Low-dose tenecteplase during cardiopulmonary resuscitation in massive pulmonary embolism.

We report the case of an 18-year-old male who presented to the Emergency Department with sudden onset dyspnea. The patient was intubated on arrival, but suffered a cardiac arrest soon after. Point-of-care echocardiography during cardiopulmonary resuscitation revealed a grossly dilated right atrium and right ventricle, which alerted the Emergency physician to the possibility of massive pulmonary embolism leading to cardiac arrest. Due to no discernible history or risk factors in favour of pulmonary embolism, a decision was taken for thrombolysis with half dose Tenecteplase. Return of spontaneous circulation was achieved 14 min after thrombolysis, with massive pulmonary embolism subsequently being confirmed on CT Pulmonary Angiography.

An observer tool to enhance learning of medical students during simulation training of cardiopulmonary resuscitation: a randomised controlled trial.

BACKGROUND: Simulation training in cardiopulmonary resuscitation (CPR) is effective but active practice time is limited given the large number of students and the learning effect size remains small. To improve learning during observation, the use of an observer tool (OT) has been advocated. The aim was to assess the value of OT to improve medical students' learning outcomes during CPR simulation training. METHODS: This prospective, randomized study took place during CPR training of medical students. The workshop targeted recognition of unconsciousness, absence of breathing, call for help, cardiac massage and defibrillation. Students practicing in dyads were randomized to use an OT (i.e., a checklist summarizing CPR skills and step-by-step actions) (OT +) or not (OT-) when observing others. At the end of the training, the global performance of the dyad was assessed by an evaluator using the OT checklist (primary outcome). The non-technical skills (NTS), chest compression quality, perceived improvement in knowledge and skills and knowledge score (MCQ) were also recorded. RESULTS: The student dyads were included (OT + : n = 40 and OT-: n = 41). Immediately after training, the global performance was similar between the two groups: OT + : 24 [23-25] and OT-: 23 [21-24] (out of 25), p = 0.052. However, better learning of breathing assessment and cardiac massage performance, as well as a better knowledge score, were found in the OT + group. No significant difference was observed for NTS or perceived improvement in knowledge and skills. Satisfaction was higher in the OT- group. CONCLUSIONS: The use of an OT during CPR simulation did not show any pedagogical benefit on the global performance of medical students. However, a potential benefit was found for several important secondary outcomes. Further studies are needed to confirm these positive results.

Standby extracorporeal membrane oxygenation: a better strategy for high-risk percutaneous coronary intervention.

Background: The incidence of cardiac arrest (CA) during percutaneous coronary intervention (PCI) is relatively rare. However, when it does occur, the mortality rate is extremely high. Extracorporeal cardiopulmonary resuscitation (ECPR) has shown promising survival rates for in-hospital cardiac arrests (IHCA), with low-flow time being an independent prognostic factor for CA. However, there is no definitive answer on how to reduce low-flow time. Methods: This retrospective study, conducted at a single center, included 39 patients who underwent ECPR during PCI between January 2016 and December 2022. The patients were divided into two cohorts based on whether standby extracorporeal membrane oxygenation (ECMO) was utilized during PCI: standby ECPR (SBE) (n = 13) and extemporaneous ECPR (EE) (n = 26). We compared the 30-day mortality rates between these two cohorts and investigated factors associated with survival. Results: Compared to the EE cohort, the SBE cohort showed significantly lower low-flow time (P < 0.01), ECMO operation time (P < 0.01), and a lower incidence of acute kidney injury (AKI) (P = 0.017), as well as peak lactate (P < 0.01). Stand-by ECMO was associated with improved 30-day survival (p = 0.036), while prolonged low-flow time (p = 0.004) and a higher SYNTAX II score (p = 0.062) predicted death at 30 days. Conclusions: Standby ECMO can provide significant benefits for patients who undergo ECPR for CA during PCI. It is a viable option for high-risk PCI cases and may enhance the overall prognosis. The low-flow time remains a critical determinant of survival.

Clinical characteristics of extracorporeal cardiopulmonary resuscitation in China: a multicenter retrospective study.

PURPOSE: Extracorporeal cardiopulmonary resuscitation (ECPR) might markedly increase the survival of selected patients with refractory cardiac arrest. But the application situation and indications remained unclear. MATERIALS AND METHODS: We respectively reviwed all adult patients who underwent ECPR from January 2017 to March 2021. Patient characteristics, initiation and management of ECMO, complications, and outcomes were collected and compared between the survivors and nonsurvivors. LASSO regression was used to screen risk factors. Multivariate logistic regression was performed with several parameters screened by LASSO regression. RESULTS: Data were reported from 42 ECMO centers covering 19 provinces of China. A total of 648 patients were included in the study, including 491 (75.8%) males. There were 11 ECPR centers in 2017, and the number increased to 42 in 2020. The number of patients received ECPR increased from 33 in 2017 to 274 in 2020, and the survival rate increased from 24.2% to 33.6%. Neurological complications, renal replacement therapy, epinephrine dosage after ECMO, recovery of spontaneous circulation before ECMO, lactate clearance and shockable rhythm were risk factors independently associated with outcomes of whole process. Sex, recovery of spontaneous circulation before ECMO, lactate, shockable rhythm and causes of arrest were pre-ECMO risk factors independently affecting outcomes. CONCLUSIONS: From January 2017 to March 2021, the numbers of ECPR centers and cases in mainland China increased gradually over time, as well as the survival rate. Pre-ECMO risk factors, especially recovery of spontaneous circulation before ECMO, shockable rhythm and lactate, are as important as post-ECMO management,. Neurological complications are vital risk factors after ECMO that deserved close attention. TRIAL REGISTRATION: NCT04158479, registered on 2019/11/08. https://clinicaltrials.gov/NCT04158479.

Early bolus epinephrine administration during pediatric cardiopulmonary resuscitation for bradycardia with poor perfusion: an ICU-resuscitation study.

BACKGROUND: Half of pediatric in-hospital cardiopulmonary resuscitation (CPR) events have an initial rhythm of non-pulseless bradycardia with poor perfusion. Our study objectives were to leverage granular data from the ICU-RESUScitation (ICU-RESUS) trial to: (1) determine the association of early epinephrine administration with survival outcomes in children receiving CPR for bradycardia with poor perfusion; and (2) describe the incidence and time course of the development of pulselessness. METHODS: Prespecified secondary analysis of ICU-RESUS, a multicenter cluster randomized trial of children (< 19 years) receiving CPR in 18 intensive care units in the United States. Index events (October 2016-March 2021) lasting ≥ 2 min with a documented initial rhythm of bradycardia with poor perfusion were included. Associations between early epinephrine (first 2 min of CPR) and outcomes were evaluated with Poisson multivariable regression controlling for a priori pre-arrest characteristics. Among patients with arterial lines, intra-arrest blood pressure waveforms were reviewed to determine presence of a pulse during CPR interruptions. The temporal nature of progression to pulselessness was described and outcomes were compared between patients according to subsequent pulselessness status. RESULTS: Of 452 eligible subjects, 322 (71%) received early epinephrine. The early epinephrine group had higher pre-arrest severity of illness and vasoactive-inotrope scores. Early epinephrine was not associated with survival to discharge (aRR 0.97, 95%CI 0.82, 1.14) or survival with favorable neurologic outcome (aRR 0.99, 95%CI 0.82, 1.18). Among 186 patients with invasive blood pressure waveforms, 118 (63%) had at least 1 period of pulselessness during the first 10 min of CPR; 86 (46%) by 2 min and 100 (54%) by 3 min. Sustained return of spontaneous circulation was highest after bradycardia with poor perfusion (84%) compared to bradycardia with poor perfusion progressing to pulselessness (43%) and bradycardia with poor perfusion progressing to pulselessness followed by return to bradycardia with poor perfusion (62%) (p < 0.001). CONCLUSIONS: In this cohort of pediatric CPR events with an initial rhythm of bradycardia with poor perfusion, we failed to identify an association between early bolus epinephrine and outcomes when controlling for illness severity. Most children receiving CPR for bradycardia with poor perfusion developed subsequent pulselessness, 46% within 2 min of CPR onset.

Artificial intelligence-based evaluation of carotid artery compressibility via point-of-care ultrasound in determining the return of spontaneous circulation during cardiopulmonary resuscitation.

AIM: This study introduces RealCAC-Net, an artificial intelligence (AI) system, to quantify carotid artery compressibility (CAC) and determine the return of spontaneous circulation (ROSC) during cardiopulmonary resuscitation. METHODS: A prospective study based on data from a South Korean emergency department from 2022 to 2023 investigated carotid artery compressibility in adult patients with cardiac arrest using a novel AI model, RealCAC-Net. The data comprised 11,958 training images from 161 cases and 15,080 test images from 134 cases. RealCAC-Net processes images in three steps: TransUNet-based segmentation, the carotid artery compressibility measurement algorithm for improved segmentation and CAC calculation, and CAC-based classification from 0 (indicating a circular shape) to 1 (indicating high compression). The accuracy of the ROSC classification model was tested using metrics such as the dice similarity coefficient, intersection-over-union, precision, recall, and F1 score. RESULTS: RealCAC-Net, which applied the carotid artery compressibility measurement algorithm, performed better than the baseline model in cross-validation, with an average dice similarity coefficient of 0.90, an intersection-over-union of 0.84, and a classification accuracy of 0.96. The test set achieved a classification accuracy of 0.96 and an F1 score of 0.97, demonstrating its efficacy in accurately identifying ROSC in cardiac arrest situations. CONCLUSIONS: RealCAC-Net enabled precise CAC quantification for ROSC determination during cardiopulmonary resuscitation. Future research should integrate this AI-enhanced ultrasound approach to revolutionize emergency care.

Teaching team competencies within resuscitation training: A systematic review.

Objectives: To evaluate the effectiveness of life support training with specific emphasis on team competencies on clinical and educational outcomes. Methods: This systematic review was prospectively registered (PROSPERO CRD42023473154) and followed the PICOST (population, intervention, comparison, outcome, study design, timeframe) format. All randomized controlled trials and non-randomized studies evaluating learners undertaking life support training with specific emphasis on team competencies in any setting (actual and simulated resuscitations) were included. Unpublished studies were excluded. Medline, Embase and Cochrane databases as well as trial registries were searched from inception to August 2023 (updated January 18, 2024). Two researchers performed title and abstract screening, full-text screening, data extraction, assessment of risk of bias (using RoB2 and ROBINS-I) and certainty of evidence (using GRADE). PRISMA reporting checklist was used to report the results. No funding was obtained to perform this systematic review. Results: The literature search identified 5470 manuscripts. After the removal of 2073 duplicates, reviewing the remaining articles' titles and abstracts yielded 31 articles for full-text review. Of these, 17 studies were finally included. The studies involved the following training levels: basic life support, adult advanced life support, paediatric and neonatal resuscitations. Most studies (n = 16) evaluated outcomes in simulated, and only one study in actual resuscitations. Studies included in all training contexts showed either neutrality and/or benefits of life support training with specific emphasis on team competencies. Team competencies training improved CPR skill performance and CPR quality. Specific team competencies that improved included leadership, communication, decision-making and task management. No undesirable effects were observed. Meta-analysis was not possible due to significant methodological heterogeneity. Sub-group analysis was impossible due to lack of data. Risk of bias assessment ranged from some concerns to serious. Overall certainty of evidence was rated as low to very low due to risk of bias and imprecision. Conclusion: This systematic review identified very low and low certainty evidence, almost entirely derived from simulation studies. The studies and their findings were heterogenous but suggest that teaching team competencies can improve resuscitation skills performance and CPR quality, as well as improve team competencies, specifically leadership, communication, decision-making, and task management. Further research is required to understand optimal configuration of team competencies training interventions and to understand the effect on clinical outcomes and cost-effectiveness.

International facets of the 'chain of survival' for out-of-hospital and in-hospital cardiac arrest - A scoping review.

Background: The "chain of survival" was first systematically addressed in 1991, and its sequence still forms the cornerstone of current resuscitation guidelines. The term "chain of survival" is widely used around the world in literature, education, and awareness campaigns, but growing heterogeneity in the components of the chain has led to confusion. It is unclear which of these emerging chains is most suitable, or if adaptations are needed in particular contexts to depict key actions of resuscitation in the 21st century. This scoping review provides an overview of the variety of chains of survival described. Objectives: To identify published facets of the chain of survival, to assess views and strategies about adapting the chain, and to identify reports on how the chain of survival affects teaching, implementation, or patient outcomes. Methods eligibility criteria and sources of evidence: A scoping review as part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR) was conducted. MEDLINE(R) ALL (Ovid), Embase (Ovid), APA PsycINFO (Ovid), CINAHL (Ebscohost), ERIC (Ebscohost), Web of Science (Clarivate), Scopus (Elsevier), and Cochrane Library (Wiley Online) were searched. All publications in all languages describing chains of survival were eligible, without time restrictions. Due to the heterogeneity and publication types of the relevant studies, we did not pursue a systematic review or meta-analysis. Results: A primary search yielded 1713 studies and after screening we included 43 publications. Modified versions of the chain of survival for specific contexts were found (e.g., in-hospital cardiac arrest or paediatric resuscitation). There were also numerous versions with minor adaptations of the existing chain. Three publications suggested an impact of the use of the chain of survival on patient outcomes. No educational or implementation outcomes were reported. Conclusion: There is a vast heterogeneity of chain of survival concepts published. Future research is warranted, especially into the concept's importance concerning educational, implementation, and clinical outcomes.

A smartwatch-based CPR feedback device improves chest compression quality among health care professionals and lay rescuers.

Background: Cardiopulmonary resuscitation (CPR) quality significantly impacts patient outcomes during cardiac arrests. With advancements in health care technology, smartwatch-based CPR feedback devices have emerged as potential tools to enhance CPR delivery. Objective: This study evaluated a novel smartwatch-based CPR feedback device in enhancing chest compression quality among health care professionals and lay rescuers. Methods: A single-center, open-label, randomized crossover study was conducted with 30 subjects categorized into 3 groups based on rescuer category. The Relay Response BLS smartwatch application was compared to a defibrillator-based feedback device (Zoll OneStep CPR Pads). Following an introduction to the technology, subjects performed chest compressions in 3 modules: baseline unaided, aided by the smartwatch-based feedback device, and aided by the defibrillator-based feedback device. Outcome measures included effectiveness, learnability, and usability. Results: Across all groups, the smartwatch-based device significantly improved mean compression depth effectiveness (68.4% vs 29.7%; P < .05) and mean rate effectiveness (87.5% vs 30.1%; P < .05), compared to unaided compressions. Compression variability was significantly reduced with the smartwatch-based device (coefficient of variation: 14.9% vs 26.6%), indicating more consistent performance. Fifteen of 20 professional rescuers reached effective compressions using the smartwatch-based device in an average 2.6 seconds. A usability questionnaire revealed strong preference for the smartwatch-based device over the defibrillator-based device. Conclusion: The smartwatch-based device enhances the quality of CPR delivery by keeping compressions within recommended ranges and reducing performance variability. Its user-friendliness and rapid learnability suggest potential for widespread adoption in both professional and lay rescuer scenarios, contributing positively to CPR training and real-life emergency responses.

Open-chest cardiopulmonary resuscitation through a transdiaphragmatic approach in dogs: a cadaveric study to describe the surgical approach and manipulations.

OBJECTIVE: To describe the detailed surgical procedure for open-chest CPR (OC-CPR) through a transdiaphragmatic (TD) approach during planned laparotomy and to evaluate the procedure time and damage to organs. ANIMALS: 7 mixed-breed canine cadavers. METHODS: The procedure was divided into 3 stages. Durations for each of the 3 stages of the procedure and total time from diaphragmatic incision to the end of Rumel tourniquet application were recorded. Subjective assessment of ease of procedures and postprocedural physical evaluation of thoracoabdominal organs were also performed. RESULTS: Mean time from diaphragmatic incision to pericardiotomy was 15.1 seconds (SD, 4.0). Performing 10 cardiac compressions took 12.0 seconds (SD, 1.8). Dissection of the aorta and application of a Rumel tourniquet took 130.4 seconds (SD, 52.2). The mean total time from start of first procedure to end of last procedure was 157.6 seconds (SD, 21.5). The mean length of diaphragmatic incision was 11.5 cm (SD, 2.2). Lung laceration was identified in one dog, and liver laceration was identified in another dog. The mean ease of pericardiotomy was 10, and application of a Rumel tourniquet was 4 (SD, 1.9). There was no instance of abdominal organs moving into the thoracic cavity during the procedure in any of the dogs. CLINICAL RELEVANCE: Resuscitation techniques during TD OC-CPR can be performed with acceptable timing and effort, except for aortic Rumel tourniquet application, which was difficult and time consuming. Avoidable damage to thoracoabdominal organs can occur.

Aetiology and predictors of outcome in non-shockable in-hospital cardiac arrest: A retrospective cohort study from the Swedish Registry for Cardiopulmonary Resuscitation.

BACKGROUND: Non-shockable in-hospital cardiac arrest (IHCA) is a condition with diverse aetiology, predictive factors, and outcome. This study aimed to compare IHCA with initial asystole or pulseless electrical activity (PEA), focusing specifically on their aetiologies and the significance of predictive factors. METHODS: Using the Swedish Registry of Cardiopulmonary Resuscitation, adult non-shockable IHCA cases from 2018 to 2022 (n = 5788) were analysed. Exposure was initial rhythm, while survival to hospital discharge was the primary outcome. A random forest model with 28 variables was used to generate permutation-based variable importance for outcome prediction. RESULTS: Overall, 60% of patients (n = 3486) were male and the median age was 75 years (IQR 67-81). The most frequent arrest location (46%) was on general wards. Comorbidities were present in 79% of cases and the most prevalent comorbidity was heart failure (33%). Initial rhythm was PEA in 47% (n = 2702) of patients, and asystole in 53% (n = 3086). The most frequent aetiologies in both PEA and asystole were cardiac ischemia (24% vs. 19%, absolute difference [AD]: 5.4%; 95% confidence interval [CI] 3.0% to 7.7%), and respiratory failure (14% vs. 13%, no significant difference). Survival was higher in asystole (24%) than in PEA (17%) (AD: 7.3%; 95% CI 5.2% to 9.4%). Cardiopulmonary resuscitation (CPR) durations were longer in PEA, 18 vs 15 min (AD 4.9 min, 95% CI 4.0-5.9 min). The duration of CPR was the single most important predictor of survival across all subgroup and sensitivity analyses. Aetiology ranked as the second most important predictor in most analyses, except in the asystole subgroup where responsiveness at cardiac arrest team arrival took precedence. CONCLUSIONS: In this nationwide registry study of non-shockable IHCA comparing asystole to PEA, cardiac ischemia and respiratory failure were the predominant aetiologies. Duration of CPR was the most important predictor of survival, followed by aetiology. Asystole was associated with higher survival compared to PEA, possibly due to shorter CPR durations and a larger proportion of reversible aetiologies.

Molecular mechanism of HDAC6-mediated pyroptosis in neurological function recovery after cardiopulmonary resuscitation in rats.

Brain injury after cardiac arrest (CA) and cardiopulmonary resuscitation (CPR) is the leading cause of neurological dysfunction and death. This study aimed to explore the mechanism of histone deacetylase 6 (HDAC6) in neurofunctional recovery following CA/CPR in rats. A rat model was established by CA/CPR treatment. Adenovirus-packaged sh-HDAC6 was injected into the tail vein. To evaluate the neurofunction of rats, survival time, neurofunctional scores, serum NSE/S100B, and brain water content were measured and Morris water maze test was performed. HDAC6, microRNA (miR)-138-5p, Nod-like receptor protein 3 (NLRP3), and pyroptotic factors levels were determined by real-time quantitative polymerase chain reaction or Western blot assay. HDAC6 and H3K9ac enrichment on miR-138-5p promoter were examined by chromatin immunoprecipitation. miR-138-5p-NLRP3 binding was analyzed by dual-luciferase reporter assay. NLRP3 inflammasome was activated with nigericin sodium salt. After CPR treatment, HDAC6 was highly expressed, while miR-138-5p was downregulated. HDAC6 downregulation improved neurofunction and reduced pyroptosis. HDAC6 enrichment on the miR-138-5p promoter deacetylated H3K9ac, inhibiting miR-138-5p, and promoting NLRP3-mediated pyroptosis. Downregulating miR-138-5p partially reversed the protective effect of HDAC6 inhibition after CPR. In Conclusion, HDAC6 enrichment on miR-138-5p promoter deacetylated H3K9ac, inhibiting miR-138-5p expression and promoting NLRP3-mediated pyroptosis, worsening neurological dysfunction in rats after CPR.

Exploring the Functionality of Technology-driven CPR Training Methodologies Among Healthcare Practitioners: A Randomized Control Pilot Study.

Introduction: Cardiopulmonary resuscitation training in Malaysia has evolved from traditional to modern approaches, embracing technology for better outcomes. Smartphone-based training apps offer interactive learning with simulations and real-time feedback, improving cardiopulmonary resuscitation skills anytime, anywhere. This study evaluates the effectiveness of the smart-cardiopulmonary resuscitation application for healthcare practitioners. Methods: This randomized controlled pilot study was conducted with 30 healthcare practitioners at the University of Malaysia Sabah. Participants underwent a Cardiopulmonary Resuscitation Practical formal educational training program, and data were collected using a Basic Life Support questionnaire and skills assessment checklist sourced from the American Heart Association (2020). Data analysis was conducted utilizing repeated analysis of variance and the Cochran 'Q' test supported by Statistical Package for the Social Sciences statistical software. Result: The control and intervention groups showed improved knowledge and skills from pre-to post-cardiopulmonary resuscitation courses; a significant increase was observed in the intervention group compared to the control group. The F-test indicated a significant time-group effect (F-stat (df) = 16.14 (2), p = 0.01). Cochran's 'Q' test also revealed significant changes in the proportion of healthcare practitioners passing their skills assessments over time (2 = 14.90, control 01). Conclusion: The smart-cardiopulmonary resuscitation application is convenient for refreshing cardiopulmonary resuscitation skills and maintaining proficiency. While it doesn't replace formal cardiopulmonary resuscitation courses, it saves healthcare practitioners and the community time and money. Both groups showed improved cardiopulmonary resuscitation knowledge and skills, with the intervention group using the smart-cardiopulmonary resuscitation application showing higher success rates after two months. Adopting smartphone-based cardiopulmonary resuscitation training with comprehensive content is recommended.

Adenosine 2A Receptor Agonism Improves Survival in Extracorporeal Cardiopulmonary Resuscitation.

INTRODUCTION: Despite resuscitation advances including extracorporeal cardiopulmonary resuscitation (ECPR), freedom from neurologic and myocardial insult after cardiac arrest remains unlikely. We hypothesized that adenosine 2A receptor (A2AR) agonism, which attenuates reperfusion injury, would improve outcomes in a porcine model of ECPR. METHODS: Adult swine underwent 20 min of circulatory arrest followed by defibrillation and 6 h of ECPR. Animals were randomized to receive saline vehicle or A2AR agonist (ATL1223 or Regadenoson) infusion during extracorporeal membrane oxygenation. Animals were weaned off extracorporeal membrane oxygenation and monitored for 24 h. Clinical and biochemical end points were compared. RESULTS: The administration of A2AR agonists increased survival (P = 0.01) after cardiac arrest compared to vehicle. Markers of neurologic damage including S100 calcium binding protein B and glial fibrillary acidic protein were significantly lower with A2AR agonist treatment. CONCLUSIONS: In a model of cardiac arrest treated with ECPR, A2AR agonism increased survival at 24 h and reduced neurologic damage suggesting A2AR activation may be a promising therapeutic target after cardiac arrest.

Active Decompression during Automated Head-up Cardiopulmonary Resuscitation.

BACKGROUND: The combination of active compression-decompression cardiopulmonary resuscitation (ACD-CPR) with an impedance threshold device (ITD) and controlled head-up positioning (AHUP-CPR) is associated with improved outcomes compared with conventional CPR (C-CPR). This study focused on the role of active decompression (AD) during AHUP-CPR. METHODS: Farm pigs (n=10, ∼40 kg) were anesthetized, intubated and ventilated. Physiological parameters and right ventricular pressure-volume loops were recorded continuously. Ventricular fibrillation was induced and left untreated for 10 mins, followed by automated C-CPR (2 min), ACD+ITD CPR in the flat position (2 min), and then AHUP-CPR with 3 cm of lift above the neutral chest position. After 15 minutes of CPR, AD was discontinued and then restarted incrementally to 4 cm. Data were analyzed with a linear mixed-effects model, using random intercepts for individual pigs. RESULTS: Upon cessation of AD during AHUP-CPR, decompression right atrial pressure (+59%) increased (p<0.01), whereas multiple hemodynamic parameters positively associated with perfusion, including coronary (-25%) and cerebral perfusion pressures (-11%), end-tidal CO2 (-13%), stroke volume and cardiac output (-26%), decreased immediately and significantly with p<0.05. Restoration of AD reduced right atrial pressure and increased positive perfusion parameters in an incremental manner. Only with ≥3 cm of AD were all hemodynamic parameters restored to ≥90% of pre-AD discontinuation levels. CONCLUSION: Full chest wall lift, achieved with ≥3 cm of AD, was needed to maintain and optimize hemodynamics during AHUP-CPR in pigs. These findings should be considered when optimizing care with this new approach.

Correlation Between Hospital Rates of Survival to Discharge and Long-term Survival for In-hospital Cardiac Arrest: Insights from Get With The Guidelines®-Resuscitation Registry.

AIM: Given challenges in collecting long-term outcomes for survivors of in-hospital cardiac arrest (IHCA), most studies have focused on in-hospital survival. We evaluated the correlation between a hospital's risk-standardized survival rate (RSSR) at hospital discharge for IHCA with its RSSR for long-term survival. METHODS: We identified patients ≥65 years of age with IHCA at 472 hospitals in Get With The Guidelines®-Resuscitation registry during 2000-2012, who could be linked to Medicare files to obtain post-discharge survival data. We constructed hierarchical logistic regression models to compute RSSR at discharge, and 30-day, 1-year, and 3-year RSSRs for each hospital. The association between in-hospital and long-term RSSR was evaluated with weighted Kappa coefficients. RESULTS: Among 56,231 Medicare beneficiaries (age 77.2±7.5 years and 25,206 [44.8%] women), 10,536 (18.7%) survived to discharge and 8,485 (15.1%) survived to 30 days after discharge. Median in-hospital, 30-day, 1-year, and 3-year RSSRs were 18.6% (IQR, 16.7%-20.4%), 14.9% (13.2%-16.7%), 10.3% (9.1%-12.1%), and 7.6% (6.8%-8.8%), respectively. The weighted Kappa coefficient for the association between a hospital's RSSR at discharge with its 30-day, 1-year, and 3-year RSSRs were 0.72 (95% CI, 0.68-0.76), 0.56 (0.50-0.61), and 0.47 (0.41-0.53), respectively. CONCLUSIONS: There was a strong correlation between a hospital's RSSR at discharge and its 30-day RSSR for IHCA, although this correlation weakens over time. Our findings suggest that a hospital's RSSR at discharge for IHCA may be a reasonable surrogate of its 30-day post-discharge survival and could be used by Medicare to benchmark hospital performance for this condition without collecting 30-day survival data.

The association of out-of-hospital cardiac arrest barriers to cardiopulmonary resuscitation initiation and continuation during the emergency call: A retrospective cohort study.

Background: In a previous study, we identified eight types of potential barriers to bystander cardiopulmonary resuscitation (CPR) initiation and continuation until the arrival of emergency medical services (EMS) on scene, in the context of emergency calls for out-of-hospital cardiac arrest (OHCA). Many cases had multiple barriers. In this study, we aimed to estimate the independent effects of these barriers after adjusting for case characteristics. Methods: We used data for the 295 non-trauma OHCAs from the St John Western Australian (SJ-WA) OHCA Database. Excluded cases were: EMS-witnessed OHCA, callers not with/close to the patient, OHCA not recognised during the emergency call, bystander CPR in progress prior to the call and calls coded as obvious death by SJ-WA. We conducted two multivariable logistic regression models including the eight barriers (callers: 1) perceived inappropriateness of CPR, 2) emotional distress, 3) reluctance to perform CPR, 4) physical limitations, 5) access to the patient, 6) leaving the scene, 7) communication failure, and 8) on-scene distractions) and case characteristics. Results: The callers perceiving CPR as inappropriate (adjusted odds ratio [AOR] = 0.20, 0.11-0.37) and witnessed arrest (AOR = 2.88, 95% CI 1.48-5.60) were independently associated with CPR initiation. Caller distractions such as performing other tasks or relaying information to other bystanders were negatively significantly associated with callers continuing CPR to EMS arrival (AOR = 0.27, 0.10-0.73). Conclusions: Perceptions of inappropriateness and caller distractions were independent risk factors for the delivery of bystander CPR. Further research around how call-takers navigate these barriers and encourage callers should be performed.