Characteristics of the most severely ill and injured patients in a Norwegian helicopter emergency medical service: a retrospective cohort study.

BACKGROUND: Physician-staffed helicopter emergency medical services (HEMS) are dispatched to a variety of incidents, ranging from less serious to life-threatening. The skillset of a physician may be important to provide appropriate care for the most critically ill and severely injured patients. A better understanding of these patients may therefore be important to optimize dispatch criteria, training, and equipment setups for HEMS units. The aim of this study was to describe the characteristics of patients with the national advisory committee on aeronautics (NACA) score 5 and 6, primarily by diagnostic group and interventions performed. METHODS: Retrospective cohort study on aggregated data from the HEMS-base in Trondheim, Norway. All patients with NACA score 5 and 6 in the 10-year period from 2013 to 2022 were included. Patients with return of spontaneous circulation (ROSC) after successful cardiopulmonary resuscitation were described separately from non-cardiac arrest patients. RESULTS: Out of 9546 patient encounters, 2598 patients were included, with 1640 in the NACA 5 and 958 in NACA 6 group. Patient age was median 63 (interquartile range 45-74) and 64% of the patients were male. Post-ROSC patients accounted for 24% of patients. Of the non-cardiac arrest patients, the most frequent aetiology was trauma (16%), cardiac (15%), neurologic (14%) and respiratory (11%). The most common physician-requiring advanced interventions were general anaesthesia (22%), intubation (21%), invasive blood pressure monitoring (21%) and ventilator treatment (18%). The mean number of advanced interventions per mission were consistent during the study period (1,78, SD 0,25). CONCLUSION: Twenty-seven percent of all HEMS dispatches were to NACA 5 and 6 patients. Twenty-four percent of these were post-ROSC patients. Sixty-three percent of all patients received at least one advanced physician-requiring intervention and the average number of interventions were consistent during the last 10 years. Hence, the competence a physician-staffed HEMS resource provide is utilized in a high number of critically ill and injured patients.

A prospective observational study on impact of epinephrine administration route on acute myocardial infarction patients with cardiac arrest in the catheterization laboratory (iCPR study).

BACKGROUND: Epinephrine is routinely utilized in cardiac arrest; however, it is unclear if the route of administration affects outcomes in acute myocardial infarction patients with cardiac arrest. OBJECTIVES: To compare the efficacy of epinephrine administered via the peripheral intravenous (IV), central IV, and intracoronary (IC) routes. METHODS: Prospective two-center pilot cohort study of acute myocardial infarction patients who suffered cardiac arrest in the cardiac catheterization laboratory during percutaneous coronary intervention. We compared the outcomes of patients who received epinephrine via peripheral IV, central IV, or IC. RESULTS: 158 participants were enrolled, 48 (30.4%), 50 (31.6%), and 60 (38.0%) in the central IV, IC, and peripheral IV arms, respectively. Peripheral IV epinephrine administration route was associated with lower odds of achieving return of spontaneous circulation (ROSC, odds ratio = 0.14, 95% confidence interval = 0.05-0.36, p < 0.0001) compared with central IV and IC administration. (There was no difference between central IV and IC routes; p = 0.9343.) The odds of stent thrombosis were significantly higher with the IC route (IC vs. peripheral IV OR = 4.6, 95% CI = 1.5-14.3, p = 0.0094; IC vs. central IV OR = 6.0, 95% CI = 1.9-19.2, p = 0.0025). Post-ROSC neurologic outcomes were better for central IV and IC routes when compared with peripheral IV. CONCLUSION: Epinephrine administration via central IV and IC routes was associated with a higher rate of ROSC and better neurologic outcomes compared with peripheral IV administration. IC administration was associated with a higher risk of stent thrombosis. Trial registration This trial is registered at NCT05253937 .

Decreases in out of hospital cardiac arrest (OHCA) outcome metrics persist when known COVID patients are excluded from analysis.

OBJECTIVE: A decline in OHCA performance metrics during the pandemic has been reported in the literature but the cause is still not known. The Montgomery County Fire and Rescue Service (MCFRS) observed a decline in both the rate of return of spontaneous circulation (ROSC) and the proportion of resuscitations that resulted in cerebral performance category (CPC) 1 or 2 discharge of the patient beginning in March of 2020. This study examines whether the decline in these performance metrics persists when known COVID positive patients are excluded from the analysis. METHODS: Two samples of OHCA patients for similar time periods (one year apart) before and after the start of the COVID pandemic were developed. A database of known COVID positive patients among EMS encounters was used to identify and exclude COVID positive patients. OHCA outcomes in these two groups were then compared using a Chi-square test and Fisher's exact test for difference in proportions and Analysis of Variance (ANOVA) for difference in means. A two-stage multivariable logistic regression model was used to develop odds ratios for achieving ROSC and CPC 1 or 2 discharge in each period. RESULTS: After excluding known COVID patients, 32.5% of the patients in the pre-COVID period achieved ROSC compared to 25.1% in the COVID period (p = 0.007). 6% of patients in the pre-COVID period were discharged with CPC 1 or 2 compared to 3.2% from the COVID era (p = 0.026). Controlling for all available patient characteristics, patients undergoing OHCA resuscitation prior to be beginning of the pandemic were 1.2 times more likely to achieve ROSC and 1.6 times more likely to be discharged with CPC 1 or 2 than non-COVID patients in the pandemic era sample. CONCLUSIONS: When known COVID patients are excluded, pre-pandemic OHCA resuscitation patients were more likely to achieve ROSC and CPC 1 or 2 discharge. The prevalence of known COVID positive patients among all OHCA resuscitations during the pandemic was not sufficient to fully account for the marked decrease in both ROSC and CPC 1 or 2 discharges. Other causative factors must be sought.

Assessment of Cerebral Blood Oxygenation by Near-Infrared Spectroscopy before and after Resuscitation in a Rat Asphyxia Cardiac Arrest Model.

Clinical investigators have focused on the real-time evaluation of cerebral blood oxygenation (CBO) by near-infrared spectroscopy (NIRS) during cardiopulmonary resuscitation (CPR). A previous study showed that an abrupt increase of oxy-hemoglobin (Hb) level and tissue oxygenation index (TOI) was associated with the timing of return of spontaneous circulation (ROSC). However, it is not clear how TOI alters before and after CPR including a period of cardiac arrest (CA). Therefore, this study aimed to assess CBO with asphyxia CA and its association with CPR to ROSC in rats. Male Sprague-Dawley rats were used. We attached NIRS (NIRO-200NX, Hamamatsu Photonics, Japan) from the nasion to the upper cervical spine in rats. A ten-minute asphyxia was given to induce CA. After CA, mechanical ventilation was restarted, and manual CPR was performed. We examined the mean arterial pressure (MAP), end-tidal carbon dioxide (ETCO2), and Oxy/Deoxy-Hb and TOI. Out of 14 rats, 11 obtained sustained ROSC. After the induction of asphyxia, a rapid drop of TOI was observed, followed by a subsequent increase of Oxy-Hb, Deoxy-Hb, and TOI with CPR. Recent CPR guidelines suggest the use of ETCO2 during CPR since its abrupt increase is a reasonable indicator of ROSC. In this study, abrupt increases in MAP, ETCO2, and TOI were observed at the time of ROSC. TOI can be an alternative to ETCO2 for identifying ROSC after CA, and it also has the capability of monitoring CBO during and after CPR.

A Machine Learning Model for the Prognosis of Pulseless Electrical Activity during Out-of-Hospital Cardiac Arrest.

Pulseless electrical activity (PEA) is characterized by the disassociation of the mechanical and electrical activity of the heart and appears as the initial rhythm in 20-30% of out-of-hospital cardiac arrest (OHCA) cases. Predicting whether a patient in PEA will convert to return of spontaneous circulation (ROSC) is important because different therapeutic strategies are needed depending on the type of PEA. The aim of this study was to develop a machine learning model to differentiate PEA with unfavorable (unPEA) and favorable (faPEA) evolution to ROSC. An OHCA dataset of 1921 5s PEA signal segments from defibrillator files was used, 703 faPEA segments from 107 patients with ROSC and 1218 unPEA segments from 153 patients with no ROSC. The solution consisted of a signal-processing stage of the ECG and the thoracic impedance (TI) and the extraction of the TI circulation component (ICC), which is associated with ventricular wall movement. Then, a set of 17 features was obtained from the ECG and ICC signals, and a random forest classifier was used to differentiate faPEA from unPEA. All models were trained and tested using patientwise and stratified 10-fold cross-validation partitions. The best model showed a median (interquartile range) area under the curve (AUC) of 85.7(9.8)% and a balance accuracy of 78.8(9.8)%, improving the previously available solutions at more than four points in the AUC and three points in balanced accuracy. It was demonstrated that the evolution of PEA can be predicted using the ECG and TI signals, opening the possibility of targeted PEA treatment in OHCA.

Socioeconomic disparities in prehospital cardiac arrest outcomes: An analysis of the NEMSIS database.

BACKGROUND: Socioeconomic disparities are engrained in the US healthcare system and may extend to the prehospital cardiac arrest setting where mortality is high. METHODS: Using the National Emergency Medical Services Information System (NEMSIS) database, 150,003 cases were analyzed comparing socioeconomic status and cardiac arrest outcomes. Cardiac arrest outcomes were measured by the percent of cases that achieved return of spontaneous circulation (ROSC) and the percent of cases in which ROSC occurred in the Emergency Department (ED) as opposed to a prehospital setting which was a proxy for the length of time spent in cardiac arrest. Chi-square tests checked for statistical significance and effect size was measured using Pearson's r values and linear regression coefficients. RESULTS: Comparing neighborhood poverty level and the percent of cardiac arrest cases that achieved ROSC resulted in a Pearson's r value of 0.9424 (R2 = 0.8881, p < 0.005) and a linear regression coefficient of 2.088 (p < 0.05, R2 = 0.8881, 95% CI [1.059, 3.117]) meaning for every interval increase in poverty, the chance of an individual in cardiac arrest achieving ROSC decreases 2.09%. Comparing neighborhood poverty level and the percent of ROSC cases that occurred in the ED yielded a Pearson's r value of 0.9005 (R2 = 0.8109, p < 0.05) and a linear regression coefficient of 0.7701 (p < 0.05, R2 = 0.8109, 95% CI [0.254, 1.286]) meaning for every interval increase in poverty, the chance that ROSC is delayed increases 0.77%. CONCLUSIONS: Low income individuals in cardiac arrest have a statistically significant lower probability of achieving ROSC and a higher chance of delayed ROSC.

Adult out-of-hospital cardiac arrest based on chain of survival in Taoyuan County, northern Taiwan.

BACKGROUND: Most out-of-hospital cardiac arrest (OHCA) studies have been conducted in developed countries or metropolitan areas, and few in developing countries or rural areas. OBJECTIVES: The aims of this study were to determine the weak links in the chain of survival and to estimate the outcomes of OHCA patients in Taoyuan, a nonmetropolitan area in Taiwan. METHODS: A retrospective review and analysis of OHCA data was conducted. The three outcomes were whether a return of spontaneous circulation (ROSC) was achieved, whether the patient survived to admission, or whether the patient survived to hospital discharge. RESULTS: From April to December 2008, 1048 OHCA patients were resuscitated, and 712 (67.9%) adult cardiac patients were used in this study. Among these 712 patients, 17.8% achieved ROSC (95% confidence interval [CI] 15.2-20.8%), 16.3% survived to admission (95% CI 13.6-19.0%), and 1.4% survived to discharge (95% CI 0.5-2.3%). Factors significantly associated with the three outcomes were witness status, response time to emergency medical services, and whether the patient had a shockable rhythm. Bystander cardiopulmonary resuscitation (CPR) did not add a notable benefit to the outcomes of OHCA. CONCLUSIONS: The survival rate of OHCA patients in nonmetropolitan Taiwan was very low (1.4%). Lower witnessed rate, lower bystander CPR rate, and longer response interval in remote areas are the main causes of inferior survival rate.

Factors predicting the return of spontaneous circulation rate of cardiopulmonary resuscitation in China: Development and evaluation of predictive nomogram.

Background: This study aimed to construct and internally validate a probability of the return of spontaneous circulation (ROSC) rate nomogram in a Chinese population of patients with cardiac arrest (CA). Methods: Patients with CA receiving standard cardiopulmonary resuscitation (CPR) were studied retrospectively. The minor absolute shrinkage and selection operator (LASSO) regression analysis and multivariable logistic regression evaluated various demographic and clinicopathological characteristics. A predictive nomogram was constructed and evaluated for accuracy and reliability using C-index, the area under the receiver operating characteristic curve (AUC), calibration plot, and decision curve analysis (DCA). Results: A cohort of 508 patients who had experienced CA and received standard CPR was randomly divided into training (70 %, n = 356) and validation groups (30 %, n = 152) for the study. LASSO regression analysis and multivariable logistic regression revealed that thirteen variables, such as age, CPR start time, Electric defibrillation, Epinephrine, Sodium bicarbonate (NaHCO3), CPR Compression duration, The postoperative prothrombin (PT) time, Lactate (Lac), Cardiac troponin (cTn), Potassium (K+), D-dimer, Hypertension (HBP), and Diabetes mellitus (DM), were found to be independent predictors of the ROSC rate of CPR. The nomogram model showed exceptional discrimination, with a C-index of 0.933 (95 % confidence interval: 0.882-0.984). Even in the internal validation, a remarkable C-index value of 0.926 (95 % confidence interval: 0.875-0.977) was still obtained. The accuracy and reliability of the model were also verified by the AUC of 0.923 in the training group and 0.926 in the validation group. The calibration curve showed the model agreed with the actual results. DCA suggested that the predictive nomogram had clinical utility. Conclusions: A predictive nomogram model was successfully established and proved to identify the influencing factors of the ROSC rate in patients with CA. During cardiopulmonary resuscitation, adjusting the emergency treatment based on the influence factors on ROSC rate is suggested to improve the treatment rate of patients with CA.

Cardiac arrest centres for patients with non-traumatic cardiac arrest: A systematic review.

INTRODUCTION: Regionalisation and organised pathways of care using specialist centre hospitals can improve outcomes for critically ill patients. Cardiac arrest centre hospitals (CAC) may optimise the delivery of post-resuscitation care. The International Liaison Committee on Resuscitation (ILCOR) has called for a review of the current evidence base. AIM: This systematic review aimed to assess the effect of cardiac arrest centres for patients with non-traumatic cardiac arrest. METHODS: Articles were included if they met the prospectively registered (PROSPERO) inclusion criteria. These followed the PICOST framework for ILCOR systematic reviews. A strict definition for a CAC was used, reflecting current position statements and clinical practice. MEDLINE, Embase and the Cochrane Library were searched using pre-determined criteria from inception to 31 December 2023. Risk of bias was assessed using Cochrane's Risk of Bias tool and ROBINS-I. The certainty of evidence for each outcome was assessed using the GRADE approach. Substantial heterogeneity precluded meta-analysis and a narrative synthesis with visualisation of effect estimates in forest plots was performed. RESULTS: Sixteen studies met eligibility criteria, including data on over 145,000 patients. One was a randomised controlled trial (RCT) at low risk of bias and the remainder were observational studies, all at moderate or serious risk of bias. All studies included adults with out-of-hospital cardiac arrest. One study used initial shockable rhythm as an inclusion criterion and most studies (n = 12) included patients regardless of prehospital ROSC status. Two studies, including the RCT, excluded patients with ST elevation. Survival to hospital discharge with a favourable neurological outcome was reported by 11 studies and favoured CAC care in all observational studies, but the RCT showed no difference. Survival to 30 days with a favourable neurological outcome was reported by two observational studies and favoured CAC care in both. Survival to hospital discharge was reported by 13 observational studies and generally favoured CAC care. Survival to 30 days was reported by two studies, where the observational study favoured CAC care, but the RCT showed no difference. CONCLUSION: This review supports a weak recommendation that adults with out-of-hospital cardiac arrest are cared for at CACs based on very low certainty of evidence. Randomised evidence has not confirmed the benefits of CACs found in observational studies, however this RCT was a single trial in a very specific setting and a population without ST elevation on post-ROSC ECG. The role of CACs in shockable and non-shockable subgroups, direct versus secondary transfer, as well as the impact of increased transport time and bypassing local hospitals remains unclear.

A Rare Phenomenon of Pulseless Body Movements Induced During Prolonged Cardiopulmonary Resuscitation.

Patients receiving cardiopulmonary resuscitation (CPR) may rarely experience cardiopulmonary resuscitation-induced consciousness (CPRIC), manifesting as body movements, eye-opening, or even awareness. We present a case report of a 55-year-old male patient who experienced CPRIC but did not survive despite resuscitative measures. The patient suffered a sudden cardiac arrest and received early initiation of CPR. However, CPRIC posed a treatment dilemma for our resuscitation team as the patient displayed body movements, requiring careful management to avoid interruptions in CPR. The challenge of differentiating CPRIC from the return of spontaneous circulation (ROSC) highlights the need for further research and evidence-based guidelines. Effective management strategies for CPRIC are necessary to guide resuscitation teams in making informed decisions. Understanding and addressing CPRIC can improve the quality of CPR and post-resuscitation care, supporting the well-being of both patients and healthcare providers. Further investigation is essential to developing comprehensive approaches to managing CPRIC and improving patient outcomes.

A simulation-based randomized trial of ABCDE style cognitive aid for emergency medical services CHecklist In Prehospital Settings: the CHIPS-study.

BACKGROUND: Checklists are a powerful tool for reduction of mortality and morbidity. Checklists structure complex processes in a reproducible manner, optimize team interaction, and prevent errors related to human factors. Despite wide dissemination of the checklist, effects of checklist use in the prehospital emergency medicine are currently unclear. The aim of the study was to demonstrate that participants achieve higher adherence to guideline-recommended actions, manage the scenario more time-efficient, and thirdly demonstrate better adherence to the ABCDE-compliant workflow in a simulated ROSC situation. METHODS: CHIPS was a prospective randomized case-control study. Professional emergency medical service teams were asked to perform cardiopulmonary resuscitation on an adult high-fidelity patient simulator achieving ROSC. The intervention group used a checklist which transferred the ERC guideline statements of ROSC into the structure of the 'ABCDE' mnemonic. Guideline adherence (performance score, PS), utilization of process time (items/minute) and workflow were measured by analyzing continuous A/V recordings of the simulation. Pre- and post-questionnaires addressing demographics and relevance of the checklist were recorded. Effect sizes were determined by calculating Cohen's d. The level of significance was defined at p < 0.05. RESULTS: Twenty scenarios in the intervention group (INT) and twenty-one in the control group (CON) were evaluated. The average time of use of the checklist (CU) in the INT was 6.32 min (2.39-9.18 min; SD = 2.08 min). Mean PS of INT was significantly higher than CON, with a strong effect size (p = 0.001, d = 0.935). In the INT, significantly more items were completed per minute of scenario duration (INT, 1.48 items/min; CON, 1.15 items/min, difference: 0.33/min (25%), p = 0.001), showing a large effect size (d = 1.11). The workflow did not significantly differ between the groups (p = 0.079), although a medium effect size was shown (d = 0.563) with the tendency of the CON group deviating stronger from the ABCDE than the INT. CONCLUSION: Checklists can have positive effects on outcome in the prehospital setting by significantly facilitates adherence to guidelines. Checklist use may be time-effective in the prehospital setting. Checklists based on the 'ABCDE' mnemonic can be used according to the 'do verify' approach. Team Time Outs are recommended to start and finish checklists.

Outcomes of Cardiopulmonary Resuscitation and Predictors of Its Outcomes in the Emergency Department in King Saud Medical City, Saudi Arabia.

BACKGROUND: Cardiac arrest is a medical emergency marked by the cessation of cardiac mechanical activity and insufficient blood flow. CPR (cardiopulmonary resuscitation) is a life-saving method that involves restoring the essential functions of two vital organs: the heart and lungs. This study was conducted to identify the outcome of CPR in cardiac arrest patients presented to the emergency department (ED) and to identify predictors of CPR outcomes. METHODOLOGY: This was a retrospective, descriptive study. All in-hospital cardiac arrest patients who underwent CPR in the King Saud Medical City (KSMC) ED between January 2017 and January 2020 were analyzed, with a sample size of 351 patients. RESULTS: Overall return of spontaneous circulation (ROSC) and survival to discharge (STD) were achieved in 106 (30.2%) and 40 (11.39%) patients, respectively. When assessing the predictors of ROSC, the analyses showed that patient age, pre-arrest intubation, the method used to deliver oxygen, and CPR duration were all statistically significant predictors for ROSC. Similarly, when assessing predictors associated with STD, the analyses showed that patient age, pre-arrest intubation, the method used to deliver oxygen, and CPR duration were positively associated with STD. CONCLUSION: Comparing the study's findings to those of similar studies, it shows a CPR outcome rate within the range of similar studies. It also highlights that CPR outcomes are highly associated with CPR duration (a maximum of 30 minutes), younger age, and endotracheal intubation.

Recognition of Pulseless Ventricular Tachycardia Through the Second Analysis of Automated External Defibrillators, Leading to Successful Shock Delivery in a Patient With Dilated Cardiomyopathy: A Case Report.

