Prediction of Neurological Recovery After Cardiac Arrest Using Neurofilament Light Chain is Improved by a Proteomics-Based Multimarker Panel.

BACKGROUND: Continuous advances in resuscitation care have increased survival, but the rate of favorable neurological outcome remains low. We have shown the usefulness of proteomics in identifying novel biomarkers to predict neurological outcome. Neurofilament light chain (NfL), a marker of axonal damage, has since emerged as a promising single marker. The aim of this study was to assess the predictive value of NfL in comparison with and in addition to our established model. METHODS: NfL was measured in plasma samples drawn at 48 h after cardiac arrest using single-molecule assays. Neurological function was recorded on the cerebral performance category (CPC) scale at discharge from the intensive care unit and after 6 months. The ability to predict a dichotomized outcome (CPC 1-2 vs. 3-5) was assessed with receiver operating characteristic (ROC) curves. RESULTS: Seventy patients were included in this analysis, of whom 21 (30%) showed a favorable outcome (CPC 1-2), compared with 49 (70%) with an unfavorable outcome (CPC 3-5) at discharge. NfL increased from CPC 1 to 5 (16.5 pg/ml to 641 pg/ml, p < 0.001). The addition of NfL to the existing model improved it significantly (Wald test, p < 0.001), and the combination of NfL with a multimarker model showed high areas under the ROC curve (89.7% [95% confidence interval 81.7-97.7] at discharge and 93.7% [88.2-99.2] at 6 months) that were significantly greater than each model alone. CONCLUSIONS: The combination of NfL with other plasma and clinical markers is superior to that of either model alone and achieves high areas under the ROC curve in this relatively small sample.

Proteomics-Enriched Prediction Model for Poor Neurologic Outcome in Cardiac Arrest Survivors.

OBJECTIVES: Neurologic outcome prediction in out-of-hospital cardiac arrest survivors is highly limited due to the lack of consistent predictors of clinically relevant brain damage. The present study aimed to identify novel biomarkers of neurologic recovery to improve early prediction of neurologic outcome. DESIGN: Prospective, single-center study, SETTING:: University-affiliated tertiary care center. PATIENTS: We prospectively enrolled 96 out-of-hospital cardiac arrest survivors into our study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Neurologic outcome was assessed by the Cerebral Performance Categories score. To identify plasma biomarkers for poor neurologic outcome (Cerebral Performance Categories score ≥ 3), we performed a three-step proteomics strategy of preselection by shotgun analyses, crosschecking in brain tissue samples, and verification by targeted proteomic analyses using a multistep statistical modeling approach. Sixty-three patients (66%) had a poor neurologic outcome. Out of a total of 299 proteins, we identified α-enolase, 14-3-3 protein ζ/δ, cofilin-1, and heat shock cognate 71 kDa protein as novel biomarkers for poor neurologic outcome. The implementation of these biomarkers into a clinical multimarker model, consisting of previously identified covariates associated to outcome, resulted in a significant improvement of neurologic outcome prediction (C-index, 0.70; explained variation, 11.9%; p for added value, 0.019). CONCLUSIONS: This study identified four novel biomarkers for the prediction of poor neurologic outcome in out-of-hospital cardiac arrest survivors. The implementation of α-enolase, 14-3-3 protein ζ/δ, cofilin-1, and heat shock cognate 71 kDa protein into a multimarker predictive model along with previously identified risk factors significantly improved neurologic outcome prediction. Each of the proteomically identified biomarkers did not only outperform current risk stratification models but may also reflect important pathophysiologic pathways undergoing during cerebral ischemia.

On detection of spontaneous pulse by photoplethysmography in cardiopulmonary resuscitation.

