Long-term outcomes among out-of-hospital cardiac arrest survivors with reversible versus non-reversible causes.

BACKGROUND: Reversible cause of out-of-hospital cardiac arrest (OHCA) is vaguely defined in international guidelines as an identifiable transient or potentially correctable condition. Moreover, studies evaluating long-term outcomes of patients experiencing OHCA due to reversible and non-reversible causes are lacking. We aimed to determine differences in long-term outcomes in OHCA-survivors according to different etiology. METHODS: From the British Columbia Cardiac Arrest registry, adults with non-traumatic OHCA (2009-2016) surviving to hospital discharge were identified. Patients were categorized by OHCA etiology combining reversibility and underlying ischemic etiology. The primary outcome was a composite of all-cause mortality, recurrent OHCA, or re-hospitalization for sudden cardiac arrest or ventricular arrhythmias. Using the Kaplan-Meier method and multivariable Cox regression models, we compared the risk of the composite outcome according to different OHCA-etiology. RESULTS: Of 1,325 OHCA hospital-discharge survivors (median age 62.8, 77.9% male), 431 (32.5%) had reversible ischemic, 415 (31.3%) non-reversible ischemic, 99 (7.5%) reversible non-ischemic and 380 (28.7%) non-reversible non-ischemic etiology. At 3 years post-discharge, Kaplan-Meier event-free rate was highest in patients with a reversible ischemic etiology (91%, 95% CI 87-94%), and lowest in those with a reversible non-ischemic etiology (62%, 95% CI 51-72%). In multivariate analyses, compared to non-reversible non-ischemic cause, reversible ischemic cause was associated with a significantly lower hazard ratio (HR) (0.52, 95% confidence interval [CI], 0.33-0.81), reversible non-ischemic cause with a significantly higher HR (1.53, 95% CI, 1.03-2.32) and non-reversible ischemic cause with a non-significant HR 0.92 (95% CI, 0.64-1.33) for the composite outcome. CONCLUSIONS: The presence of a reversible ischemic cause is associated with long-term OHCA-outcomes.

Survival After Intra-Arrest Transport vs On-Scene Cardiopulmonary Resuscitation in Children.

Importance: For pediatric out-of-hospital cardiac arrest (OHCA), emergency medical services (EMS) may elect to transport to the hospital during active cardiopulmonary resuscitation (CPR) (ie, intra-arrest transport) or to continue on-scene CPR for the entirety of the resuscitative effort. The comparative effectiveness of these strategies is unclear. Objective: To evaluate the association between intra-arrest transport compared with continued on-scene CPR and survival after pediatric OHCA, and to determine whether this association differs based on the timing of intra-arrest transport. Design, Setting, and Participants: This cohort study included pediatric patients aged younger than 18 years with EMS-treated OHCA between December 1, 2005 and June 30, 2015. Data were collected from the Resuscitation Outcomes Consortium Epidemiologic Registry, a prospective 10-site OHCA registry in the US and Canada. Data analysis was performed from May 2022 to February 2024. Exposures: Intra-arrest transport, defined as an initiation of transport prior to the return of spontaneous circulation, and the interval between EMS arrival and intra-arrest transport. Main Outcomes and Measures: The primary outcome was survival to hospital discharge. Patients who underwent intra-arrest transport at any given minute after EMS arrival were compared with patients who were at risk of undergoing intra-arrest transport within the same minute using time-dependent propensity scores calculated from patient demographics, arrest characteristics, and EMS interventions. We examined subgroups based on age (<1 year vs ≥1 year). Results: Of 2854 eligible pediatric patients (median [IQR] age, 1 [0-9] years); 1691 males [59.3%]) who experienced OHCA between December 2005 and June 2015, 1892 children (66.3%) were treated with intra-arrest transport and 962 children (33.7%) received continued on-scene CPR. The median (IQR) time between EMS arrival and intra-arrest transport was 15 (9-22) minutes. In the propensity score-matched cohort (3680 matched cases), there was no significant difference in survival to hospital discharge between the intra-arrest transport group and the continued on-scene CPR group (87 of 1840 patients [4.7%] vs 95 of 1840 patients [5.2%]; risk ratio [RR], 0.81 [95% CI, 0.59-1.10]). Survival to hospital discharge was not modified by the timing of intra-arrest transport (P value for the interaction between intra-arrest transport and time to matching = .10). Among patients aged younger than 1 year, intra-arrest transport was associated with lower survival to hospital discharge (RR, 0.52; 95% CI, 0.33-0.83) but there was no association for children aged 1 year or older (RR, 1.22; 95% CI, 0.77-1.93). Conclusions and Relevance: In this cohort study of a North American OHCA registry, intra-arrest transport compared with continued on-scene CPR was not associated with survival to hospital discharge among children with OHCA. However, intra-arrest transport was associated with a lower likelihood of survival to hospital discharge among children aged younger than 1 year.