The use of a defibrillator with a monitor is recommended for the shock indication algorithm for in-hospital cardiac arrest; however, it is likely that many medical facilities are still equipped only with automated external defibrillators (AEDs). We experienced a case of dilated cardiomyopathy (DCM) complicated by pulseless ventricular tachycardia (pVT) in which an AED was used, but shock was deemed unnecessary after the first analysis. We believe that this case is suggestive of resuscitating cardiac arrest, for which defibrillation is indicated and reported here. A 65-year-old man who had DCM and diabetic nephropathy was admitted to our institution because of worsening heart failure. In the hospital, he suddenly had syncope and was diagnosed with cardiac arrest. Thereafter, cardiopulmonary resuscitation (CPR) was performed using an AED, and the monitor on the AED showed pVT. The first analysis of the AED announced unnecessary shock delivery. The pads of the AED were pressed firmly against the chest wall while continuous high-quality CPR was administered for two minutes. The second analysis of the AED revealed the necessity of providing shock for shockable rhythm. The patient experienced the return of spontaneous circulation after shock delivery. We were reminded that there are some clinical cases in which AED shock is not indicated for pVT and that even in such cases, it is important to continue high-quality CPR without panicking.

Pulseless electrical activity in in-hospital cardiac arrest - A crossroad for decisions.

BACKGROUND: PEA is often seen during resuscitation, either as the presenting clinical state in cardiac arrest or as a secondary rhythm following transient return of spontaneous circulation (ROSC), ventricular fibrillation/tachycardia (VF/VT), or asystole (ASY). The aim of this study was to explore and quantify the evolution from primary/secondary PEA to ROSC in adults during in-hospital cardiac arrest (IHCA). METHODS: We analyzed 700 IHCA episodes at one Norwegian hospital and three U.S. hospitals at different time periods between 2002 and 2021. During resuscitation ECG, chest compressions, and ventilations were recorded by defibrillators. Each event was manually annotated using a graphical application. We quantified the transition intensities, i.e., the propensity to change from PEA to another clinical state using time-to-event statistical methods. RESULTS: Most patients experienced PEA at least once before achieving ROSC or being declared dead. Time average transition intensities to ROSC from primary PEA (n = 230) and secondary PEA after ASY (n = 72) were 0.1 per min, peaking at 4 and 7 minutes, respectively; thus, a patient in these types of PEA showed a 10% chance of achieving ROSC in one minute. Much higher transition intensities to ROSC, average of 0.15 per min, were observed for secondary PEA after VF/VT (n = 83) or after ROSC (n = 134). DISCUSSION: PEA is a crossroad in which the subsequent course is determined. The four distinct presentations of PEA behave differently on important characteristics. A transition to PEA during resuscitation should encourage the resuscitation team to continue resuscitative efforts.

The first case series analysis on efficacy of esmolol injection for in-hospital cardiac arrest patients with refractory shockable rhythms in China.

Background: This study assessed the effects of esmolol injection in patients with in-hospital cardiac arrest (IHCA) with refractory ventricular fibrillation (VF)/pulseless ventricular tachycardia (pVT). Methods: From January 2018 to December 2021, 29 patients with IHCA with refractory shockable rhythm were retrospectively reviewed. Esmolol was administered after advanced cardiovascular life support (ACLS)-directed procedures, and outcomes were assessed. Results: Among the 29 cases, the rates of sustained return of spontaneous circulation (ROSC), 24-h ROSC, and 72-h ROSC were 79%, 62%, and 59%, respectively. Of those patients, 59% ultimately survived to discharge. Four patients with cardiac insufficiency died. The duration from CA to esmolol infusion was significantly shorter for patients in the survival group (SG) than for patients in the dead group (DG) (12 min, IQR: 8.5-19.5 vs. 23.5 min, IQR: 14.4-27 min; p = 0.013). Of those patients, 76% (22 of 29) started esmolol administration after the second dose of amiodarone. No significant difference was observed in the survival rate between this group and groups administered an esmolol bolus simultaneously or before the second dose of amiodarone (43% vs. 64%, p = 0.403). Of those patients, 31% (9 of 29) were administered an esmolol bolus for defibrillation attempts ≤ 5, while the remaining 69% of patients received an esmolol injection after the fifth defibrillation attempt. No significant differences were observed in the rates of ≥ 24-h ROSC (67% vs. 60%, p = 0.73), ≥ 72-h ROSC (67% vs. 55%, p = 0.56), and survival to hospital discharge (67% vs. 55%, p = 0.56) between the groups administered an esmolol bolus for defibrillation attempts ≤ 5 and defibrillation attempts > 5. Conclusion: IHCA patients with refractory shockable rhythms receiving esmolol bolus exhibited a high chance of sustained ROSC and survival to hospital discharge. Patients with end-stage heart failure tended to have attenuated benefits from beta-blockers. Further large-scale, prospective studies are necessary to determine the effects of esmolol in patients with IHCA with refractory shockable rhythms.

The Impact of Prehospital and Hospital Care on Clinical Outcomes in Out-of-Hospital Cardiac Arrest.

Background: In recent years, several actions have been made to shorten the chain of survival in out-of-hospital cardiac arrest (OHCA). These include placing defibrillators in public places, training first responders, and providing dispatcher-assisted CPR (DA-CPR). In this work, we aimed to evaluate the impact of these changes on patients' outcomes, including achieving return of spontaneous circulation (ROSC), survival to discharge, and survival with favorable neurological function. Methods: We retrospectively retrieved data of all calls to the national emergency medical service in Ashdod city, Israel, of individuals who underwent OHCA at the age of 18 and older between the years 2018 and 2021. Data was collected on prehospital and hospital interventions. The association between pre-hospital and hospital interventions to ROSC, survival to discharge, and neurological outcomes was evaluated. Logistic regression was used for multivariable analysis. Results: During the years 2018-2021, there were 1253 OHCA cases in the city of Ashdod. ROSC was achieved in 207 cases (32%), survival to discharge was attained in 48 cases (7.4%), and survival with favorable neurological function was obtained in 26 cases (4%). Factors significantly associated with good prognosis were shockable rhythm, witnessed arrest, DA-CPR, use of AED, and treatment for STEMI. All patients that failed to achieve ROSC outside of the hospital setting had a poor prognosis. Conclusions: This study demonstrates the prognostic role of the initial rhythm and the use of AED in OHCA. Hospital management, including STEMI documentation and catheterization, was also an important prognostication factors. Additionally, when ROSC is not achieved in the field, hospital transfer should be considered.

End-Stage Renal Disease Patients Undergoing Hemodialysis Have Higher Possibility of Return of Spontaneous Circulation during Out-of-Hospital Cardiac Arrest and Non-Inferior Short-Term Survival.

End-stage renal disease (ESRD) patients on long-term hemodialysis (HD) have an elevated risk of sudden cardiac death. This study hypothesizes, for the first time, that these patients have a higher odds of return of spontaneous circulation (ROSC) and subsequent better hospital-outcomes, post out-of-hospital cardiac arrest (OHCA), as opposed to non-ESRD patients. A national database from Taiwan was utilized, in which 101,876 ESRD patients undergoing HD and propensity score-matched non-ESRD patients were used to conduct two analyses: (i) Cox-proportional-hazards-regression for OHCA incidence and (ii) logistic-regression analysis of attaining ROSC after OHCA, both for ESRD patients in comparison to non-ESRD patients. Kaplan-Meier analyses were conducted to determine the difference of survival rates after ROSC between the two cohorts. ESRD patients were found to be at a higher risk of OHCA (adjusted-HR = 2.11, 95% CI: (1.89−2.36), p < 0.001); however, they were at higher odds of attaining ROSC (adjusted-OR = 2.47, 95% CI: 1.90−3.21, p < 0.001), as opposed to non-ESRDs. Further, Kaplan-Meier analysis demonstrated ESRD patients with a better 30-day hospital survival rate than non-ESRD patients. Although ESRD patients had a higher risk of OHCA, they demonstrated higher possibility of ROSC and a better short-term hospital outcome than non-ESRDs. Chronic toxin tolerance and the training of vascular-compliance during regular HD may be possible explanations for better outcomes in ESRD patients.

Traumatic Cardiac Arrest: Scoping Review of Utilization of Resuscitative Endovascular Balloon Occlusion of the Aorta.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is increasingly used in trauma resuscitation for patients with life-threatening hemorrhage below the diaphragm and may also be used for patients with traumatic cardiac arrest (TCA). Resuscitative thoracotomy with aortic cross clamping (RT-ACC) maneuver was traditionally performed for patients with TCA due to hemorrhagic shock; however, REBOA has been substituted for RT-ACC in selected TCA cases. During cardiopulmonary resuscitation (CPR) in TCA, REBOA increases cerebral and coronary perfusion, and temporary bleeding control. Both animal and clinical studies have reported the efficacy of REBOA for TCA, and a recent observational study suggested that REBOA may contribute to the return of spontaneous circulation after TCA. Although multiple questions remain unanswered, REBOA has been applied to trauma fields as a novel technology.

