Emergency Department Point-of-Care Tests during Cardiopulmonary Resuscitation to Predict Cardiac Arrest Outcomes.

Introduction: This study evaluated the role of point-of-care tests (POCT) such as blood lactate, anion gap (AG), base deficit, pH, N-terminal pro B-type natriuretic peptide (NT-proBNP), and troponin as the predictors of cardiac arrest outcomes in the emergency department (ED). Methods: We conducted a prospective, observational study in the ED of a tertiary care hospital in India. All the adult patients who received cardiopulmonary resuscitation (CPR) in the ED were included in the study. Blood samples were collected within 10 min of initiation of CPR for assay of POCTs. Outcomes assessed were the return of spontaneous circulation (ROSC), 24-h survival, survival to hospital discharge (STHD), survival at 7 days, and favorable neurological outcome (FNO) at day 7 of admission. Results: One hundred and fifty-one patients were included in the study (median age: 50 years, 65% males). Out of 151 cases, ROSC, survival at 7 days, STHD, and FNO was observed in 86 patients, six patients, five patients, and two patients, respectively. "No-ROSC" could be significantly predicted by raised lactate (odds ratio [OR]: 1.14, 95% confidence interval: 1.07-1.22) and NT-proBNP (OR: 1.05, 1.01-1.09) values at the time of cardiac arrest. "24-h mortality" could be significantly predicted by the raised lactate (OR: 1.14, 1.01-1.28), low arterial pH (OR: 0.05, 0.01-0.52), raised AG (OR: 1.08, 1.01-1.15), and lower base deficit (<-15) (OR: 1.07, 1.01-1.14). None of the other POCTs was found to be a predictor of other cardiac arrest outcomes. Conclusion: Among various POCTs, raised lactate assayed within 10 min of cardiac arrest can predict poor outcomes like "no-ROSC" and 24-h mortality.

Prospective Validation of a Novel Triage System Developed in a Middle Income Country - AIIMS Triage Protocol.

Introduction: Triage is a crucial process not only to identify sick patients and prioritize prompt management but also to foster efficient resource utilization. In low-and middle-income countries (LMICs) most emergency departments (ED) still have an informal triage process. Although an important element of emergency care, triage research has not been a priority in LMICs, and hence, very few triage systems have been validated. The All India Institute of Medical Sciences (AIIMS) triage protocol or ATP for adult patients was developed by expert consensus at AIIMS using the Delphi method. We attempted a prospective validation of the ATP in terms of mortality and intensive care unit (ICU)/hospital admission at 24 h. Methods: Patients presenting to the ED, who were 14 years and above were included in the study. The patients were followed up at 24 h and their outcome documented on a standardized data collection form. Mortality and ICU admission were noted at 24 h. Results: A total of 15,505 patients were recruited. After exclusion, among 13,754 patients, 6303 (45.83%) were triaged red and 7451 (54.17%) were triaged yellow. Mortality at 24 h was 10.31% (650) in red triaged patients and 0.35% (26) in yellow triaged patients. The 24-h mortality of red triaged patients was significantly higher (P <0.001) than that of yellow triaged patients. The presence of one or more ATP "Red" criteria was 96.2% (95% confidence interval [CI]: 94.42%-97.47%) sensitive and 56.8% (95% CI: 55.92%-57.63%) specific in predicting 24-h mortality. The sensitivity and specificity of ATP "Red" criteria for 24-h ICU admission were 98.5% (95% CI: 97.7%-99.1%) and 59.6% (95% CI: 58.8%-60.5%), respectively. Conclusion: When applied to adult nontrauma patients, ATP had a high accuracy in recognizing sick patients presenting to the ED. A time-tested and validated triage system like ATP may be a good starting point for public hospital EDs in LMICs.

"Six-dial Strategy"-Mechanical Ventilation during Cardiopulmonary Resuscitation.

As per current guidelines, whenever an advanced airway is in place during cardiopulmonary resuscitation, positive pressure ventilation should be provided without pausing for chest compression. Positive pressure ventilation can be provided through bag-valve resuscitator (BV) or mechanical ventilator (MV), which was found to be equally efficacious. In a busy emergency department, with less trained personnel use of MV is advantageous over BV in terms of reducing human errors and relieving the airway manager to focus on other resuscitation tasks. Currently, there are no guidelines specific to MV settings in cardiac arrest. We present a concept of "six-dial ventilator strategy during CPR" that encompasses the evidence-based settings appropriate during chest compression. We suggest use of volume control ventilation with the following settings: (1) positive end-expiratory pressure of 0 cm of water (to allow venous return), (2) tidal volume of 8 mL/kg with fraction of inspired oxygen at 100% (for adequate oxygenation), (3) respiratory rate of 10 per minute (for adequate ventilation), (4) maximum peak inspiratory pressure or P max alarm of 60 cm of water (to allow tidal volume delivery during chest compression), (5) switching OFF trigger (to avoid trigger by chest recoil), and (6) inspiratory to expiratory time ratio of 1:5 (to provide adequate inspiratory time of 1 second). How to cite this article: Sahu AK, Timilsina G, Mathew R, Jamshed N, Aggarwal P. "Six-dial Strategy"-Mechanical Ventilation during Cardiopulmonary Resuscitation. Indian J Crit Care Med 2020;24(6):487-489.