Amplitude spectral area of ventricular fibrillation can discriminate survival of patients with out-of-hospital cardiac arrest.

Background: Evidence of the association between AMplitude Spectral Area (AMSA) of ventricular fibrillation and outcome after out-of-hospital cardiac arrest (OHCA) is limited to short-term follow-up. In this study, we assess whether AMSA can stratify the risk of death or poor neurological outcome at 30 days and 1 year after OHCA in patients with an initial shockable rhythm or with an initial non-shockable rhythm converted to a shockable one. Methods: This is a multicentre retrospective study of prospectively collected data in two European Utstein-based OHCA registries. We included all cases of OHCAs with at least one manual defibrillation. AMSA values were calculated after data extraction from the monitors/defibrillators used in the field by using a 2-s pre-shock electrocardiogram interval. The first detected AMSA value, the maximum value, the average value, and the minimum value were computed, and their outcome prediction accuracy was compared. Multivariable Cox regression models were run for both 30-day and 1-year deaths or poor neurological outcomes. Neurological cerebral performance category 1-2 was considered a good neurological outcome. Results: Out of the 578 patients included, 494 (85%) died and 10 (2%) had a poor neurological outcome at 30 days. All the AMSA values considered (first value, maximum, average, and minimum) were significantly higher in survivors with good neurological outcome at 30 days. The average AMSA showed the highest area under the receiver operating characteristic curve (0.778, 95% CI: 0.7-0.8, p < 0.001). After correction for confounders, the highest tertiles of average AMSA (T3 and T2) were significantly associated with a lower risk of death or poor neurological outcome compared with T1 both at 30 days (T2: HR 0.6, 95% CI: 0.4-0.9, p = 0.01; T3: HR 0.6, 95% CI: 0.4-0.9, p = 0.02) and at 1 year (T2: HR 0.6, 95% CI: 0.4-0.9, p = 0.01; T3: HR 0.6, 95% CI: 0.4-0.9, p = 0.01). Among survivors at 30 days, a higher AMSA was associated with a lower risk of mortality or poor neurological outcome at 1 year (T3: HR 0.03, 95% CI: 0-0.3, p = 0.02). Discussion: Lower AMSA values were significantly and independently associated with the risk of death or poor neurological outcome at 30 days and at 1 year in OHCA patients with either an initial shockable rhythm or a conversion rhythm from non-shockable to shockable. The average AMSA value had the strongest association with prognosis.

Amplitude spectral area of ventricular fibrillation and defibrillation success at low energy in out-of-hospital cardiac arrest.

The optimal energy for defibrillation has not yet been identified and very often the maximum energy is delivered. We sought to assess whether amplitude spectral area (AMSA) of ventricular fibrillation (VF) could predict low energy level defibrillation success in out-of-hospital cardiac arrest (OHCA) patients. This is a multicentre international study based on retrospective analysis of prospectively collected data. We included all OHCAs with at least one manual defibrillation. AMSA values were calculated by analyzing the data collected by the monitors/defibrillators used in the field (Corpuls 3 and Lifepak 12/15) and using a 2-s-pre-shock electrocardiogram interval. We run two different analyses dividing the shocks into three tertiles (T1, T2, T3) based on AMSA values. 629 OHCAs were included and 2095 shocks delivered (energy ranging from 100 to 360 J; median 200 J). Both in the "extremes analysis" and in the "by site analysis", the AMSA values of the effective shocks at low energy were significantly higher than those at high energy (p = 0.01). The likelihood of shock success increased significantly from the lowest to the highest tertile. After correction for age, call to shock time, use of mechanical CPR, presence of bystander CPR, sex and energy level, high AMSA value was directly associated with the probability of shock success [T2 vs T1 OR 3.8 (95% CI 2.5-6) p < 0.001; T3 vs T1 OR 12.7 (95% CI 8.2-19.2), p < 0.001]. AMSA values are associated with the probability of low-energy shock success so that they could guide energy optimization in shockable cardiac arrest patients.

Use of Mechanical Chest Compression for Resuscitation in Out-Of-Hospital Cardiac Arrest-Device Matters: A Propensity-Score-Based Match Analysis.

BACKGROUND: Devices for mechanical cardiopulmonary resuscitation (CPR) are recommended when high quality CPR cannot be provided. Different devices are available, but the literature is poor in direct comparison studies. Our aim was to assess whether the type of mechanical chest compressor could affect the probability of return of spontaneous circulation (ROSC) and 30-day survival in Out-of-Hospital Cardiac Arrest (OHCA) patients as compared to manual standard CPR. METHODS: We considered all OHCAs that occurred from 1 January 2015 to 31 December 2022 in seven provinces of the Lombardy region equipped with three different types of mechanical compressor: Autopulse®(ZOLL Medical, MA), LUCAS® (Stryker, MI), and Easy Pulse® (Schiller, Switzerland). RESULTS: Two groups, 2146 patients each (manual and mechanical CPR), were identified by propensity-score-based random matching. The rates of ROSC (15% vs. 23%, p < 0.001) and 30-day survival (6% vs. 14%, p < 0.001) were lower in the mechanical CPR group. After correction for confounders, Autopulse® [OR 2.1, 95%CI (1.6-2.8), p < 0.001] and LUCAS® [OR 2.5, 95%CI (1.7-3.6), p < 0.001] significantly increased the probability of ROSC, and Autopulse® significantly increased the probability of 30-day survival compared to manual CPR [HR 0.9, 95%CI (0.8-0.9), p = 0.005]. CONCLUSION: Mechanical chest compressors could increase the rate of ROSC, especially in case of prolonged resuscitation. The devices were dissimilar, and their different performances could significantly influence patient outcomes. The load-distributing-band device was the only mechanical chest able to favorably affect 30-day survival.

aMplitude spectral area of ventricular fibrillation and amiOdarone Study in patients with out-of-hospital cArdIaC arrest. The MOSAIC study.

Objective: Antiarrhythmic drugs are recommended for out of hospital cardiac arrest (OHCA) with shock-refractory ventricular fibrillation (VF). Amplitude Spectral Area (AMSA) of VF is a quantitative waveform measure that describes the amplitude-weighted mean frequency of VF, it correlates with intramyocardial adenosine triphosphate (ATP) concentration, it is a predictor of shock efficacy and an emerging indicator to guide defibrillation and resuscitation efforts. How AMSA might be influenced by amiodarone administration is unknown. Methods: In this international multicentre observational study, all OHCAs receiving at least one shock were included. AMSA values were calculated by retrospectively analysing the pre-shock ECG interval of 2 s. Multivariable models were run and a propensity score based on the probability of receiving amiodarone was created to compare two randomly matched samples. Results: 2,077 shocks were included: 1,407 in the amiodarone group and 670 in the non-amiodarone group. AMSA values were lower in the amiodarone group [8.8 (6-12.7) mV·Hz vs. 9.8 (6-14) mV·Hz, p = 0.035]. In two randomly matched propensity score-based groups of 261 shocks, AMSA was lower in the amiodarone group [8.2 (5.8-13.5) mV·Hz vs. 9.6 (5.6-11.6), p = 0.042]. AMSA was a predictor of shock success in both groups but the predictive power was lower in the amiodarone group [Area Under the Curve (AUC) non-amiodarone group 0.812, 95%CI: 0.78-0.841 vs. AUC amiodarone group 0.706, 95%CI: 0.68-0.73; p < 0.001]. Conclusions: Amiodarone administration was independently associated with the probability of recording lower values of AMSA. In patients who have received amiodarone during cardiac arrest the predictive value of AMSA for shock success is significantly lower, but still statistically significant.

End-tidal carbon dioxide (ETCO2) at intubation and its increase after 10 minutes resuscitation predicts survival with good neurological outcome in out-of-hospital cardiac arrest patients.

AIM: To evaluate whether end-tidal carbon dioxide (ETCO2) value at intubation and its early increase (10 min) after intubation predict both the survival to hospital admission and the survival at hospital discharge, including good neurological outcome (CPC 1-2), in patients with out-of-hospital cardiac arrest (OHCA). METHODS: All consecutive OHCA patients of any etiology between 2015 and 2018 in Pavia Province (Italy) and Ticino Region (Switzerland) were considered. Patients died before ambulance arrival, with a "do-not-resuscitate" order, without ETCO2 value or with incomplete data were excluded. RESULTS: The study population consisted of 668 patients. An ETCO2 value at intubation > 20 mmHg and its increase 10 min after intubation were independent predictors (after correction for known predictors of OHCA outcome) of survival to hospital admission and survival at hospital discharge. Relative to hospital discharge with good neurological outcome, ETCO2 at intubation and its 10-min change were confirmed predictors both individually and in a bivariable analysis (OR 1.83, 95 %CI 1.02-3.3; p = 0.04 and OR 3.9, 95 %CI 1.97-7.74; p < 0.001, respectively). This was confirmed also when accounting for gender, age, etiology and location. After further adjustment for bystander and CPR status, presenting rhythm and EMS arrival time, the ETCO2 change remained an independent predictor. CONCLUSIONS: ETCO2 value > 20 mmHg at intubation and its increase during resuscitation improve the prediction of survival at hospital discharge with good neurological outcome of OHCA patients. ETCO2 increase during resuscitation is a more powerful predictor than ETCO2 at intubation. A larger prospective study to confirm this finding appears warranted.

Relationship between out-of-hospital cardiac arrests and COVID-19 during the first and second pandemic wave. The importance of monitoring COVID-19 incidence.

BACKGROUND: The relationship between COVID-19 and out-of-hospital cardiac arrests (OHCAs) has been shown during different phases of the first pandemic wave, but little is known about how to predict where cardiac arrests will increase in case of a third peak. AIM: To seek for a correlation between the OHCAs and COVID-19 daily incidence both during the two pandemic waves at a provincial level. METHODS: We considered all the OHCAs occurred in the provinces of Pavia, Lodi, Cremona, Mantua and Varese, in Lombardy Region (Italy), from 21/02/2020 to 31/12/2020. We divided the study period into period 1, the first 157 days after the outbreak and including the first pandemic wave and period 2, the second 158 days including the second pandemic wave. We calculated the cumulative and daily incidence of OHCA and COVID-19 for the whole territory and for each province for both periods. RESULTS: A significant correlation between the daily incidence of COVID-19 and the daily incidence of OHCAs was observed both during the first and the second pandemic period in the whole territory (R = 0.4, p<0.001 for period 1 and 2) and only in those provinces with higher COVID-19 cumulative incidence (period 1: Cremona R = 0.3, p = 0.001; Lodi R = 0.4, p<0.001; Pavia R = 0.3; p = 0.01; period 2: Varese R = 0.4, p<0.001). CONCLUSIONS: Our results suggest that strictly monitoring the pandemic trend may help in predict which territories will be more likely to experience an OHCAs' increase. That may also serve as a guide to re-allocate properly health resources in case of further pandemic waves.

Peripheral perfusion index and diagnostic accuracy of the post-ROSC electrocardiogram in patients with medical out-of-hospital cardiac arrest.

AIM: A 12-lead electrocardiogram (ECG) after the return of spontaneous circulation (ROSC) is recommended to diagnose a ST-segment elevation myocardial infarction (STEMI). In the early post-ROSC phase, the ECG can show signs of ischemia not necessarily of coronary origin and post-ROSC hypoperfusion could affect ECG reliability. We sought for an association between peripheral perfusion index (PI) values after ROSC and the percentage of false-positive ECG for STEMI. METHODS: We considered all the consecutive patients with sustained ROSC after OHCA, admitted to the Fondazione IRCCS Policlinico San Matteo (Pavia) between January 1st, 2015 and December 31st, 2020. ECGs were defined false-positive if meeting the STEMI criteria but without a critical obstructive coronary artery disease worthy of treatment. The mean value of PI over 30 min-monitoring (MPI30) were calculated. RESULTS: Among 351 eligible patients post-ROSC ECG, PI monitoring and an invasive coronary angiography (ICA) were available in 84 cases. The rate of false positive was 16/54 (29.6%) and it differed significantly in the three MPI30 tertiles [T1 (0.2-1): 28.6%; T2 (1.1-2.5): 24.1%; T3 (2.6-6.9): 3.7%, p = 0.04; p for trend = 0.02]. Cardiac arrest duration [OR 1.06 (95 %CI 1-1.1), p = 0.007] and MPI30 [T3 vs T1: OR 0.09 (95 %CI 0.01-0.8), p = 0.03] were significantly associated with the probability of acquiring a false-positive ECG. This association was also confirmed when MPI30 was adjusted for cardiac arrest duration [OR 0.2 (95 %CI 0.1-0.6), p=<0.001]. CONCLUSIONS: The rate of false-positive ECG for STEMI after ROSC is related with low perfusion. Our results could help to identify the adequate candidates for an immediate ICA.

Physical activity and quality of cardiopulmonary resuscitation: A secondary analysis of the MANI-CPR trial.

INTRODUCTION: The association between the level of physical activity and quality of cardio-pulmonary resuscitation (CPR) performed by laypeople is unclear. The aim of this study was to evaluate the associations between physical activity level and laypeople performance during an eight-minute scenario of CPR. MATERIALS AND METHODS: This study was a secondary analysis of the MANI-CPR Trial. The entire cohort of participants was grouped based on the level of physical activity assessed using the International Physical Activity Questionnaire (IPAQ) into a "low-moderate" level group and a "high" level group. Descriptive statistics were used for unadjusted analysis and multivariate logistic and linear regression models were also performed. RESULTS: A total of 492 participants who reached the score of "Advanced CPR performer" at the 1-min final test monitored by Laerdal Resusci Anne QCPR were included in this analysis; 224 with a low-moderate level and 268 with a high level of physical activity. A statistically significant difference was found for the outcome of percentage of compressions with adequate depth (low-moderate group: 87.8% [41·4%-99·3%], high group: 97% [63·2%-100%]; P = 0·003). No associations remained significant after controlling for biometric characteristics of the participants, compression protocols and sex. CONCLUSION: Adequate quality CPR may not need high baseline level of physical activity to be performed by a lay rescuer.

Out-of-hospital cardiac arrest and ambient air pollution: A dose-effect relationship and an association with OHCA incidence.

BACKGROUND: Pollution has been suggested as a precipitating factor for cardiovascular diseases. However, data about the link between air pollution and the risk of out-of-hospital cardiac arrest (OHCA) are limited and controversial. METHODS: By collecting data both in the OHCA registry and in the database of the regional agency for environmental protection (ARPA) of the Lombardy region, all medical OHCAs and the mean daily concentration of pollutants including fine particulate matter (PM10, PM2.5), benzene (C6H6), carbon monoxide (CO), nitrogen dioxide (NO2), sulphur dioxide (SO2), and ozone (O3) were considered from January 1st to December 31st, 2019 in the southern part of the Lombardy region (provinces of Pavia, Lodi, Cremona and Mantua; 7863 km2; about 1550000 inhabitants). Days were divided into high or low incidence of OHCA according to the median value. A Probit dose-response analysis and both uni- and multivariable logistic regression models were provided for each pollutant. RESULTS: The concentrations of all the pollutants were significantly higher in days with high incidence of OHCA except for O3, which showed a significant countertrend. After correcting for temperature, a significant dose-response relationship was demonstrated for all the pollutants examined. All the pollutants were also strongly associated with high incidence of OHCA in multivariable analysis with correction for temperature, humidity, and day-to-day concentration changes. CONCLUSIONS: Our results clarify the link between pollutants and the acute risk of cardiac arrest suggesting the need of both improving the air quality and integrating pollution data in future models for the organization of emergency medical services.

A Multicenter International Randomized Controlled Manikin Study on Different Protocols of Cardiopulmonary Resuscitation for Laypeople: The MANI-CPR Trial.

BACKGROUND: Compression-only cardiopulmonary resuscitation (CPR) is a suggested technique for laypeople facing out-of-hospital cardiac arrest (OHCA). However, it is difficult performing high-quality CPR until emergency medical services arrival with this technique. We aimed to verify whether incorporating intentional interruptions of different frequency and duration increases laypeople's CPR quality during an 8-minute scenario compared with compression-only CPR. METHODS: We performed a multicenter randomized manikin study selecting participants from 2154 consecutive laypeople who followed a basic life support/automatic external defibrillation course. People who achieved high-quality CPR in 1-minute test on a computerized manikin were asked to participate. Five hundred seventy-six were enrolled, and 59 were later excluded for technical reasons or incorrect test recording. Participants were randomized in an 8-minute OHCA scenario using 3 CPR protocols (30 compressions and 2-second pause, 30c2s; 50 compressions and 5-second pause, 50c5s; 100 compressions and 10-second pause, 100c10s) or compression-only technique. The main outcome was the percentage of chest compressions with adequate depth. RESULTS: Five hundred seventeen participants were evaluated. There was a statistically significant difference regarding the percentage of compressions with correct depth among the groups (30c2s, 96%; 50c5s, 96%; 100c10s, 92%; compression only, 79%; P = 0.006). Post hoc comparison showed a significant difference for 30c2s (P = 0.023) and for 50c5s (P = 0.003) versus compression only. Regarding secondary outcome, there were a higher chest compression fraction in the compression-only group and a higher rate of pauses longer than 10 seconds in the 100c10s. CONCLUSIONS: In a simulated OHCA, 30c2s and 50c5s protocols were characterized by a higher rate of chest compressions with correct depth than compression only. This could have practical consequences in laypeople CPR training and recommendations.Clinical Trial Registration: NCT02632500.

Post-ROSC peripheral perfusion index discriminates 30-day survival after out-of-hospital cardiac arrest.

BACKGROUND: Prognostication after an out-of-hospital cardiac arrest (OHCA) remains a challenge. The peripheral-derived perfusion index (PI) is a simple and non-invasive way to assess perfusion. We sought to assess whether the PI was able to discriminate the prognosis of patients resuscitated from an OHCA. METHODS: All the reports generated by the manual monitor/defibrillator (Corpuls 3 by GS Elektromedizinische Geräte G. Stemple GmbH, Germany) used for all the OHCAs who achieved ROSC treated by our Emergency Medical Service from January 2015 to December 2018 were reviewed. The mean PI value of each minute after ROSC was automatically provided by the device and the mean value of 30 min of monitoring (MPI30) was calculated. Pre-hospital data were collected according to the Utstein 2014 recommendations. RESULTS: Among 1,909 resuscitation attempts, ROSC was achieved in 346 and it was possible to calculate an MPI30 in 164. MPI30 was higher in the patients who survived at 30 days [1.6 (95% CI 1.2-2.1) vs 1 (95% CI 0.8-1.3), p = 0.0017]. At the multivariable Cox regression model, after correction for shockable rhythm, witnessed status, bystander CPR, age, and blood pressure, MPI30 was found to be an independent predictor of both 30-day mortality [RR 0.83 (95% CI 0.69-0.99), p = 0.036] and 30-day mortality or poor neurologic outcome [RR 0.85 (95% CI 0.72-0.99), p = 0.04]. Overall 30-day survival with good neurologic outcome was significantly different in the three tertiles [T1: 0.1-0.8; T2: 0.9-1.8 and T3: 1.82-7.8, log-rank p = 0.007]. CONCLUSION: The post-ROSC peripheral perfusion index was found to be an independent predictor of 30-day mortality or poor neurologic outcome. It could help prognostication in OHCA patients.

End-tidal carbon dioxide (ETCO2) and ventricular fibrillation amplitude spectral area (AMSA) for shock outcome prediction in out-of-hospital cardiac arrest. Are they two sides of the same coin?

AIM: Ventricular fibrillation amplitude spectral area (AMSA) and end-tidal carbon dioxide (ETCO2) are predictors of shock success, understood as restoration of an organized rhythm, and return of spontaneous circulation (ROSC). However, little is known about their combined use. We aimed to assess the prediction accuracy when combined, and to clarify if they are correlated in out of hospital cardiac arrest' victims. MATERIALS AND METHODS: Records acquired by external defibrillators in out-of-hospital cardiac arrest patients of the Lombardia Cardiac Arrest registry were processed. The 1-min pre-shock ETCO2 median value (METCO2) was computed from the capnogram and AMSA (2-48 mV.Hz range) computed applying the Fast Fourier Transform to a 2-second pre-shock filtered ECG interval (0.5-30 Hz). Support Vector Machine (SVM) predictive models based on METCO2, AMSA and their combination were fit; results were given as the area under the curve (AUC) of the receiver operating characteristic (ROC) curves. RESULTS: We considered 112 patients with 391 shocks delivered. METCO2 and AMSA were predictors of shock success [AUC (IQR) of the ROC curve: 0.59 (0.56-0.62); 0.68 (0.65-0.72), respectively] and of ROSC [0.56 (0.53-0.59); 0.74 (0.71-0.78),]. Their combination in a SVM model increased the accuracy for predicting shock success [AUC (IQR) of the ROC curve: 0.71 (0.68-0.75)] and ROSC [0.77 (0.73-0.8)]. AMSA and METCO2 were significantly correlated only in patients who achieved ROSC (rho = 0.33 p = 0.03). CONCLUSIONS: AMSA and ETCO2 predict shock success and ROSC after every shock, and their predictive power increases if combined. Notably, they were correlated only in patients who achieved ROSC.

Treatment of out-of-hospital cardiac arrest in the COVID-19 era: A 100 days experience from the Lombardy region.

INTRODUCTION: An increase in the incidence of OHCA during the COVID-19 pandemic has been recently demonstrated. However, there are no data about how the COVID-19 epidemic influenced the treatment of OHCA victims. METHODS: We performed an analysis of the Lombardia Cardiac Arrest Registry comparing all the OHCAs occurred in the Provinces of Lodi, Cremona, Pavia and Mantua (northern Italy) in the first 100 days of the epidemic with those occurred in the same period in 2019. RESULTS: The OHCAs occurred were 694 in 2020 and 520 in 2019. Bystander cardiopulmonary resuscitation (CPR) rate was lower in 2020 (20% vs 31%, p<0.001), whilst the rate of bystander automated external defibrillator (AED) use was similar (2% vs 4%, p = 0.11). Resuscitation was attempted by EMS in 64.5% of patients in 2020 and in 72% in 2019, whereof 45% in 2020 and 64% in 2019 received ALS. At univariable analysis, the presence of suspected/confirmed COVID-19 was not a predictor of resuscitation attempt. Age, unwitnessed status, non-shockable presenting rhythm, absence of bystander CPR and EMS arrival time were independent predictors of ALS attempt. No difference regarding resuscitation duration, epinephrine and amiodarone administration, and mechanical compression device use were highlighted. The return of spontaneous circulation (ROSC) rate at hospital admission was lower in the general population in 2020 [11% vs 20%, p = 0.001], but was similar in patients with ALS initiated [19% vs 26%, p = 0.15]. Suspected/confirmed COVID-19 was not a predictor of ROSC at hospital admission. CONCLUSION: Compared to 2019, during the 2020 COVID-19 outbreak we observed a lower attitude of laypeople to start CPR, while resuscitation attempts by BLS and ALS staff were not influenced by suspected/confirmed infection, even at univariable analysis.

Emergency Department and Out-of-Hospital Emergency System (112-AREU 118) integrated response to Coronavirus Disease 2019 in a Northern Italy centre.

Since December 2019, the world has been facing the life-threatening disease, named Coronavirus disease-19 (COVID-19), recognized as a pandemic by the World Health Organization. The response of the Emergency Medicine network, integrating "out-of-hospital" and "hospital" activation, is crucial whenever the health system has to face a medical emergency, being caused by natural or human-derived disasters as well as by a rapidly spreading epidemic outbreak. We here report the Pavia Emergency Medicine network response to the COVID-19 outbreak. The "out-of-hospital" response was analysed in terms of calls, rescues and missions, whereas the "hospital" response was detailed as number of admitted patients and subsequent hospitalisation or discharge. The data in the first 5 weeks of the Covid-19 outbreak (February 21-March 26, 2020) were compared with a reference time window referring to the previous 5 weeks (January 17-February 20, 2020) and with the corresponding historical average data from the previous 5 years (February 21-March 26). Since February 21, 2020, a sudden and sustained increase in the calls to the AREU 112 system was noted (+ 440%). After 5 weeks, the number of calls and missions was still higher as compared to both the reference pre-Covid-19 period (+ 48% and + 10%, respectively) and the historical control (+ 53% and + 22%, respectively). Owing to the overflow from the neighbouring hospitals, which rapidly became overwhelmed and had to temporarily close patient access, the population served by the Pavia system more than doubled (from 547.251 to 1.135.977 inhabitants, + 108%). To minimize the possibility of intra-hospital spreading of the infection, a separate "Emergency Department-Infective Disease" was created, which evaluated 1241 patients with suspected infection (38% of total ED admissions). Out of these 1241 patients, 58.0% (n = 720) were admitted in general wards (n = 629) or intensive care unit (n = 91). To allow this massive number of admissions, the hospital reshaped many general ward Units, which became Covid-19 Units (up to 270 beds) and increased the intensive care unit beds from 32 to 60. In the setting of a long-standing continuing emergency like the present Covid-19 outbreak, the integration, interaction and team work of the "out-of-hospital" and "in-hospital" systems have a pivotal role. The present study reports how the rapid and coordinated reorganization of both might help in facing such a disaster. AREU-112 and the Emergency Department should be ready to finely tune their usual cooperation to respond to a sudden and overwhelming increase in the healthcare needs brought about by a pandemia like the current one. This lesson should shape and reinforce the future.

COVID-19 kills at home: the close relationship between the epidemic and the increase of out-of-hospital cardiac arrests.

AIMS: An increase in out-of-hospital cardiac arrest (OHCA) incidence has been reported in the very early phase of the COVID-19 epidemic, but a clear demonstration of a correlation between the increased incidence of OHCA and COVID-19 is missing so far. We aimed to verify whether there is an association between the OHCA difference compared with 2019 and the COVID-19 epidemic curve. METHODS AND RESULTS: We included all the consecutive OHCAs which occurred in the Provinces of Lodi, Cremona, Pavia, and Mantova in the 2 months following the first documented case of COVID-19 in the Lombardia Region and compared them with those which occurred in the same time frame in 2019. The cumulative incidence of COVID-19 from 21 February to 20 April 2020 in the study territory was 956 COVID-19/100 000 inhabitants and the cumulative incidence of OHCA was 21 cases/100 000 inhabitants, with a 52% increase as compared with 2019 (490 OHCAs in 2020 vs. 321 in 2019). A strong and statistically significant correlation was found between the difference in cumulative incidence of OHCA between 2020 and 2019 per 100 000 inhabitants and the COVID-19 cumulative incidence per 100 000 inhabitants both for the overall territory (ρ 0.87, P < 0.001) and for each province separately (Lodi: ρ 0.98, P < 0.001; Cremona: ρ 0.98, P < 0.001; Pavia: ρ 0.87, P < 0.001; Mantova: ρ 0.81, P < 0.001). CONCLUSION: The increase in OHCAs in 2020 is significantly correlated to the COVID-19 pandemic and is coupled with a reduction in short-term outcome. Government and local health authorities should seriously consider our results when planning healthcare strategies to face the epidemic, especially considering the expected recurrent outbreaks.

Extracorporeal membrane oxygenation for refractory cardiac arrest: a retrospective multicenter study.

PURPOSE: The aim of this study was to assess the neurologic outcome following extracorporeal cardiopulmonary resuscitation (ECPR) in five European centers. METHODS: Retrospective database analysis of prospective observational cohorts of patients undergoing ECPR (January 2012-December 2016) was performed. The primary outcome was 3-month favorable neurologic outcome (FO), defined as the cerebral performance categories of 1-2. Survival to ICU discharge and the number of patients undergoing organ donation were secondary outcomes. A subgroup of patients with stringent selection criteria (i.e., age ≤ 65 years, witnessed bystander CPR, no major co-morbidity and ECMO implemented within 1 h from arrest) was also analyzed. RESULTS: A total of 423 patients treated with ECPR were included (median age 57 [48-65] years; male gender 78%); ECPR was initiated for OHCA in 258 (61%) patients. Time from arrest to ECMO implementation was 65 [48-84] min. Eighty patients (19%) had favorable neurological outcome. ICU survival was 24% (n = 102); 23 (5%) non-survivors underwent organ donation procedures. Favorable neurological outcome rate was lower (9% vs. 34%, p < 0.01) in out-of-hospital than in-hospital cardiac arrest and was significantly associated with shorter time from collapse to ECMO. The application of stringent ECPR criteria (n = 105) resulted in 38% of patients with favorable neurologic outcome. CONCLUSIONS: ECPR was associated with intact neurological recovery in 19% of unselected cardiac arrest victims, with 38% favorable outcome if stringent selection criteria would have been applied.