OBJECTIVE: This work investigates the potential of photoplethysmography (PPG) to detect a spontaneous pulse from the finger, nose or ear in order to support pulse checks during cardiopulmonary resuscitation (CPR). METHODS: In a prospective single-center cross-sectional study, PPG signals were acquired from cardiac arrest victims who underwent CPR. The PPG signals were analyzed and compared to arterial blood pressure (ABP) signals as a reference during three distranaisco; Date: 2/2/2020; Time:18:44:23inct phases of CPR: compression pauses, on-going compressions and at very low arterial blood pressure. Data analysis was based on a qualitative subjective visual description of similarities of the frequency content of PPG and ABP waveform. RESULTS: In 9 patients PPG waveforms corresponded to ABP waveforms during normal blood pressures. During ABP in the clinically challenging range of 60 to 90 mmHg and during chest compressions and pauses, PPG continued to resemble ABP, as both signals showed similar frequency components as a result of chest compressions as well as cardiac activity. Altogether 1199 s of PPG data in compression pauses were expected to show a spontaneous pulse, of which 732 s (61%) of data were artifact-free and showed the spontaneous pulse as visible in the ABP. CONCLUSIONS: PPG signals at all investigated sites can indicate pulse presence at the moment the heart resumes beating as verified via the ABP signal. Therefore, PPG may provide decision support during CPR, especially related to preventing and shortening interruptions for unnecessary pulse checks. This could have impact on CPR outcome and should further be investigated.

Extracorporeal cardiopulmonary resuscitation at the emergency department: A retrospective patient selection evaluation.

BACKGROUND: There is an increasing use of extracorporeal life support in refractory cardiac arrest. Recent studies highlighted the importance of an early and accurate patient selection for this invasive procedure. OBJECTIVES: The aim of this study was to retrospectively validate a six-criteria-screening-checklist (witnessed collapse, bystander-cardiopulmonary resuscitation/first medical contact <5 min, shockable, age <70 years, end tidal carbon dioxide >14 mmHg and pupils not anisocoric/distorted/mydriatic) as an early screening tool in patients treated with extracorporeal cardiopulmonary resuscitation (eCPR) at the emergency department. DESIGN: Retrospective observational study. SETTING/PATIENTS: All patients at least 18 years of age with nontraumatic cardiac arrest and without return of spontaneous circulation before eCPR treatment at our department between January 2013 and December 2018 were included in this retrospective observational study. INTERVENTION: No specific intervention was set in this observational study. MAIN OUTCOME MEASURES: Primary outcome was the rate of patients who fulfilled all criteria, secondary outcome was 30-day and 6-month survival in accordance with the criteria. RESULTS: Overall, data from a total of 92 patients were eligible for analyses. Out of these, 27 patients (29%) met all criteria. Patients, who fulfilled all criteria, showed significantly higher odds for 30-day survival [OR 6.0 (95% CI 1.78 to 20.19)] P = 0.004. Patients, who did not fulfil all criteria, showed significantly higher rates of early mortality after eCPR initiation [OR 4.57 (95% CI 1.69 to 12.37)] P = 0.003. CONCLUSION: Patients fulfilling all inclusion criteria showed higher rates of survival after eCPR. Our results affirm that there is a possibility and even an obvious necessity for early patient selection based on standardised criteria before eCPR treatment. Large randomised trials are urgently needed to answer this question accurately.

Initial end-tidal carbon dioxide as a predictive factor for return of spontaneous circulation in nonshockable out-of-hospital cardiac arrest patients: A retrospective observational study.

BACKGROUND: Early outcome prediction in out-of-hospital cardiac arrest is still a challenge. End-tidal carbon dioxide (ETCO2) has been shown to be a reliable parameter to reflect the quality of cardiopulmonary resuscitation and the chance of return of spontaneous circulation (ROSC). OBJECTIVES: This study assessed the validity of early capnography as a predictive factor for ROSC and survival in out-of-hospital cardiac arrest victims with an underlying nonshockable rhythm. DESIGN: Retrospective observational study. SETTING/PATIENTS: During a 2-year observational period, data from 2223 out-of-hospital cardiac arrest victims within the city of Vienna were analysed. The focus was on the following patients: age more than 18 years, an underlying nonshockable rhythm, and advanced airway management within the first 15 min of advanced life support with subsequent capnography. INTERVENTION: No specific intervention was set in this observational study. MAIN OUTCOME MEASURES: The first measured ETCO2, assessed immediately after placement of an advanced airway, was used for further analysis. The primary outcome was defined as sustained ROSC, and the secondary outcome was 30-day survival. RESULTS: A total of 526 patients met the inclusion criteria. These were stratified into three groups according to initial ETCO2 values (<20, 20 to 45, >45 mmHg). Baseline data and resuscitation factors were similar among all groups. The odds of sustained ROSC and survival were significantly higher for patients presenting with higher values of initial ETCO2 (>45 mmHg): 3.59 [95% CI, 2.19 to 5.85] P = 0.001 and 5.02 [95% CI, 2.25 to 11.23] P = 0.001, respectively. On the contrary ETCO2 levels less than 20 mmHg were associated with significantly poorer outcomes. CONCLUSION: Patients with a nonshockable out-of-hospital cardiac arrest who presented with higher values of initial ETCO2 had an increased chance of sustained ROSC and survival. This finding could help decision making as regards continuation of resuscitation efforts.

Age-dependent effect of targeted temperature management on outcome after cardiac arrest.

BACKGROUND: In elder patients after out-of-hospital cardiac arrest, diminished neurologic function as well as reduced neuronal plasticity may cause a low response to targeted temperature management (TTM). Therefore, we investigated the association between TTM (32-34°C) and neurologic outcome in cardiac arrest survivors with respect to age. MATERIAL AND METHODS: This retrospective cohort study included patients 18 years of age or older suffering a witnessed out-of-hospital cardiac arrest with presumed cardiac cause, which remained comatose after return of spontaneous circulation. Patients were a priori split by age into four groups (<50 years (n = 496); 50-64 years (n = 714); 65-74 years (n = 395); >75 years (n = 280)). Subsequently, within these groups, patients receiving TTM were compared to those not treated with TTM. RESULTS: Out of 1885 patients, 921 received TTM for 24 hours. TTM was significantly associated with good neurologic outcome in patients <65 years of age whereas showing no effect in elders (65-74 years: OR: 1.49 (95% CI: 0.90-2.47); > 75 years: OR 1.44 (95% CI 0.79-2.34)). CONCLUSION: In our cohort, it seems that TTM might not be able to achieve the same benefit for neurologic outcome in all age groups. Although the results of this study should be interpreted with caution, TTM was associated with improved neurologic outcome only in younger individuals, patients with 65 years of age or older did not benefit from this treatment.

Neurologic causes of cardiac arrest and outcomes.

BACKGROUND: Sudden cardiac arrest as a complication of neurologic disorders is rare, occasionally acute neurologic events present with cardiac arrest as initial manifestation. OBJECTIVE: Our aim was to describe neurologic disorders as a cause of cardiac arrest in order to enable better recognition. METHODS: We retrospectively analyzed prospectively collected resuscitation data of all patients treated between 1991 and 2011 at the emergency department after cardiac arrest caused by a neurologic event, including diagnosis, therapy, and outcomes. RESULTS: Over 20 years, 154 patients suffered cardiac arrest as a result of a neurologic event. Out-of-hospital cardiac arrest occurred in 126 (82%) patients, 78 (51%) were male, median age was 51 years (interquartile range 17 to 89 years). As initial electrocardiogram rhythm, pulseless electrical activity was found in 77 (50%) cases, asystole in 61 (40%), and ventricular fibrillation in 16 (10%) cases. The most common cause was subarachnoid hemorrhage in 74 (48%) patients, 33 (21%) patients had intracerebral hemorrhage, 23 (15%) had epileptic seizure, 11 (7%) had ischemic stroke, and 13 (8%) had other neurologic diseases. Return of spontaneous circulation was achieved in 139 (90%) patients. Of these, 22 (14%) were alive at follow-up after 6 months, 14 (9%) with favorable neurologic outcome, 8 of these with epileptic seizure, and most of them with history of epilepsy. CONCLUSIONS: Subarachnoidal hemorrhage is the leading neurologic cause of cardiac arrest. Most of the patients with cardiac arrest caused by neurologic disorder have a very poor prognosis.

Gastric regurgitation predicts neurological outcome in out-of-hospital cardiac arrest survivors.

Hypoxic-ischemic brain injury can affect and disturb the autonomous nervous system (ANS), which regulates various visceral systems including the gastro-intestinal and emetic system. The present study aimed to analyze the predictive value of gastric regurgitation (GReg) for neurological outcome in out-of-hospital cardiac arrest (OHCA) survivors. In this prospective, single-center study, 79 OHCA survivors treated at a university-affiliated tertiary care centre were included and GReg was measured at the first day after successful cardiopulmonary resuscitation. Neurological outcome was assessed by the Cerebral Performance Categories score at discharge. Seventy-six percent of the study population had a poor neurological outcome. GReg was found to be associated with poor neurological outcome with an adjusted OR of 5.37 (95% CI 1.41-20.46; p = 0.01). The area under the ROC curve for GReg was 0.69 (95% CI, 0.56-0.81) for poor neurological outcome. GReg on the first day after OHCA is an early, strong and independent predictor for poor neurological outcome in comatose OHCA survivors. These results are particularly compelling because measurement of GReg is inexpensive and routinely performed in critical care units.

Catalase Predicts In-Hospital Mortality after Out-of-Hospital Cardiac Arrest.

The generation of harmful reactive oxygen species (ROS), including hydrogen peroxide, in out-of-hospital cardiac arrest (OHCA) survivors causes systemic ischemia/reperfusion injury that may lead to multiple organ dysfunction and mortality. We hypothesized that the antioxidant enzyme catalase may attenuate these pathophysiological processes after cardiac arrest. Therefore, we aimed to analyze the predictive value of catalase levels for mortality in OHCA survivors. In a prospective, single-center study, catalase levels were determined in OHCA survivors 48 h after the return of spontaneous circulation. Thirty-day mortality was defined as the study end point. A total of 96 OHCA survivors were enrolled, of whom 26% (n = 25) died within the first 30 days after OHCA. The median plasma intensity levels (log2) of catalase were 8.25 (IQR 7.64-8.81). Plasma levels of catalase were found to be associated with mortality, with an adjusted HR of 2.13 (95% CI 1.07-4.23, p = 0.032). A Kaplan-Meier analysis showed a significant increase in 30-day mortality in patients with high catalase plasma levels compared to patients with low catalase levels (p = 0.012). High plasma levels of catalase are a strong and independent predictor for 30-day mortality in OHCA survivors. This indicates that ROS-dependent tissue damage is playing a crucial role in fatal outcomes of post-cardiac syndrome patients.

Hypoxic liver injury after in- and out-of-hospital cardiac arrest: Risk factors and neurological outcome.

