When to Stop CPR and When to Perform Rhythm Analysis: Potential Confusion Among ACLS Providers.

BACKGROUND: Health care providers nationwide are routinely trained in Advanced Cardiac Life Support (ACLS), an American Heart Association program that teaches cardiac arrest management. Recent changes in the ACLS approach have de-emphasized routine pulse checks in an effort to promote uninterrupted chest compressions. We hypothesized that this new ACLS algorithm may lead to uncertainty regarding the appropriate action following detection of a pulse during a cardiac arrest. METHODS: We conducted an observational study in which a Web-based survey was sent to ACLS-trained medical providers at 4 major urban tertiary care centers in the United States. The survey consisted of 5 multiple-choice, scenario-based ACLS questions, including our question of interest. Adult staff members with a valid ACLS certification were included. RESULTS: A total of 347 surveys were analyzed. The response rate was 28.1%. The majority (53.6%) of responders were between 18 and 32 years old, and 59.9% were female. The majority (54.2%) of responders incorrectly stated that they would continue CPR and possibly administer additional therapies when a team member detects a pulse immediately following defibrillation. Secondarily, only 51.9% of respondents correctly chose to perform a rhythm check following 2 minutes of CPR. The other 3 survey questions were correctly answered an average of 89.1% of the time. CONCLUSION: Confusion exists regarding whether or not CPR and cardiac medications should be continued in the presence of a pulse. Education may be warranted to emphasize avoiding compressions and medications when a palpable pulse is detected.

The relationship between age and outcome in out-of-hospital cardiac arrest patients.

AIM: To determine the association between age and outcome in a large multicenter cohort of out-of-hospital cardiac arrest patients. METHODS: Retrospective, observational, cohort study of out-of-hospital cardiac arrest from the CARES registry between 2006 and 2013. Age was categorized into 5-year intervals and the association between age group and outcomes (return of spontaneous circulation (ROSC), survival and good neurological outcome) was assessed in univariable and multivariable analysis. We performed a subgroup analysis in patients who had return of spontaneous circulation. RESULTS: A total of 101,968 people were included. The median age was 66 years (quartiles: 54, 78) and 39% were female. 31,236 (30.6%) of the included patients had sustained ROSC, 9761 (9.6%) survived to hospital discharge and 8058 (7.9%) survived with a good neurological outcome. The proportion of patients with ROSC was highest in those with age <20 years (34.1%) and lowest in those with age 95-99 years (23.5%). Patients with age <20 years had the highest proportion of survival (16.7%) and good neurological outcome (14.8%) whereas those with age 95-99 years had the lowest proportion of survival (1.7%) and good neurological outcome (1.2%). In the full cohort and in the patients with ROSC there appeared to be a progressive decline in survival and good neurological outcome after the age of approximately 45-64 years. Age alone was not a good predictor of outcome. CONCLUSIONS: Advanced age is associated with outcomes in out-of-hospital cardiac arrest. We did not identify a specific age threshold beyond which the chance of a meaningful recovery was excluded.

Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: retrospective analysis of large in-hospital data registry.

OBJECTIVE: To determine if earlier administration of epinephrine (adrenaline) in patients with non-shockable cardiac arrest rhythms is associated with increased return of spontaneous circulation, survival, and neurologically intact survival. DESIGN: Post hoc analysis of prospectively collected data in a large multicenter registry of in-hospital cardiac arrests (Get With The Guidelines-Resuscitation). SETTING: We utilized the Get With The Guidelines-Resuscitation database (formerly National Registry of Cardiopulmonary Resuscitation, NRCPR). The database is sponsored by the American Heart Association (AHA) and contains prospective data from 570 American hospitals collected from 1 January 2000 to 19 November 2009. PARTICIPANTS: 119,978 adults from 570 hospitals who had a cardiac arrest in hospital with asystole (55%) or pulseless electrical activity (45%) as the initial rhythm. Of these, 83,490 arrests were excluded because they took place in the emergency department, intensive care unit, or surgical or other specialty unit, 10,775 patients were excluded because of missing or incomplete data, 524 patients were excluded because they had a repeat cardiac arrest, and 85 patients were excluded as they received vasopressin before the first dose of epinephrine. The main study population therefore comprised 25,095 patients. The mean age was 72, and 57% were men. MAIN OUTCOME MEASURES: The primary outcome was survival to hospital discharge. Secondary outcomes included sustained return of spontaneous circulation, 24 hour survival, and survival with favorable neurologic status at hospital discharge. RESULTS: 25,095 adults had in-hospital cardiac arrest with non-shockable rhythms. Median time to administration of the first dose of epinephrine was 3 minutes (interquartile range 1-5 minutes). There was a stepwise decrease in survival with increasing interval of time to epinephrine (analyzed by three minute intervals): adjusted odds ratio 1.0 for 1-3 minutes (reference group); 0.91 (95% confidence interval 0.82 to 1.00; P=0.055) for 4-6 minutes; 0.74 (0.63 to 0.88; P<0.001) for 7-9 minutes; and 0.63 (0.52 to 0.76; P<0.001) for >9 minutes. A similar stepwise effect was observed across all outcome variables. CONCLUSIONS: In patients with non-shockable cardiac arrest in hospital, earlier administration of epinephrine is associated with a higher probability of return of spontaneous circulation, survival in hospital, and neurologically intact survival.