Target Temperature Management and Survival with Favorable Neurological Outcome After Out-of-Hospital Cardiac Arrest in Children: A Nationwide Multicenter Prospective Study in Japan.

To assess whether target temperature management (TTM) is effective for 1-month survival with favorable neurological outcome among pediatric patients who achieved return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA). The Japanese Association for Acute Medicine-out-of-hospital cardiac arrest (JAAM-OHCA) Registry, a multicenter prospective observational registry in Japan, included OHCA patients aged ≤17 years who achieved ROSC between June 2014 and December 2017. The primary outcome was 1-month survival with favorable neurological outcomes, defined as pediatric cerebral performance category 1 or 2. We conducted a propensity score analysis with inverse-probability-of-treatment weighting (IPTW) and evaluated the effect of TTM using logistic regression models with IPTW. A total of 167 patients [120 in the non-TTM group (71.9%) and 47 in the TTM group (28.1%)] were eligible for our analysis. The proportion of patients demonstrating 1-month survival with favorable neurological outcomes was 25.5% (12/47) in the TTM group and 16.7% (20/120) in the non-TTM group; there were no significant differences in favorable neurological outcomes (odds ratio, 1.36; 95% confidence interval, 0.55-3.35) between the non-TTM and TTM groups after performing adjustments with IPTW. In our study population composed of pediatric patients who achieved ROSC after OHCA, we did not find a positive association between TTM implementation and 1-month survival with favorable neurological outcomes.

Optimal Time of Collapse to Return of Spontaneous Circulation to Apply Targeted Temperature Management for Cardiac Arrest: A Bayesian Network Meta-Analysis.

Background: Both the American Heart Association (AHA) and European Resuscitation Council (ERC) have strongly recommended targeted temperature management (TTM) for patients who remain in coma after return of spontaneous circulation (ROSC). However, the role of TTM, especially hypothermia, in cardiac arrest patients after TTM2 trials has become much uncertain. Methods: We searched four online databases (PubMed, Embase, CENTRAL, and Web of Science) and conducted a Bayesian network meta-analysis. Based on the time of collapse to ROSC and whether the patient received TTM or not, we divided this analysis into eight groups (<20 min + TTM, <20 min, 20-39 min + TTM, 20-39 min, 40-59 min + TTM, 40-59 min, ≥60 min + TTM and ≥60 min) to compare their 30-day and at-discharge survival and neurologic outcomes. Results: From an initial search of 3,023 articles, a total of 9,005 patients from 42 trials were eligible and were included in this network meta-analysis. Compared with other groups, patients in the <20 min + TTM group were more likely to have better survival and good neurologic outcomes (probability = 46.1 and 52.5%, respectively). In comparing the same time groups with and without TTM, only the survival and neurologic outcome of the 20-39 min + TTM group was significantly better than that of the 20-39 min group [odds ratio = 1.41, 95% confidence interval (1.04-1.91); OR = 1.46, 95% CI (1.07-2.00) respectively]. Applying TTM with <20 min or more than 40 min of collapse to ROSC did not improve survival or neurologic outcome [ <20 min vs. <20 min + TTM: OR = 1.02, 95% CI (0.61-1.71)/OR = 1.03, 95% CI (0.61-1.75); 40-59 min vs. 40-59 min + TTM: OR = 1.50, 95% CI (0.97-2.32)/OR = 1.40, 95% CI (0.81-2.44); ≧60 min vs. ≧60 min + TTM: OR = 2.09, 95% CI (0.70-6.24)/OR = 4.14, 95% CI (0.91-18.74), respectively]. Both survival and good neurologic outcome were closely related to the time from collapse to ROSC. Conclusion: Survival and good neurologic outcome are closely associated with the time of collapse to ROSC. These findings supported that 20-40 min of collapse to ROSC should be a more suitable indication for TTM for cardiac arrest patients. Moreover, the future trials should pay more attention to these patients who suffer from moderate injury. Systematic Review Registration: [https://inplasy.com/?s=202180027], identifier [INPLASY202180027].