The relationship between the number of COVID-19 vaccines and infection with Omicron ACE2 inhibition at 18-months post initial vaccination in an adult cohort of Canadian paramedics.

The coronavirus disease 2019 (COVID-19) pandemic, caused by the SARS-CoV-2 virus, has rapidly evolved since late 2019, due to highly transmissible Omicron variants. While most Canadian paramedics have received COVID-19 vaccination, the optimal ongoing vaccination strategy is unclear. We investigated neutralizing antibody (NtAb) response against wild-type (WT) Wuhan Hu-1 and Omicron BA.4/5 lineages based on the number of doses and past SARS-CoV-2 infection, at 18 months post-initial vaccination (with a Wuhan Hu-1 platform mRNA vaccine [BNT162b2 or mRNA-1273]). Demographic information, previous COVID-19 vaccination, infection history, and blood samples were collected from paramedics 18 months post-initial mRNA COVID-19 vaccine dose. Outcome measures were ACE2 percent inhibition against Omicron BA.4/5 and WT antigens. We compared outcomes based on number of vaccine doses (two vs. three) and previous SARS-CoV-2 infection status, using the Mann-Whitney U test. Of 657 participants, the median age was 40 years (IQR 33-50) and 251 (42 %) were females. Overall, median percent inhibition to BA.4/5 and WT was 71.61 % (IQR 39.44-92.82) and 98.60 % (IQR 83.07-99.73), respectively. Those with a past SARS-CoV-2 infection had a higher median percent inhibition to BA.4/5 and WT, when compared to uninfected individuals overall and when stratified by two or three vaccine doses. When comparing two vs. three WT vaccine doses among SARS-CoV-2 negative participants, we did not detect a difference in BA.4/5 percent inhibition, but there was a difference in WT percent inhibition. Among those with previous SARS-CoV-2 infection(s), when comparing two vs. three WT vaccine doses, there was no observed difference between groups. These findings demonstrate that additional Whttps://www.covid19immunitytaskforce.ca/citf-databank/#accessing https://www.covid19immunitytaskforce.ca/citf-databank/#accessinguhan Hu-1 platform mRNA vaccines did not improve NtAb response to BA.4/5, but prior SARS-CoV-2 infection enhances NtAb response.

Left ventricle chest compression improves ETCO2, blood pressure, and cerebral blood velocity in a swine model of cardiac arrest and cardiopulmonary resuscitation.

Introduction: During cardiopulmonary resuscitation (CPR), high quality chest compressions are critical to organ perfusion, especially the brain. Yet, the optimal location for chest compressions is unclear. It was hypothesized that compared with the standard chest compression (SCC) location, left ventricle chest compressions (LVCCs) would result in greater ETCO2, blood pressure (BP), and cerebral blood velocity (CBV) during CPR in swine. Methods: Female Landrace swine (N = 32; 35 ± 2 kg) underwent two mins of untreated asphyxiated cardiac arrest (CA). Thereafter, swine were treated with three 2-min cycles of either SCC or LVCC mechanical basic life support CPR (LUCAS 3). ETCO2 (in-line sampling), BP (arterial catheter line), and CBV (transcranial Doppler) were measured during the pre-CA, untreated-CA, and CPR-treated phases. Results: ETCO2, BP, and CBV were similar between groups at pre- and during untreated-CA (P ≥ 0.188). During CPR, ETCO2 (36 ± 6 versus 24 ± 10 mmHg, P < 0.001), mean arterial BP (MAP; 49 ± 9 versus 37 ± 9 mmHg, P = 0.002), and CBV (11 ± 5 versus 5 ± 2 cm/s, P < 0.001) were significantly greater in the LVCC versus SCC group. Moreover, a greater proportion of animals obtained targets for ETCO2 (ETCO2 ≥ 20 mmHg; 52 % (17/33) versus 100 % (32/32), P < 0.001) and diastolic BP (DBP ≥ 25 mmHg; 82 % (33/40) versus 97 % (48/49), P = 0.020) in the LVCC versus SCC group. Conclusion: Indicators of cardiac output, BP, and cerebral perfusion during CPR were greatest in the LVCC group, suggesting the quality of chest compressions during BLS CPR may be improved by performing compressions over the left ventricle compared to the centre of the chest.

Predictors of neurological outcome after out-of-hospital cardiac arrest: sex-based analysis: do males derive greater benefit from hypothermia management than females?

BACKGROUND: Previous studies of the effect of sex on after out-of-hospital cardiac arrest (OHCA) outcomes focused on survival to hospital discharge and 1-month survival. Studies on the effect of sex on neurological function after OHCA are still limited. The objective of this study was to identify the predictors of favorable neurological outcome and to examine the association between sex as a biological variable and favorable neurological outcome OHCA. METHODS: Retrospective analyses of clustered data from the Resuscitation Outcomes Consortium multi-center randomized controlled trial (2011-2015). We included adults with non-traumatic OHCA and EMS-attended OHCA. We used multilevel logistic regression to examine the association between sex and favorable neurological outcomes (modified Rankin Scale) and to identify the predictors of favorable neurological outcome. RESULTS: In total, 22,416 patients were included. Of those, 8109 (36.2%) were females. The multilevel analysis identified the following variables as significant predictors of favorable neurological outcome: younger age, shorter duration of EMS arrival to the scene, arrest in public location, witnessed arrest, bystander CPR, chest compression rate (CCR) of 100-120 compressions per minute, induction of hypothermia, and initial shockable rhythm. Two variables, insertion of an advanced airway and administration of epinephrine, were associated with poor neurological outcome. Our analysis showed that males have higher crude rates of survival with favorable neurological outcome (8.6 vs. 4.9%, p < 0.001). However, the adjusted rate was not significant. Further analyses showed that hypothermia had a significantly greater effect on males than females. CONCLUSIONS: Males had significantly higher crude rates of survival with favorable neurological outcome. However, the adjusted rate was not statistically significant. Males derived significantly greater benefit from hypothermia management than females, but this can possibly be explained by differences in arrest characteristics or in-hospital treatment. In-depth confirmatory studies on the hypothermia effect size by sex are required.

Long-term Mortality, Readmission, and Resource Utilization Among Hospital Survivors of Out-of-Hospital Cardiac Arrest.

BACKGROUND: Among patients with out-of-hospital cardiac arrest (OHCA), the influence of pre- and in-hospital factors on long-term survival, readmission, and resource utilization is ill-defined, mainly related to challenges combining disparate data sources. METHODS: Adult nontraumatic OHCA from the British Columbia Cardiac Arrest Registry (January 2009 to December 2016) were linked to provincial datasets comprising comorbidities, medications, cardiac procedures, mortality, and hospital admission and discharge. Among hospital-discharge survivors, the 3-year end point of mortality or mortality and all-cause readmission was examined with the use of the Kaplan-Meier method and multivariable Cox regression model for predictors. The use of publicly funded home care and community services within 1 year after discharge also was evaluated. RESULTS: Of the 10,674 linked, emergency medical services-treated adult OHCAs, 3230 were admitted to hospital and 1325 survived to hospital discharge. At 3 years after discharge, the estimated Kaplan-Meier survival rate was 84.1% (95% CI 81.7%-86.1%) and freedom from death or all-cause readmission was 31.8% (29.0%-34.7%). After exclusions, 26.6% (n = 315/1186) accessed residential or home care services within 1 year. Independent predictors of long-term outcomes included age and comorbidities, but also favourable arrest characteristics and in-hospital factors such as revascularization or receipt of an intracardiac defibrillator before discharge. CONCLUSIONS: Among OHCA hospital survivors, the long-term death or readmission risk persists and is modulated by both pre- and in-hospital factors. However, only 1 in 4 survivors required residential or home care after discharge. These results support efforts to improve care processes to increase survival to hospital discharge.

Rationale, development and implementation of the ReACanROC registry for out-of-hospital cardiac arrests in France and Canada.

France and Canada prehospital systems and care delivery in out-of-hospital cardiac arrests (OHCAs) show substantial differences. This article aims to describe the rationale, design, implementation and expected research implications of the international, population-based, France-Canada registry for OHCAs, namely ReACanROC, which is built from the merging of two nation-wide, population-based, Utstein-style prospectively implemented registries for OHCAs attended to by emergency medical services. Under the supervision of an international steering committee and research network, the ReACanROC dataset will be used to run in-depth analyses on the differences in organisational, practical and geographic predictors of survival after OHCA between France and Canada. ReACanROC is the first Europe-North America registry ever created to meet this goal. To date, it covers close to 80 million people over the two countries, and includes approximately 200 000 cases over a 10-year period.

Premenopausal-aged females have no neurological outcome advantage after out-of-hospital cardiac arrest: A multilevel analysis of North American populations.

AIM: We investigated the impact of premenopausal age on neurological function at hospital discharge in patients with out-of-hospital cardiac arrest (OHCA). We hypothesized that premenopausal-aged females (18-47 years of age) with OHCA would have a higher probability of survival with favourable neurological function at hospital discharge compared with males of the same age group, older males, and older females (>53 years of age). METHODS: Retrospective analyses of data from the Resuscitation Outcomes Consortium multi-center randomized controlled trial (June 2011-May 2015). We included adults with non-traumatic OHCA treated by emergency medical service. We stratified the cohort into four groups by age and sex: premenopausal-aged females (18-47 years of age), older females (≥53 years old), younger males (18-47 years of age), and older male. We used multilevel logistic regression to examine the association between age-sex and favourable neurological outcomes (modified Rankin Scale ≤ 3). RESULTS: In total, 23,725 patients were included: 1050 (4.5%) premenopausal females; 1930 (8.1%) younger males; 7569 (31.9%) older females; and 13,176 (55.5%) older males. The multilevel analysis showed no difference in neurological outcome between younger males and younger females (OR 0.95, 95% CI 0.69-1.32, p = 0.75). Both older females (OR 0.36, 95% CI 0. 0.26-0.48, p < 0.001) and older males (OR 0.52, 95% CI 0.39-0.69, p < 0.001) had a significantly lower odds of favourable neurological outcome than younger females. Among all groups, older females had the worst outcomes. CONCLUSIONS: We did not detect an association between premenopausal age and survival with good neurological outcome, suggesting females sex hormones do not impact OHCA outcomes. Our findings are not in line with results from other studies. Studies that rigorously evaluate menopausal status are required to definitively assess the impact of female sex hormones on outcomes.

Cardiac Intensive Care Unit Management of Patients After Cardiac Arrest: Now the Real Work Begins.

Survival with a good quality of life after cardiac arrest continues to be abysmal. Coordinated resuscitative care does not end with the effective return of spontaneous circulation (ROSC)-in fact, quite the contrary is true. Along with identifying and appropriately treating the precipitating cause, various components of the post-cardiac arrest syndrome also require diligent observation and management, including post-cardiac arrest neurologic injury and myocardial dysfunction, systemic ischemia-reperfusion phenomenon with potential consequent multiorgan failure, and the various sequelae of critical illness. There is growing evidence that an early invasive approach to coronary reperfusion with percutaneous coronary intervention, together with active targeted temperature management and optimization of hemodynamic, ventilator, and metabolic parameters, may improve survival and neurologic outcomes in cardiac arrest survivors. Neuroprognostication is complex, as are survivorship issues and long-term rehabilitation. Our paramedics, emergency physicians, and resuscitation specialists are all to be congratulated for ever-increasing success with ROSC… but now the real work begins.

Prevalence, natural history, and time-dependent outcomes of a multi-center North American cohort of out-of-hospital cardiac arrest extracorporeal CPR candidates.

AIM: Estimate prevalence of ECPR-eligible subjects in a large, North American, multi-center cohort, describe natural history with conventional resuscitation, and predict optimal timing of transition to ECPR. METHODS: Secondary analysis of clinical trial enrolling adults with non-traumatic OHCA. Primary outcome was survival to discharge with favorable outcome (mRS 0-3). Subjects were additionally classified as survival with unfavorable outcome (mRS 4-5), ROSC without survival (mRS 6), or without ROSC. We plotted subject accrual as a function of resuscitation duration (CPR onset to return of spontaneous circulation (ROSC) or termination of resuscitation), and estimated time-dependent probabilities of ROSC and mRS 0-3 at discharge. Adjusted logistic regression models tested the association between resuscitation duration and survival with mRS 0-3. RESULTS: Of 11,368 subjects, 1237 (10.9%; 95%CI 10.3-11.5%) were eligible for ECPR, Of these, 778 (63%) achieved ROSC, 466 (38%) survived to discharge, and 377 (30%) had mRS 0-3 at discharge. Half with eventual mRS 0-3 achieved ROSC within 8.8min (95%CI 8.3-9.2min) of resuscitation, and 90% within 21.0min (95%CI 19.1-23.7min). Time-dependent probabilities of ROSC and mRS 0-3 declined over elapsed resuscitation, and the likelihood of additional cases with mRS 0-3 beyond 20min was 8.4% (95%CI 5.9-11.0%). Resuscitation duration was independently associated with survival to discharge with mRS 0-3 (OR 0.95; 95%CI 0.92-0.97). CONCLUSION: Approximately 11% of subjects were eligible for ECPR. Only one-third survived to discharge with favorable outcome. Performing 9-21min of conventional resuscitation captured most ECPR-eligible subjects with eventual mRS 0-3 at hospital discharge.

Association Between Duration of Resuscitation and Favorable Outcome After Out-of-Hospital Cardiac Arrest: Implications for Prolonging or Terminating Resuscitation.

BACKGROUND: Little evidence guides the appropriate duration of resuscitation in out-of-hospital cardiac arrest, and case features justifying longer or shorter durations are ill defined. We estimated the impact of resuscitation duration on the probability of favorable functional outcome in out-of-hospital cardiac arrest using a large, multicenter cohort. METHODS: This was a secondary analysis of a North American, single-blind, multicenter, cluster-randomized, clinical trial (ROC-PRIMED [Resuscitation Outcomes Consortium Prehospital Resuscitation Using an Impedance Valve and Early Versus Delayed]) of consecutive adults with nontraumatic, emergency medical services-treated out-of-hospital cardiac arrest. Primary exposure was duration of resuscitation in minutes (onset of professional resuscitation to return of spontaneous circulation [ROSC] or termination of resuscitation). Primary outcome was survival to hospital discharge with favorable outcome (modified Rankin scale [mRS] score of 0-3). Subjects were additionally classified as survival with unfavorable outcome (mRS score of 4-5), ROSC without survival (mRS score of 6), or without ROSC. Subject accrual was plotted as a function of resuscitation duration, and the dynamic probability of favorable outcome at discharge was estimated for the whole cohort and subgroups. Adjusted logistic regression models tested the association between resuscitation duration and survival with favorable outcome. RESULTS: The primary cohort included 11 368 subjects (median age, 69 years [interquartile range, 56-81 years]; 7121 men [62.6%]). Of these, 4023 (35.4%) achieved ROSC, 1232 (10.8%) survived to hospital discharge, and 905 (8.0%) had an mRS score of 0 to 3 at discharge. Distribution of cardiopulmonary resuscitation duration differed by outcome (P<0.00001). For cardiopulmonary resuscitation duration up to 37.0 minutes (95% confidence interval, 34.9-40.9 minutes), 99% with an eventual mRS score of 0 to 3 at discharge achieved ROSC. The dynamic probability of an mRS score of 0 to 3 at discharge declined over elapsed resuscitation duration, but subjects with initial shockable cardiac rhythm, witnessed cardiac arrest, and bystander cardiopulmonary resuscitation were more likely to survive with favorable outcome after prolonged efforts (30-40 minutes). After adjustment for prehospital (odds ratio, 0.93; 95% confidence interval, 0.92-0.95) and inpatient (odds ratio, 0.97; 95% confidence interval, 0.95-0.99) covariates, resuscitation duration was associated with survival to discharge with an mRS score of 0 to 3. CONCLUSIONS: Shorter resuscitation duration was associated with likelihood of favorable outcome at hospital discharge. Subjects with favorable case features were more likely to survive prolonged resuscitation up to 47 minutes. CLINICAL TRIAL REGISTRATION: URL: http://clinicaltrials.gov. Unique identifier: NCT00394706.

Speed and accuracy of text-messaging emergency department electrocardiograms from a small community hospital to a provincial referral center.

BACKGROUND: Currently, transmission of electrocardiograms (EKGs) from a small emergency department (ED) to specialists at referral hospitals can be a time-consuming and laborious process. We investigate whether text messaging by use of short message service (SMS) of EKGs from a small hospital to consultants at a large hospital is rapid and accurate. METHODS: This study involved a one-month prospective evaluation of consecutive EKGs recorded in a small community ED. Investigators obtained de-identified photographs of each EKG via a mobile phone camera. Each EKG picture, along with a brief patient clinical history, was sent via SMS to on-call emergency physicians located at a large referral care site. All images were evaluated solely on a mobile phone. The primary outcome was the proportion of SMS that were received within two minutes of being sent. As a secondary outcome, the intra-rater evaluation of the initial EKG and the SMS EKG image were compared on 13 standardized features. The tertiary outcome was cost of text messaging. RESULTS: A total of 298 patients (14.6%) had 409 EKGs performed and a total of 926 SMS were sent. 921 SMS (99.5%, 95% confidence interval (CI) 98.7-99.8%) arrived within two minutes with a median transmission time of nine seconds (interquartile range (IQR) 3-32 s). Between the gold standard original EKG, and the interpretation of the texted image, six out of 409 (1.5%, 95% CI 0.6-3.3%) had any differences recorded, across all 13 categories. Overall, the study cost 4.1 cents per texted image. CONCLUSIONS: Systematic text messaging of ED EKGs from a small community hospital to a referral center is a rapid, accurate, portable, and inexpensive method of data transfer. This may be a safe and effective strategy to communicate vital patient information.

Association between hospital post-resuscitative performance and clinical outcomes after out-of-hospital cardiac arrest.

BACKGROUND: Survival varies among those resuscitated from out-of-hospital cardiac arrest (OHCA). Evidence-based performance measures have been used to describe hospital quality of care in conditions such as acute coronary syndrome and major trauma. It remains unclear if adherence to performance measures is associated with better outcome in patients hospitalized after OHCA. OBJECTIVES: To assess whether a composite performance score based on evidence-based guidelines for care of patients resuscitated from OHCA was independently associated with clinical outcomes. METHODS: Included were 3252 patients with OHCA who received care at 111 U.S. and Canadian hospitals participating in the Resuscitation Outcomes Consortium (ROC-PRIMED) study between June 2007 and October 2009. We calculated composite performance scores for all patients, aggregated these at the hospital level, then associated them with patient mortality and favorable neurological status at discharge. RESULTS: Composite performance scores varied widely (median [IQR] scores from lowest to highest hospital quartiles, 21% [20%, 25%] vs. 59% [55%, 64%]. Adjusted survival to discharge increased with each quartile of performance score (from lowest to highest: 16.2%, 20.8%, 28.5%, 34.8%, P<0.01), with similar findings for adjusted rates of good neurologic status. Hospital score was significantly associated with outcome after risk adjustment for established baseline factors (highest vs. lowest adherence quartile: adjusted OR of survival 1.64; 95% CI 1.13, 2.38). CONCLUSIONS: Greater survival and favorable neurologic status at discharge were associated with greater adherence to recommended hospital based post-resuscitative care guidelines. Consideration should be given to measuring, reporting and improving hospital adherence to guideline-based performance measures, which could improve outcomes following OHCA.

Targeted temperature management after out-of-hospital cardiac arrest: who, when, why, and how?

OBJECTIVE: To provide a succinct review of the evidence, framed for the emergency department clinician, for the application of targeted temperature management (TTM) for patients after out-of-hospital cardiac arrest (OHCA). SOURCES OF INFORMATION: MEDLINE, EMBASE, and the Cochrane database were searched for prospective and retrospective studies relevant to the indications of TTM, optimal timing of TTM initiation, method of cooling, and target temperature. MAIN MESSAGE: Two prospective interventional trials reported improved neurologically intact survival with the use of TTM (goal temperatures of 32°C to 34°C) compared with no temperature management in comatose OHCA patients with shockable initial cardiac arrest rhythms. A more recent, high-quality randomized controlled trial including OHCA patients with shockable and nonshockable initial rhythms compared TTM at 33°C versus TTM at 36°C. Despite the study being well powered, superiority of one target temperature over the other was not demonstrated. The benefit of TTM in patients with initial nonshockable rhythms is not clear; however, some observational studies have suggested benefit. There is no evidence that any particular method of temperature regulation is superior. The relationship between time and TTM initiation has not been well established. CONCLUSION: Targeted temperature management, with a target temperature between 32°C and 36°C, as a component of comprehensive critical care is a beneficial intervention for comatose patients with return of spontaneous circulation after OHCA.

Emergency Department Corticosteroid Use for Allergy or Anaphylaxis Is Not Associated With Decreased Relapses.

STUDY OBJECTIVE: Corticosteroids (steroids) are often used to mitigate symptoms and prevent subsequent reactions in emergency department (ED) patients with allergic reactions, despite a lack of evidence to support their use. We sought to determine the association of steroid administration with improved clinical outcomes. METHODS: Adult allergy-related encounters to 2 urban EDs during a 5-year period were identified and classified as "anaphylaxis" or "allergic reaction." Regional and provincial databases identified subsequent ED visits or deaths within a 7-day period. The primary outcome was allergy-related ED revisits in the steroid- and nonsteroid-exposed groups, adjusting for potential confounders with a propensity score analysis; secondary outcomes included the number of clinically important biphasic reactions and deaths. RESULTS: Two thousand seven hundred one encounters (473 anaphylactic) were included; 48% were treated with steroids. Allergy-related ED revisits occurred in 5.8% and 6.7% of patients treated with and without steroids, respectively (adjusted odds ratio [OR] 0.91; 95% confidence interval [CI] 0.64 to 1.28), with a number needed to treat (NNT) to benefit of 176 (95% CI NNT to benefit 39 to ∞ to NNT to harm 65). The adjusted OR in the anaphylaxis subgroup was 1.12 (95% CI 0.41 to 3.27). In the allergic reaction group, the adjusted OR was 0.91 (95% CI 0.63 to 1.31), with an NNT to benefit of 173 (95% CI NNT to benefit 38 to ∞ to NNT to harm 58). In the steroid and nonsteroid groups, there were 4 and 1 clinically important biphasic reactions, respectively. There were no deaths. CONCLUSION: Among ED patients with allergic reactions or anaphylaxis, corticosteroid use was not associated with decreased relapses to additional care within 7 days.