BACKGROUND: Hypoxic liver injury (HLI) is a frequent and life-threatening complication in critically ill patients that occurs in up to ten percent of critically ill patients. However, there is a lack of data on HLI following cardiac arrest and its clinical implications on outcome. Aim of this study was to investigate incidence, outcome and functional outcome of patients with HLI after in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA). METHODS: We conducted an analysis of a cardiac arrest registry data over a 7-year period. All patients with non-traumatic OHCA and IHCA with return of spontaneous circulation (ROSC) treated at the emergency department of a tertiary care hospital were included in the study. HLI was defined according to established criteria. Predictors of HLI, occurrence, clinical and neurological outcome were assessed using multivariable regression. RESULTS: Out of 1068 patients after IHCA and OHCA with ROSC, 219 (21%) patients developed HLI. Rate of HLI did not differ significantly in IHCA and OHCA patients. Multivariate regression analysis identified time-to-ROSC [OR 1.18, 95% CI (1.01-1.38); p < 0.05], presence of cardiac failure [OR 2.57, 95% CI (1.65-4.01); p < 0.001] and Charlson comorbidity index [OR 0.83, 95% CI (0.72-0.95); p < 0.01] as independent predictors for occurrence of HLI. Good functional outcome was significantly lower in patients suffering from HLI after 28-days (35% vs. 48%, p < 0.001) and 1-year (34% vs. 44%, p < 0.001). Occurrence of HLI was associated with unfavourable neurological outcome [OR 1.74, 95% CI (1.16-2.61); p < 0.01] in multivariate regression analysis. CONCLUSION: New onset of HLI is a frequent finding after IHCA and OHCA. HLI is associated with increased mortality, unfavourable neurological and overall outcome.

The impact of airway strategy on the patient outcome after out-of-hospital cardiac arrest: A propensity score matched analysis.

BACKGROUND: While guidelines mentioned supraglottic airway management in the case of out-of- hospital cardiac arrest, robust data of their impact on the patient outcome remain scare and results are inconclusive. METHODS: To assess the impact of the airway strategy on the patient outcome we prospectively enrolled 2224 individuals suffering cardiac arrest who were treated by the Viennese municipal emergency medical service. To control for potential confounders, propensity score matching was performed. Patients were matched in four groups with a 1:1:1:1 ratio ( n=210/group) according to bag-mask-valve, laryngeal tube, endotracheal intubation and secondary endotracheal intubation after primary laryngeal tube ventilation. RESULTS: The laryngeal tube subgroup showed the lowest 30-day survival rate among all tested devices ( p<0.001). However, in the case of endotracheal intubation after primary laryngeal tube ventilation, survival rates were comparable to the primary endotracheal tube subgroup. The use of a laryngeal tube was independently and directly associated with mortality with an adjusted odds ratio of 1.97 (confidence interval: 1.14-3.39; p=0.015). Additionally, patients receiving laryngeal tube ventilation showed the lowest rate of good neurological performance (6.7%; p<0.001) among subgroups. However, if patients received endotracheal intubation after initial laryngeal tube ventilation, the outcome proved to be significantly better (9.5%; p<0.001). CONCLUSION: We found that the use of a laryngeal tube for airway management in cardiac arrest was significantly associated with poor 30-day survival rates and unfavourable neurological outcome. A primary endotracheal airway management needs to be considered at the scene, or an earliest possible secondary endotracheal intubation during both pre-hospital and in-hospital post-return of spontaneous circulation critical care seems crucial and most beneficial for the patient outcome.

Feasibility of the capnogram to monitor ventilation rate during cardiopulmonary resuscitation.

AIM: The rates of chest compressions (CCs) and ventilations are both important metrics to monitor the quality of cardiopulmonary resuscitation (CPR). Capnography permits monitoring ventilation, but the CCs provided during CPR corrupt the capnogram and compromise the accuracy of automatic ventilation detectors. The aim of this study was to evaluate the feasibility of an automatic algorithm based on the capnogram to detect ventilations and provide feedback on ventilation rate during CPR, specifically addressing intervals where CCs are delivered. METHODS: The dataset used to develop and test the algorithm contained in-hospital and out-of-hospital cardiac arrest episodes. The method relies on adaptive thresholding to detect ventilations in the first derivative of the capnogram. The performance of the detector was reported in terms of sensitivity (SE) and Positive Predictive Value (PPV). The overall performance was reported in terms of the rate error and errors in the hyperventilation alarms. Results were given separately for the intervals with CCs. RESULTS: A total of 83 episodes were considered, resulting in 4880min and 46,740 ventilations (8741 during CCs). The method showed an overall SE/PPV above 99% and 97% respectively, even in intervals with CCs. The error for the ventilation rate was below 1.8min-1 in any group, and >99% of the ventilation alarms were correctly detected. CONCLUSION: A method to provide accurate feedback on ventilation rate using only the capnogram is proposed. Its accuracy was proven even in intervals where canpography signal was severely corrupted by CCs. This algorithm could be integrated into monitor/defibrillators to provide reliable feedback on ventilation rate during CPR.