Fever after rewarming: incidence of pyrexia in postcardiac arrest patients who have undergone mild therapeutic hypothermia.

BACKGROUND: Induction of mild therapeutic hypothermia (TH; temperature 32-34°C) has become standard of care in many hospitals for comatose survivors of cardiac arrest. Pyrexia, or fever, is known to be detrimental in patients with neurologic injuries such as stroke or trauma. The incidence of pyrexia in the postrewarming phase of TH is unknown. We attempted to determine the incidence of fever after TH and hypothesized that those patients who were febrile after rewarming would have worse clinical outcomes than those who maintained normothermia in the postrewarming period. METHODS: Retrospective data analysis of survivors of out-of-hospital cardiac arrest (OHCA) over a period of 29 months (December 2007 to April 2010). INCLUSION CRITERIA: OHCA, age >18, return of spontaneous circulation, and treatment with TH. EXCLUSION CRITERIA: traumatic arrest and pregnancy. Data collected included age, sex, neurologic outcome, mortality, and whether the patient developed fever (temperature > 100.4°F, 38°C) within 24 hours after being fully rewarmed to a normal core body temperature after TH. We used simple descriptive statistics and Fisher exact test to report our findings. RESULTS: A total of 149 patients were identified; of these, 82 (55%) underwent TH. The mean age of the TH cohort was 66 years, and 28 (31%) were female. In all, 54 patients survived for >24 hours after rewarming and were included in the analysis. Among the analyzed cohort, 28 (52%) of 54 developed fever within 24 hours after being rewarmed. Outcome measures included in-hospital mortality as well as neurologic outcome as defined by a dichotomized Cerebral Performance Category (CPC) score. When comparing neurologic outcomes between the groups, 16 (57%) of 28 in the postrewarming fever group had a poor outcome (CPC score 3-5), while 15 (58%) of 26 in the no-fever group had a favorable outcome (P = .62). In the fever group, 15 (52%) of 28 died, while in the no-fever group, 14 (54%) of 26 died (P = .62). CONCLUSION: Among a cohort of patients who underwent mild TH after OHCA, more than half of these patients developed pyrexia in the first 24 hours after rewarming. Although there were no significant differences in outcomes between febrile and nonfebrile patients identified in this study, these findings should be further evaluated in a larger cohort. Future investigations may be needed to determine whether postrewarming temperature management will improve the outcomes in this population.

APACHE II scoring to predict outcome in post-cardiac arrest.

INTRODUCTION: Despite advancements in management of cardiac arrest, mortality remains high and few severity of illness scoring systems have been calibrated in this population. The goal of the current investigation was to assess the Acute Physiology and Chronic Health Evaluation II score in post-cardiac arrest. MEASUREMENTS: This is a prospective observational study of adult post-cardiac arrest patients at a tertiary-care center. The primary outcome variable was in-hospital mortality and secondary outcome variable was neurologic outcome. APACHE II scores were used to predict outcomes using logistic modeling. MAIN RESULTS: A total of 228 subjects were included in the analysis. The median age of the cohort was 70 (IQR: 64-71) and 32% (72/228) of the patients were female. The median downtime was 15 min (IQR: 7-27) and initial lactate 5.9 mmol/L (IQR: 3.5-8.4). 71 (57%) of deaths occurred prior to the 72-h follow-up and overall in-hospital mortality was 55% (125/228). