The American Heart Association Emergency Cardiovascular Care 2030 Impact Goals and Call to Action to Improve Cardiac Arrest Outcomes: A Scientific Statement From the American Heart Association.

Every 10 years, the American Heart Association (AHA) Emergency Cardiovascular Care Committee establishes goals to improve survival from cardiac arrest. These goals align with broader AHA Impact Goals and support the AHA's advocacy efforts and strategic investments in research, education, clinical care, and quality improvement programs. This scientific statement focuses on 2030 AHA emergency cardiovascular care priorities, with a specific focus on bystander cardiopulmonary resuscitation, early defibrillation, and neurologically intact survival. This scientific statement also includes aspirational goals, such as establishing cardiac arrest as a reportable disease and mandating reporting of standardized outcomes from different sources; advancing recognition of and knowledge about cardiac arrest; improving dispatch system response, availability, and access to resuscitation training in multiple settings and at multiple time points; improving availability, access, and affordability of defibrillators; providing a focus on early defibrillation, in-hospital programs, and establishing champions for debriefing and review of cardiac arrest events; and expanding measures to track outcomes beyond survival. The ability to track and report data from these broader aspirational targets will potentially require expansion of existing data sets, development of new data sets, and enhanced integration of technology to collect process and outcome data, as well as partnerships of the AHA with national, state, and local organizations. The COVID-19 (coronavirus disease 2019) pandemic, disparities in COVID-19 outcomes for historically excluded racial and ethnic groups, and the longstanding disparities in cardiac arrest treatment and outcomes for Black and Hispanic or Latino populations also contributed to an explicit focus and target on equity for the AHA Emergency Cardiovascular Care 2030 Impact Goals.

Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation.

AIM OF THE REVIEW: Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries. METHODS: The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section. RESULTS: There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness. CONCLUSIONS: All health systems should develop, implement, and evaluate protocols designed to optimize organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.

Optimizing Outcomes After Out-of-Hospital Cardiac Arrest With Innovative Approaches to Public-Access Defibrillation: A Scientific Statement From the International Liaison Committee on Resuscitation.

Out-of-hospital cardiac arrest is a global public health issue experienced by ≈3.8 million people annually. Only 8% to 12% survive to hospital discharge. Early defibrillation of shockable rhythms is associated with improved survival, but ensuring timely access to defibrillators has been a significant challenge. To date, the development of public-access defibrillation programs, involving the deployment of automated external defibrillators into the public space, has been the main strategy to address this challenge. Public-access defibrillator programs have been associated with improved outcomes for out-of-hospital cardiac arrest; however, the devices are used in <3% of episodes of out-of-hospital cardiac arrest. This scientific statement was commissioned by the International Liaison Committee on Resuscitation with 3 objectives: (1) identify known barriers to public-access defibrillator use and early defibrillation, (2) discuss established and novel strategies to address those barriers, and (3) identify high-priority knowledge gaps for future research to address. The writing group undertook systematic searches of the literature to inform this statement. Innovative strategies were identified that relate to enhanced public outreach, behavior change approaches, optimization of static public-access defibrillator deployment and housing, evolved automated external defibrillator technology and functionality, improved integration of public-access defibrillation with existing emergency dispatch protocols, and exploration of novel automated external defibrillator delivery vectors. We provide evidence- and consensus-based policy suggestions to enhance public-access defibrillation and guidance for future research in this area.

Community Interventions for Out-of-Hospital Cardiac Arrest in Resource-Limited Settings: A Scoping Review Across Low, Middle, and High-Income Countries.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is a major global health challenge, characterized by poor survival outcomes worldwide. Resource-limited settings are burdened with suboptimal emergency response and worse outcomes than high-resource areas. Engaging the community in the response to OHCA has the potential to improve outcomes, although an overview of community interventions in resource-limited settings has not been provided. OBJECTIVE: This review evaluated the scope of community-based OHCA interventions in resource-limited settings. METHODS: Literature searches in electronic databases (MEDLINE, EMBASE, Global Health, CINAHL, Cochrane Central Register of Controlled Clinical Trials) and grey literature sources were performed. Abstract screening, full-text review, and data extraction of eligible studies were conducted independently by two reviewers. The PCC (Population, Concept, and Context) framework was used to assess study eligibility. Studies that evaluated community-based interventions for laypeople (Population), targeting emergency response activation, cardiopulmonary resuscitation (CPR), or automated external defibrillator (AED) use (Concept) in resource-limited settings (Context) were included. Resource-limited settings were identified by financial pressures (low-income or lower-middle-income country, according to World Bank data on year of publication) or geographical factors (setting described using keywords indicative of geographical remoteness in upper-middle-income or high-income country). RESULTS: Among 14,810 records identified from literature searches, 60 studies from 28 unique countries were included in this review. Studies were conducted in high-income (n = 35), upper-middle-income (n = 2), lower-middle-income (n = 22), and low-income countries (n = 1). Community interventions included bystander CPR and/or AED training (n = 34), community responder programs (n = 8), drone-delivered AED networks (n = 6), dispatcher-assisted CPR programs (n = 4), regional resuscitation campaigns (n = 3), public access defibrillation programs (n = 3), and crowdsourcing technologies (n = 2). CPR and/or AED training were the only interventions evaluated in low-income, lower-middle-income, and upper-middle-income countries. CONCLUSIONS: Interventions aimed at improving the community response to OHCA in resource-limited settings differ globally. There is a lack of reported studies from low-income countries and certain continental regions, including South America, Africa, and Oceania. Evaluation of interventions other than CPR and/or AED training in low- and middle-income countries is needed to guide community emergency planning and health policies.

2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces.

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence to Decision Framework Highlights sections. The task forces also listed priority knowledge gaps for further research.

Ranking Businesses and Municipal Locations by Spatiotemporal Cardiac Arrest Risk to Guide Public Defibrillator Placement.

BACKGROUND: Efforts to guide automated external defibrillator placement for out-of-hospital cardiac arrest (OHCA) treatment have focused on identifying broadly defined location categories without considering hours of operation. Broad location categories may be composed of many businesses with varying accessibility. Identifying specific locations for automated external defibrillator deployment incorporating operating hours and time of OHCA occurrence may improve automated external defibrillator accessibility. We aim to identify specific businesses and municipal locations that maximize OHCA coverage on the basis of spatiotemporal assessment of OHCA risk in the immediate vicinity of franchise locations. METHODS: This study was a retrospective population-based cohort study using data from the Toronto Regional RescuNET Epistry cardiac arrest database. We identified all nontraumatic public OHCAs occurring in Toronto, ON, Canada, from January 2007 through December 2015. We identified 41 unique businesses and municipal location types with ≥20 locations in Toronto from the YellowPages, Canadian Franchise Association, and the City of Toronto Open Data Portal. We obtained their geographic coordinates and hours of operation from Web sites, by phone, or in person. We determined the number of OHCAs that occurred within 100 m of each location when it was open (spatiotemporal coverage) for Toronto overall and downtown. The businesses and municipal locations were then ranked by spatiotemporal OHCA coverage. To evaluate temporal stability of the rankings, we calculated intraclass correlation of the annual coverage values. RESULTS: There were 2654 nontraumatic public OHCAs. Tim Hortons ranked first in Toronto, covering 286 OHCAs. Starbucks ranked first in downtown, covering 110 OHCAs. Coffee shops and bank machines from the 5 largest Canadian banks occupied 8 of the top 10 spots in both Toronto and downtown. The rankings exhibited high temporal stability with intraclass correlation values of 0.88 (95% confidence interval, 0.83-0.93) in Toronto and 0.79 (95% confidence interval, 0.71-0.86) in downtown. CONCLUSIONS: We identified and ranked businesses and municipal locations by spatiotemporal OHCA risk in their immediate vicinity. This approach may help policy makers and funders to identify and prioritize potential partnerships for automated external defibrillator deployment in public-access defibrillator programs.

Optimizing a Drone Network to Deliver Automated External Defibrillators.

BACKGROUND: Public access defibrillation programs can improve survival after out-of-hospital cardiac arrest, but automated external defibrillators (AEDs) are rarely available for bystander use at the scene. Drones are an emerging technology that can deliver an AED to the scene of an out-of-hospital cardiac arrest for bystander use. We hypothesize that a drone network designed with the aid of a mathematical model combining both optimization and queuing can reduce the time to AED arrival. METHODS: We applied our model to 53 702 out-of-hospital cardiac arrests that occurred in the 8 regions of the Toronto Regional RescuNET between January 1, 2006, and December 31, 2014. Our primary analysis quantified the drone network size required to deliver an AED 1, 2, or 3 minutes faster than historical median 911 response times for each region independently. A secondary analysis quantified the reduction in drone resources required if RescuNET was treated as a large coordinated region. RESULTS: The region-specific analysis determined that 81 bases and 100 drones would be required to deliver an AED ahead of median 911 response times by 3 minutes. In the most urban region, the 90th percentile of the AED arrival time was reduced by 6 minutes and 43 seconds relative to historical 911 response times in the region. In the most rural region, the 90th percentile was reduced by 10 minutes and 34 seconds. A single coordinated drone network across all regions required 39.5% fewer bases and 30.0% fewer drones to achieve similar AED delivery times. CONCLUSIONS: An optimized drone network designed with the aid of a novel mathematical model can substantially reduce the AED delivery time to an out-of-hospital cardiac arrest event.

2017 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary.

The International Liaison Committee on Resuscitation has initiated a near-continuous review of cardiopulmonary resuscitation science that replaces the previous 5-year cyclic batch-and-queue approach process. This is the first of an annual series of International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations summary articles that will include the cardiopulmonary resuscitation science reviewed by the International Liaison Committee on Resuscitation in the previous year. The review this year includes 5 basic life support and 1 pediatric Consensuses on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Each of these includes a summary of the science and its quality based on Grading of Recommendations, Assessment, Development, and Evaluation criteria and treatment recommendations. Insights into the deliberations of the International Liaison Committee on Resuscitation task force members are provided in Values and Preferences sections. Finally, the task force members have prioritized and listed the top 3 knowledge gaps for each population, intervention, comparator, and outcome question.

Mechanical versus manual chest compressions for cardiac arrest.

BACKGROUND: Mechanical chest compression devices have been proposed to improve the effectiveness of cardiopulmonary resuscitation (CPR). OBJECTIVES: To assess the effectiveness of resuscitation strategies using mechanical chest compressions versus resuscitation strategies using standard manual chest compressions with respect to neurologically intact survival in patients who suffer cardiac arrest. SEARCH METHODS: On 19 August 2017 we searched the Cochrane Central Register of Controlled Studies (CENTRAL), MEDLINE, Embase, Science Citation Index-Expanded (SCI-EXPANDED) and Conference Proceedings Citation Index-Science databases. Biotechnology and Bioengineering Abstracts and Science Citation abstracts had been searched up to November 2009 for prior versions of this review. We also searched two clinical trials registries for any ongoing trials not captured by our search of databases containing published works: Clinicaltrials.gov (August 2017) and the World Health Organization International Clinical Trials Registry Platform portal (January 2018). We applied no language restrictions. We contacted experts in the field of mechanical chest compression devices and manufacturers. SELECTION CRITERIA: We included randomised controlled trials (RCTs), cluster-RCTs and quasi-randomised studies comparing mechanical chest compressions versus manual chest compressions during CPR for patients with cardiac arrest. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We included five new studies in this update. In total, we included 11 trials in the review, including data from 12,944 adult participants, who suffered either out-of-hospital cardiac arrest (OHCA) or in-hospital cardiac arrest (IHCA). We excluded studies explicitly including patients with cardiac arrest caused by trauma, drowning, hypothermia and toxic substances. These conditions are routinely excluded from cardiac arrest intervention studies because they have a different underlying pathophysiology, require a variety of interventions specific to the underlying condition and are known to have a prognosis different from that of cardiac arrest with no obvious cause. The exclusions were meant to reduce heterogeneity in the population while maintaining generalisability to most patients with sudden cardiac death.The overall quality of evidence for the outcomes of included studies was moderate to low due to considerable risk of bias. Three studies (N = 7587) reported on the designated primary outcome of survival to hospital discharge with good neurologic function (defined as a Cerebral Performance Category (CPC) score of one or two), which had moderate quality evidence. One study showed no difference with mechanical chest compressions (risk ratio (RR) 1.07, 95% confidence interval (CI) 0.82 to 1.39), one study demonstrated equivalence (RR 0.79, 95% CI 0.60 to 1.04), and one study demonstrated reduced survival (RR 0.41, CI 0.21 to 0.79). Two other secondary outcomes, survival to hospital admission (N = 7224) and survival to hospital discharge (N = 8067), also had moderate quality level of evidence. No studies reported a difference in survival to hospital admission. For survival to hospital discharge, two studies showed benefit, four studies showed no difference, and one study showed harm associated with mechanical compressions. No studies demonstrated a difference in adverse events or injury patterns between comparison groups but the quality of data was low. Marked clinical and statistical heterogeneity between studies precluded any pooled estimates of effect. AUTHORS' CONCLUSIONS: The evidence does not suggest that CPR protocols involving mechanical chest compression devices are superior to conventional therapy involving manual chest compressions only. We conclude on the balance of evidence that mechanical chest compression devices used by trained individuals are a reasonable alternative to manual chest compressions in settings where consistent, high-quality manual chest compressions are not possible or dangerous for the provider (eg, limited rescuers available, prolonged CPR, during hypothermic cardiac arrest, in a moving ambulance, in the angiography suite, during preparation for extracorporeal CPR [ECPR], etc.). Systems choosing to incorporate mechanical chest compression devices should be closely monitored because some data identified in this review suggested harm. Special attention should be paid to minimising time without compressions and delays to defibrillation during device deployment.

Improving Appropriate Neurologic Prognostication after Cardiac Arrest. A Stepped Wedge Cluster Randomized Controlled Trial.

RATIONALE: Predictions about neurologic prognosis that are based on early clinical findings after out-of-hospital cardiac arrest (OHCA) are often inaccurate and may lead to premature decisions to withdraw life-sustaining treatments (LST) in patients who might otherwise survive with good neurologic outcomes. OBJECTIVES: To improve adherence to recommendations for appropriate neurologic prognostication after OHCA and reduce deaths from premature decisions to withdraw LST. METHODS: This was a pragmatic stepped wedge cluster randomized controlled trial evaluating a multifaceted quality intervention (education, pathways, local champions, audit-feedback). The primary outcome was appropriate neurologic prognostication, defined as (1a) no early withdrawal of LST (WLST) (within 72 h) based on estimates of poor neurologic prognosis and (1b) no WLST between 72 hours and 7 days in absence of clinical predictors of poor neurologic prognosis or (2) surviving beyond 7 days. Secondary outcomes were deaths from early WLST and survival with good neurologic outcome. MEASUREMENTS AND MAIN RESULTS: Between June 1, 2011, and June 30, 2014, a total of 905 patients with OHCA were enrolled from ICUs of 18 Ontario hospitals. Rates of appropriate neurologic prognostication increased after the intervention (68% vs. 74% patients; odds ratio [OR], 1.79; 95% confidence interval [CI], 1.01-3.19; P = 0.05). However, rates of survival to hospital discharge (46% vs. 50%; OR, 1.71; 95% CI, 0.97-3.01; P = 0.06) and survival with good neurologic outcome remained similar (38% vs. 43%; OR, 1.43; 95% CI, 0.84-2.86; P = 0.19). CONCLUSIONS: A multicenter quality intervention improved rates of appropriate neurologic prognostication after OHCA but did not increase survival with good neurologic outcome. Clinical trial registered with www.clinicaltrials.gov (NCT 01472458).

The Postcardiac Arrest Consult Team: Impact on Hospital Care Processes for Out-of-Hospital Cardiac Arrest Patients.

OBJECTIVE: To evaluate whether a Post-Arrest Consult Team improved care and outcomes for patients with out-of-hospital cardiac arrest. DESIGN: Prospective cohort study of Post-Arrest Consult Team implementation at two hospitals, with concurrent controls from 27 others. SETTING: Twenty-nine hospitals within the Strategies for Post-Arrest Care Network of Southern Ontario, Canada. PATIENTS: We included comatose adult nontraumatic out-of-hospital cardiac arrest patients surviving more than or equal to 6 hours after emergency department arrival who had no contraindications to targeted temperature management. INTERVENTION: The Post-Arrest Consult Team was an advisory consult service to improve 1) targeted temperature management, 2) assessment for percutaneous coronary intervention, 3) electrophysiology assessment, and 4) appropriately delayed neuroprognostication. MEASUREMENTS AND MAIN RESULTS: We used generalized linear mixed models to explore the association between Post-Arrest Consult Team implementation and performance of targeted processes. We included 1,006 patients. The Post-Arrest Consult Team was associated with a significant reduction over time in rates of withdrawal of life-sustaining therapy within 72 hours of emergency department arrival on the basis of predictions of poor neurologic prognosis (ratio of odds ratios, 0.13; 95% CI, 0.02-0.98). Post-Arrest Consult Team was not associated with improved successful targeted temperature management (ratio of odds ratios, 0.91; 95% CI, 0.31-2.65), undergoing angiography (ratio of odds ratios, 1.91; 95% CI, 0.17-21.04), receiving electrophysiology consultation (ratio of odds ratios, 0.93; 95% CI, 0.11-8.16), or functional survival (ratio of odds ratios, 0.75; 95% CI, 0.19-2.94). CONCLUSIONS: Implementation of a Post-Arrest Consult Team reduced premature withdrawal of life-sustaining therapy but did not improve rates of successful targeted temperature management, coronary angiography, formal electrophysiology assessments, or functional survival for comatose patients after out-of-hospital cardiac arrest.

Improving use of targeted temperature management after out-of-hospital cardiac arrest: a stepped wedge cluster randomized controlled trial.

RATIONALE: International guidelines recommend use of targeted temperature management following resuscitation from out-of-hospital cardiac arrest. This treatment, however, is often neglected or delayed. OBJECTIVE: To determine whether multifaceted quality improvement interventions would increase the proportion of eligible patients receiving successful targeted temperature management. SETTING: A network of 6 regional emergency medical services systems and 32 academic and community hospitals serving a population of 8.8 million people providing post arrest care to out-of-hospital cardiac arrest. INTERVENTIONS: Comparing interventions improve the implementation of targeted temperature management post out-of-hospital cardiac arrest through passive (education, generic protocol, order set, local champions) versus additional active quality improvement interventions (nurse specialist providing site-specific interventions, monthly audit-feedback, network educational events, internet blog) versus no intervention (baseline standard of care). MEASUREMENTS AND MAIN RESULTS: The primary process outcome was proportion of eligible patients receiving successful targeted temperature management, defined as a target temperature of 32-34ºC within 6 hours of emergency department arrival. Secondary clinical outcomes included survival and neurological outcome at hospital discharge. Four thousand three hundred seventeen out-of-hospital cardiac arrests were transported to hospital; 1,737 (40%) achieved spontaneous circulation, and 934 (22%) were eligible for targeted temperature management. After accounting for secular trends, patients admitted during the passive quality improvement phase were more likely to achieve successful targeted temperature management compared with those admitted during the baseline period (25.7% passive vs 9.0% baseline; odds ratio, 2.76; 95% CI, 1.76-4.32; p < 0.001). Active quality improvement interventions conferred no additional improvements in rates of successful targeted temperature management (26.9% active vs 25.7% passive; odds ratio, 0.96; 95% CI, 0.63-1.45; p = 0.84). Despite a significant increase in rates of successful targeted temperature management, survival to hospital discharge was unchanged. CONCLUSION: Simple quality improvement interventions significantly increased the rates of achieving successful targeted temperature management following out-of-hospital cardiac arrest in a large network of hospitals but did not improve clinical outcomes.

Chest compression rates and survival following out-of-hospital cardiac arrest.

OBJECTIVE: Guidelines for cardiopulmonary resuscitation recommend a chest compression rate of at least 100 compressions/min. A recent clinical study reported optimal return of spontaneous circulation with rates between 100 and 120/min during cardiopulmonary resuscitation for out-of-hospital cardiac arrest. However, the relationship between compression rate and survival is still undetermined. DESIGN: Prospective, observational study. SETTING: Data is from the Resuscitation Outcomes Consortium Prehospital Resuscitation IMpedance threshold device and Early versus Delayed analysis clinical trial. PARTICIPANTS: Adults with out-of-hospital cardiac arrest treated by emergency medical service providers. INTERVENTIONS: None. MEASUREMENTS MAIN RESULTS: Data were abstracted from monitor-defibrillator recordings for the first five minutes of emergency medical service cardiopulmonary resuscitation. Multiple logistic regression assessed odds ratio for survival by compression rate categories (<80, 80-99, 100-119, 120-139, ≥140), both unadjusted and adjusted for sex, age, witnessed status, attempted bystander cardiopulmonary resuscitation, location of arrest, chest compression fraction and depth, first rhythm, and study site. Compression rate data were available for 10,371 patients; 6,399 also had chest compression fraction and depth data. Age (mean±SD) was 67±16 years. Chest compression rate was 111±19 per minute, compression fraction was 0.70±0.17, and compression depth was 42±12 mm. Circulation was restored in 34%; 9% survived to hospital discharge. After adjustment for covariates without chest compression depth and fraction (n=10,371), a global test found no significant relationship between compression rate and survival (p=0.19). However, after adjustment for covariates including chest compression depth and fraction (n=6,399), the global test found a significant relationship between compression rate and survival (p=0.02), with the reference group (100-119 compressions/min) having the greatest likelihood for survival. CONCLUSIONS: After adjustment for chest compression fraction and depth, compression rates between 100 and 120 per minute were associated with greatest survival to hospital discharge.

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.

Identifying locations for public access defibrillators using mathematical optimization.

BACKGROUND: Geospatial methods using mathematical optimization to identify clusters of cardiac arrests and prioritize public locations for defibrillator deployment have not been studied. Our objective was to develop such a method and test its performance against a population-guided approach. METHODS AND RESULTS: All public location cardiac arrests in Toronto, Ontario, Canada, from December 16, 2005, to July 15, 2010, and all automated external defibrillator (AED) locations registered with Toronto Emergency Medical Services as of September 2009 were plotted geographically. Current AED coverage was quantified by determining the number of cardiac arrests occurring within 100 m of a registered AED. Clusters of cardiac arrests without a registered AED within 100 m were identified. With the use of mathematical optimization techniques, cardiac arrest coverage improvements were computed and shown to be superior to results from a population-guided deployment method. There were 1310 eligible public location cardiac arrests and 1669 registered AEDs. Of the eligible cardiac arrests, 304 were within 100 m of at least 1 registered AED (23% coverage). The average distance from a cardiac arrest to the closest AED was 281 m. With AEDs deployed in the top 30 locations, an additional 112 historical cardiac arrests would be covered (32% total coverage), and the average distance to the closest AED would be 262 m. CONCLUSIONS: Geographic clusters of cardiac arrests can be easily identified and prioritized with the use of mathematical modeling. Optimized AED deployment can increase cardiac arrest coverage and decrease the distance to the closest AED. Mathematical modeling can augment public AED deployment programs.

Ventricular tachyarrhythmias after cardiac arrest in public versus at home.

BACKGROUND: The incidence of ventricular fibrillation or pulseless ventricular tachycardia as the first recorded rhythm after out-of-hospital cardiac arrest has unexpectedly declined. The success of bystander-deployed automated external defibrillators (AEDs) in public settings suggests that this may be the more common initial rhythm when out-of-hospital cardiac arrest occurs in public. We conducted a study to determine whether the location of the arrest, the type of arrhythmia, and the probability of survival are associated. METHODS: Between 2005 and 2007, we conducted a prospective cohort study of out-of-hospital cardiac arrest in adults in 10 North American communities. We assessed the frequencies of ventricular fibrillation or pulseless ventricular tachycardia and of survival to hospital discharge for arrests at home as compared with arrests in public. RESULTS: Of 12,930 evaluated out-of-hospital cardiac arrests, 2042 occurred in public and 9564 at home. For cardiac arrests at home, the incidence of ventricular fibrillation or pulseless ventricular tachycardia was 25% when the arrest was witnessed by emergency-medical-services (EMS) personnel, 35% when it was witnessed by a bystander, and 36% when a bystander applied an AED. For cardiac arrests in public, the corresponding rates were 38%, 60%, and 79%. The adjusted odds ratio for initial ventricular fibrillation or pulseless ventricular tachycardia in public versus at home was 2.28 (95% confidence interval [CI], 1.96 to 2.66; P < 0.001) for bystander-witnessed arrests and 4.48 (95% CI, 2.23 to 8.97; P<0.001) for arrests in which bystanders applied AEDs. The rate of survival to hospital discharge was 34% for arrests in public settings with AEDs applied by bystanders versus 12% for arrests at home (adjusted odds ratio, 2.49; 95% CI, 1.03 to 5.99; P = 0.04). CONCLUSIONS: Regardless of whether out-of-hospital cardiac arrests are witnessed by EMS personnel or bystanders and whether AEDs are applied by bystanders, the proportion of arrests with initial ventricular fibrillation or pulseless ventricular tachycardia is much greater in public settings than at home. The incremental value of resuscitation strategies, such as the ready availability of an AED, may be related to the place where the arrest occurs.

Targeted temperature management processes and outcomes after out-of-hospital cardiac arrest: an observational cohort study*.

OBJECTIVES: Targeted temperature management has been shown to improve survival with good neurological outcome in patients after out-of-hospital cardiac arrest. The optimal approach to inducing and maintaining targeted temperature management, however, remains uncertain. The objective of this study was to evaluate these processes of care with survival and neurological function in patients after out-of-hospital cardiac arrest. DESIGN: An observational cohort study evaluating the association of targeted temperature management processes with survival and neurological function using bivariate and generalized estimating equation analyses. SETTING: Thirty-two tertiary and community hospitals in eight urban and rural regions of southern Ontario, Canada. PATIENTS: Consecutive adult (≥ 18 yr) patients admitted between November 1, 2007, and January 31, 2012, and who were treated with targeted temperature management following nontraumatic out-of-hospital cardiac arrest. INTERVENTIONS: Evaluate the association of targeted temperature management processes with survival and neurologic function using bivariate and generalized estimating equation analyses. MEASUREMENTS AND MAIN RESULTS: There were 5,770 consecutive out-of-hospital cardiac arrest patients, of whom 747 (12.9%) were eligible and received targeted temperature management. Among patients with available outcome data, 365 of 738 (49.5%) survived to hospital discharge and 241 of 675 (35.7%) had good neurological outcomes. After adjusting for the Utstein variables, a higher temperature prior to initiation of targeted temperature management was associated with improved neurological outcomes (odds ratio, 1.27 per °C; 95% CI, 1.08-1.50; p = 0.004) and survival (odds ratio, 1.26 per °C; 95% CI, 1.09-1.46; p = 0.002). A slower rate of cooling was associated with improved neurological outcomes (odds ratio, 0.74 per °C/hr; 95% CI, 0.57-0.97; p = 0.03) and survival (odds ratio, 0.73 per °C/hr; 95% CI, 0.54-1.00; p = 0.049). CONCLUSIONS: A higher baseline temperature prior to initiation of targeted temperature management and a slower rate of cooling were associated with improved survival and neurological outcomes. This may reflect a complex relationship between the approach to targeted temperature management and the extent of underlying brain injury causing impaired thermoregulation in out-of-hospital cardiac arrest patients.

Mechanical versus manual chest compressions for cardiac arrest.

BACKGROUND: This is the first update of the Cochrane review on mechanical chest compression devices published in 2011 (Brooks 2011). Mechanical chest compression devices have been proposed to improve the effectiveness of cardiopulmonary resuscitation (CPR). OBJECTIVES: To assess the effectiveness of mechanical chest compressions versus standard manual chest compressions with respect to neurologically intact survival in patients who suffer cardiac arrest. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Studies (CENTRAL; 2013, Issue 12), MEDLINE Ovid (1946 to 2013 January Week 1), EMBASE (1980 to 2013 January Week 2), Science Citation abstracts (1960 to 18 November 2009), Science Citation Index-Expanded (SCI-EXPANDED) (1970 to 11 January 2013) on Thomson Reuters Web of Science, biotechnology and bioengineering abstracts (1982 to 18 November 2009), conference proceedings Citation Index-Science (CPCI-S) (1990 to 11 January 2013) and clinicaltrials.gov (2 August 2013). We applied no language restrictions. Experts in the field of mechanical chest compression devices and manufacturers were contacted. SELECTION CRITERIA: We included randomised controlled trials (RCTs), cluster RCTs and quasi-randomised studies comparing mechanical chest compressions versus manual chest compressions during CPR for patients with atraumatic cardiac arrest. DATA COLLECTION AND ANALYSIS: Two review authors abstracted data independently; disagreement between review authors was resolved by consensus and by a third review author if consensus could not be reached. The methodologies of selected studies were evaluated by a single author for risk of bias. The primary outcome was survival to hospital discharge with good neurological outcome. We planned to use RevMan 5 (Version 5.2. The Nordic Cochrane Centre) and the DerSimonian & Laird method (random-effects model) to provide a pooled estimate for risk ratio (RR) with 95% confidence intervals (95% CIs), if data allowed. MAIN RESULTS: Two new studies were included in this update. Six trials in total, including data from 1166 participants, were included in the review. The overall quality of included studies was poor, and significant clinical heterogeneity was observed. Only one study (N = 767) reported survival to hospital discharge with good neurological function (defined as a Cerebral Performance Category score of one or two), demonstrating reduced survival with mechanical chest compressions when compared with manual chest compressions (RR 0.41, 95% CI 0.21 to 0.79). Data from four studies demonstrated increased return of spontaneous circulation, and data from two studies demonstrated increased survival to hospital admission with mechanical chest compressions as compared with manual chest compressions, but none of the individual estimates reached statistical significance. Marked clinical heterogeneity between studies precluded any pooled estimates of effect. AUTHORS' CONCLUSIONS: Evidence from RCTs in humans is insufficient to conclude that mechanical chest compressions during cardiopulmonary resuscitation for cardiac arrest are associated with benefit or harm. Widespread use of mechanical devices for chest compressions during cardiac events is not supported by this review. More RCTs that measure and account for the CPR process in both arms are needed to clarify the potential benefit to be derived from this intervention.

Erratum to "Wolf Creek XVII Part 5: Mobile AEDs" [Resusc. Plus 16 (2023) 100500].

[This corrects the article DOI: 10.1016/j.resplu.2023.100500.].