Improvements in the quality of advanced life support and patient outcome after implementation of a standardized real-life post-resuscitation feedback system.

BACKGROUND: Educational aspects in the training of advanced life support (ALS) represent a key role in critical care management of patients with out-of-hospital cardiac arrest (OHCA) and received special attention in guidelines of various international societies. While a positive association of feedback on ALS performance in training conditions is well established, data on the impact of a real-life post-resuscitation feedback on both ALS quality and outcome remain scarce and inconclusive. We aimed to elucidate the impact of a standardized post-resuscitation feedback on quality of ALS and improvements in patient outcome, in a real-life out-of-hospital setting. METHODS: We prospectively enrolled and analyzed 2209 patients presenting with OHCA receiving resuscitation attempts by the municipal emergency medical service (EMS) of Vienna over a two-year period. A standardized post-resuscitation feedback protocol was delivered to the respective EMS-team to elucidate its impact on the quality of ALS. RESULTS: We observed that both chest compression rates and ratios were in accordance to recommendations of recent guidelines. While interruptions of chest compressions longer than 30s declined during the observation period (-6.5%) rates of the recommended chest compressions during defibrillator-charging periods increased (+8.9%). Since the percentage of ROSC and 30-day survival remained balanced, the frequencies of both survival until hospital discharge (+6.3%) and favorable neurological outcome (+16%) in survivors significantly increased during the observation period. CONCLUSION: Improvements in the quality of advanced life support as well the patient outcome were observed after the implementation of a standardized post-resuscitation feedback protocol.

Outcome of in- and out-of-hospital cardiac arrest survivors with liver cirrhosis.

BACKGROUND: Organ failure increases mortality in patients with liver cirrhosis. Data about resuscitated cardiac arrest patients with liver cirrhosis are missing. This study aims to assess aetiology, survival and functional outcome in patients after successful cardiopulmonary resuscitation (CPR) with and without liver cirrhosis. METHODS: Analysis of prospectively collected cardiac arrest registry data of consecutively hospital-admitted patients following successful CPR was performed. Patient's characteristics, admission diagnosis, severity of disease, course of disease, short- and long-term mortality as well as functional outcome were assessed and compared between patients with and without cirrhosis. RESULTS: Out of 1068 patients with successful CPR, 47 (4%) had liver cirrhosis. Acute-on-chronic liver failure (ACLF) was present in 33 (70%) of these patients on admission, and four patients developed ACLF during follow-up. Mortality at 1 year was more than threefold increased in patients with liver cirrhosis (OR 3.25; 95% CI 1.33-7.96). Liver cirrhosis was associated with impaired neurological outcome (OR for a favourable cerebral performance category: 0.13; 95% CI 0.04-0.36). None of the patients with Child-Turcotte-Pugh (CTP) C cirrhosis survived 28 days with good neurological outcome. Overall nine (19%) patients with cirrhosis survived 28 days with good neurological outcome. All patients with ACLF grade 3 died within 28 days. CONCLUSION: Cardiac arrest survivors with cirrhosis have worse outcome than those without. Although one quarter of patients with liver cirrhosis survived longer than 28 days after successful CPR, patients with CTP C as well as advanced ACLF did not survive 28 days with good neurological outcome.

Age-specific prognostication after out-of-hospital cardiac arrest - The ethical dilemma between 'life-sustaining treatment' and 'the right to die' in the elderly.

