hospitalized patients with HF are more likely than those without HF to have VF/pVT as the FDR in CA, however the clinical magnitude of this difference is small. Overall survival and neurological outcomes are no different than hospitalized arrest patients without HF.

Adherence to CPR guidelines during perioperative cardiac arrest in a developing country

BACKGROUND AND GOAL OF STUDY: Cardiopulmonary resuscitation (CPR) is an integral part of anaesthetic training. In Nigeria, these skills are taught mainly during medical school and postgraduate training. International guidelines were introduced in 2000 and new guidelines were produced in November 2005. The study sought to assess how closely anaesthetists in a Nigerian teaching hospital abide by the 2000 guidelines. All perioperative cardiac arrests in adults that occurred in a 1-year-period were studied prospectively. All patients <15 years and cardiac arrests occurring outside the direct supervision of the anaesthetists were excluded. Time and duration of arrest, cardiac arrest rhythm and management were documented along with immediate outcome. Thirteen cardiac arrests occurred in 2147 perioperative cases (incidence: 6/1000). Seven patients had non ventricular fibrillation/pulseless ventricular tachycardia (VF/VT) rhythms. The mean age of patients was 30.23+/-11.06 years. Orotracheal intubation, manual ventilation with 100% O(2) and external chest compressions were instituted in all cases. The mean duration of arrest was 25.66+/-13.34 min. All patients received adrenaline (epinephrine) and atropine. The median interval between adrenaline doses was 7.5 min. Only one cycle of defibrillation was given to patients in VF/VT. Immediate survival occurred in five patients (38.46%). Anaesthetists in our hospital are not applying proper resuscitation guidelines. The lack of organised simulation practice resulted in deficient knowledge and skills. There is a need for continuing training in basic and advanced resuscitation for all anaesthetists according to the guidelines.

Assessment of In-Hospital Cardiopulmonary Resuscitation Using Utstein Template in a University Hospital

The aim of this study was to evaluate the effectiveness of in-hospital cardiopulmonary resuscitation (CPR) strategies and identify key predictors of post-CPR survival in a university hospital setting. Using a form recommended by the European Resuscitation Council, data regarding in-hospital CPR attempts from January 2001 to December 2002 were recorded and analyzed. The main outcomes of interest were immediate survival after CPR and survival to hospital discharge. Of 307 patients who suffered cardiac arrest in the study period, 103 (33.5%) were resuscitated. Of these 103 patients, 28 (27.2%) survived immediately and 12 (11.7%) survived to hospital discharge. The key predictors of immediate survival were CPR duration and initial cardiac rhythm as monitored by ventricular fibrillation/pulseless ventricular tachycardia (VF/VT). The key predictors of survival to hospital discharge were CPR duration, immediate defibrillation, Glasgow Coma Scale score, and Early Prediction Score. Together, our results suggest that in-hospital CPR strategies require improvement. They also underscore the importance of data collection and analysis in evaluating the effectiveness of inhospital CPR strategies.

Evaluation of a defibrillator-basic cardiopulmonary resuscitation programme for non medical personnel

To improve the outcome for out-of-hospital patients with ventricular fibrillation/pulseless ventricular tachycardia (VF/VT), the use of automated external defibrillators (AEDs) by first responders including non-medical personnel with a duty to respond to an emergency is recommended. A special CPR-AED course has been developed. We wanted to test the results (quality and speed of operating an AED and CPR) after completion of such a course and retention after approximately 1-year. At the same time we wanted to see if personnel could use an AED after receiving written information without having attended the course. Study subjects were divided randomly into groups, and tested pre-course ( n=54), post-course ( n=50), and unannounced 10±3 months after the course (retention group, n=61). For statistical analysis two sample tests for binomial proportions and Wilcoxon–Mann–Whitney test was used as appropriate. Fifteen of the 27 pairs (56%) in the pre-course group with no previous exposure to an AED decided to use it. There was no difference between the groups in electrode pad positioning, and all stayed clear of the manikin during the process of AED charging and shock delivery. The post-course group had a higher rate of checking for responsiveness (vs. pre-course), not to check for a pulse (vs. both other groups), the shortest time interval from arrival on scene to start of CPR and shock delivery, and in parallel the shortest hands-off interval (without chest compressions and ventilations) before shock delivery. The quality of chest compressions was improved by the course but decreased to a similar standard as in the pre-course when tested 10±3 months later, except for correct depth which was similar to post course. Most ventilation attempts in all groups were scored as incorrect due to the high incidence of excessively rapid inflations. The retention group had a lower frequency of correct inflations than the pre-course group, and the post-course group the highest number of correct ventilations per minute. These findings suggest that use of an AED by untrained laypersons may be feasible and that complex and time-consuming training programmes may not be necessary. The present study also supports the need for annual training and recertification.