Characteristics and thirty-day outcomes of emergency department patients with elevated creatine kinase.

OBJECTIVES: Rhabdomyolysis, as defined by an elevation in creatine kinase (CK), may lead to hemodialysis and death in emergency department (ED) patients, but the patient characteristics, associated conditions, and 30-day outcomes of patients with CK values over 1,000 U/L have not been described. METHODS: All consecutive ED patients with serum CK values over 1,000 U/L between January 1, 2006, and December 31, 2008, were retrospectively identified from two urban hospitals. Patient characteristics, ED treatment, and ED discharge diagnoses were determined by medical record review. Provincial databases were linked to identify patients who died or were treated with hemodialysis within 30 days. The primary outcome was the combined occurrence of death or need for hemodialysis within 30 days. Secondary outcomes included the incidence of acute kidney injury (AKI) and the proportion of patients with initial estimated glomerular filtration rates (eGFR) > 60 mL/min/1.73 m(2) who died or required hemodialysis. RESULTS: Four-hundred patients were identified, the median age was 50 years (interquartile range [IQR] = 35 to 69 years), and 77% were male, with 35% of patients discharged home from the ED. The most common ED discharge diagnoses were related to recreational drug use, infections, and traumatic or musculoskeletal complaints. Within 30 days, 32 (8.0%, 95% confidence interval [CI] = 5.3% to 11%) experienced primary outcomes, with 18 (4.5%, 95% CI = 2.55% to 6.5%) requiring hemodialysis and 21 deaths (5.3%, 95% CI = 3.1% to 7.4%). AKI occurred in 151 patients (38%, 95% CI = 33% to 43%). Of the 257 patients (64%) with initial eGFRs > 60 mL/min/1.73 m(2) , none required hemodialysis. CONCLUSIONS: In ED patients with initial CK > 1,000 U/L, the incidence of death or hemodialysis was 8% within 30 days. Patients with initial eGFRs > 60 mL/min/1.73 m(2) appear to be at a low risk of these outcomes from rhabdomyolysis.

Resuscitation Outcomes Consortium-Amiodarone, Lidocaine or Placebo Study (ROC-ALPS): Rationale and methodology behind an out-of-hospital cardiac arrest antiarrhythmic drug trial.

BACKGROUND: Despite their wide use, whether antiarrhythmic drugs improve survival after out-of-hospital cardiac arrest (OHCA) is not known. The ROC-ALPS is evaluating the effectiveness of these drugs for OHCA due to shock-refractory ventricular fibrillation or pulseless ventricular tachycardia (VF/VT). METHODS: ALPS will randomize 3,000 adults across North America with nontraumatic OHCA, persistent or recurring VF/VT after ≥1 shock, and established vascular access to receive up to 450 mg amiodarone, 180 mg lidocaine, or placebo in the field using a double-blind protocol, along with standard resuscitation measures. The designated target population is all eligible randomized recipients of any dose of ALPS drug whose initial OHCA rhythm was VF/VT. A safety analysis includes all randomized patients regardless of their eligibility, initial arrhythmia, or actual receipt of ALPS drug. The primary outcome of ALPS is survival to hospital discharge; a secondary outcome is functional survival at discharge assessed as a modified Rankin Scale score ≤3. RESULTS: The principal aim of ALPS is to determine if survival is improved by amiodarone compared with placebo; secondary aim is to determine if survival is improved by lidocaine vs placebo and/or by amiodarone vs lidocaine. Prioritizing comparisons in this manner acknowledges where differences in outcome are most expected based on existing knowledge. Each aim also represents a clinically relevant comparison between treatments that is worth investigating. CONCLUSIONS: Results from ALPS will provide important information about the choice and value of antiarrhythmic therapies for VF/VT arrest with direct implications for resuscitation guidelines and clinical practice.