BACKGROUND: While prognostic values on survival after out-of-hospital cardiac arrest have been well investigated, less attention has been paid to their age-specific relevance. Therefore, we aimed to identify suitable age-specific early prognostication in elderly patients suffering out-of-hospital cardiac arrest in order to reduce the burden of unnecessary treatment and harm. METHODS: In a prospective population-based observational trial on individuals suffering out-of-hospital cardiac arrest, a total of 2223 patients receiving resuscitation attempts by the local emergency medical service in Vienna, Austria, were enrolled. Patients were stratified according to age as follows: young and middle-aged individuals (<65 years), young old individuals (65-74 years), old individuals (75-84 years) and very old individuals (>85 years). RESULTS: There was an increasing rate of 30-day mortality (+21.8%, p < 0.001) and unfavourable neurological outcome (+18.8%, p < 0.001) with increasing age among age groups. Established predictive variables lost their prognostic potential with increasing age, even after adjusting for potential confounders. Independently, an initially shockable electrocardiogram proved to be directly associated with survival, with an adjusted hazard ratio (HR) of 2.04 (95% confidence interval (CI) 1.89-2.38, p = 0.003) for >85-year-olds. Frailty was directly associated with mortality (HR 1.22, 95% CI 1.01-1.51, p = 0.049), showing a 30-day survival of 5.6% and a favourable neurological outcome of 1.1% among elderly individuals. CONCLUSION: An initially shockable electrocardiogram proved to be a suitable tool for risk assessment and decision making in order to predict a successful outcome in elderly victims of out-of-hospital cardiac arrest. However, the outcomes of elderly patients seemed to be exceptionally poor in frail individuals and need to be considered in order to reduce unnecessary treatment decisions.

A survey on general and temperature management of post cardiac arrest patients in large teaching and university hospitals in 14 European countries-The SPAME trial results.

INTRODUCTION: International guidelines recommend a bundle of care, including targeted temperature management (TTM), in post cardiac arrest survivors. Aside from a few small surveys in different European countries, adherence to the European Resuscitation Council (ERC) and European Society of Intensive Care Medicine (ESICM) recommendations are unknown. METHODS: This international European telephone survey was conducted to provide an overview of current clinical practice of post cardiac arrest management with a main focus on TTM. We targeted large teaching and university hospitals within Europe as leading facilities and key opinion leaders in the field of post cardiac arrest care. Selected national principal investigators conducted the survey, which was based on a predefined questionnaire, between December 2014 and March 2015, before the publication of the ERC Guidelines 2015. RESULTS: The return rate was 94% from 268 participating intensive care units (ICU). The majority had a predefined standard operating procedure (SOP) protocol for post cardiac arrest patients. Altogether, 68% of the ICUs provided TTM at a target temperature of 32-34°C for 24h, and 33% had changed the target temperature to 36°C. The minority provided a written SOP for neurological prognostication, which was generally initiated 72h after return of spontaneous circulation (ROSC). Electroencephalography and somatosensory evoked potentials were used by most ICUs for early prognostication. Treating more than fifty patients a year was significantly associated with providing written SOPs for TTM and prognostication (p<0.01), as well as the use of a computer feedback device (p=0.03) for TTM. CONCLUSION: This international European telephone survey revealed a high rate of implementation of TTM in post cardiac arrest patients in university and teaching hospitals. Most participants also provided a SOP, but only a minority had a SOP for neurological prognostication.

Limited effect of mild therapeutic hypothermia on outcome after prolonged resuscitation.

BACKGROUND: Mild therapeutic hypothermia interferes with multiple cascades of the ischaemia/reperfusion injury that is known as primary mechanism for brain damage after cardiac arrest. First resuscitation attempts and the duration of resuscitation efforts will initiate and aggravate this pathophysiology. Therefore we investigated the interaction between the duration of basic and advanced life support and outcome after cardiac arrest in patients treated with or without mild therapeutic hypothermia. METHODS: This retrospective cohort study included patients 18 years of age or older suffering a witnessed out-of-hospital cardiac arrest with presumed cardiac cause, which remained comatose after restoration of spontaneous circulation. The basic and advanced life support 'low-flow' time, categorized into four quartiles (0-11, 12-17, 18-28, ≥ 29 min), was correlated with neurological outcome. RESULTS: Out of 1103 patients 613 were cooled to a target temperature of 33 ± 1 °C for 24h. In the three quartiles with 'low-flow' time up to 28 min cooling was associated with >2-fold odds of favourable neurological outcome. In the fourth quartile with 'low-flow' time of ≥ 29 min cooling had no influence on neurological outcome (OR: 0.73; 95% CI: 0.38-1.4, test for interaction p<0.01). CONCLUSION: The duration of resuscitation efforts, defined as 'low-flow' time, influences the effectiveness of mild therapeutic hypothermia in terms of neurologic outcome. Patients with low to moderate 'low-flow' time benefit most from this treatment.

Towards an algorithm for automatic accelerometer-based pulse presence detection during cardiopulmonary resuscitation.

Manual palpation is still the gold standard for assessment of pulse presence during cardiopulmonary resuscitation (CPR) for professional rescuers. However, this method is unreliable, time-consuming and subjective. Therefore, reliable, quick and objectified assessment of pulse presence in cardiac arrest situations to assist professional rescuers is still an unmet need. Accelerometers may present a promising sensor modality as pulse palpation technology for which pulse detection at the carotid artery has been demonstrated to be feasible. This study extends previous work by presenting an algorithm for automatic, accelerometer-based pulse presence detection at the carotid site during CPR. We show that accelerometers might be helpful in automated detection of pulse presence during CPR.

Editor's Choice-Progress in the chain of survival and its impact on outcomes of patients admitted to a specialized high-volume cardiac arrest center during the past two decades.

AIM: Cardiac arrest (CA) is still associated with high mortality and morbidity. Data on the changes in management and outcomes over a long period of time are limited. Using data from a single emergency department (ED), we assessed changes over two decades. METHODS: In this single-center observational study, we prospectively included 4133 patients receiving cardiopulmonary resuscitation and being admitted to the ED of a tertiary care hospital between January 1992 and December 2012. RESULTS: There was a significant improvement in both 6-month survival rates (+10.8%; p < 0.001) and favorable neurological outcome (+4.7%; p < 0.001). While the number of witnessed CA cases decreased (-4.7%; p < 0.001) the proportion of patients receiving bystander basic life support increased (+8.3%; p < 0.001). The proportion of patients with initially shockable ECG rhythms remained unchanged, but cardiovascular causes of CA decreased (-9.6%; p < 0.001). Interestingly, the time from CA until ED admission increased (+0.1 hours; p = 0.024). The use of percutaneous coronary intervention and therapeutic hypothermia were significantly associated with survival. CONCLUSIONS: Outcomes of patients with CA treated at a specialized ED have improved significantly within the last 20 years. Improvements in every link in the chain of survival were noted.

Surveillance of Patients in the Waiting Area of the Department of Emergency Medicine.

Many patients visiting an emergency department are in reduced general condition of health and at risk of suffering further deterioration during their stay. We wanted to test the feasibility of a new monitoring system in a waiting area of an emergency department.In an observational cross-sectional single-center study, patients with acute cardiac or pulmonary symptoms or in potentially life-threatening conditions were enrolled. Monitoring devices providing vital signs via short range radio (SRR) at certain time points and compliance evaluation forms were used.Out of 230 patients, 4 wanted to terminate their participation prematurely. No data was lost due to technical difficulties. Over a median monitoring period of 178 (118-258) min per patient, 684 h of vital sign data were collected and used to assist managing those patients. Linear regression analysis between clinical symptom category groups of patients showed significant differences in the respiratory rate and noninvasive blood pressure courses. Feedback from patients and users via questionnaires showed overall very good acceptance and patients felt that they were given better care.To assist medical staff of an emergency department waiting area to rapidly response to potentially life-threatening situations of its patients, a new monitoring system proved to be feasible and safe.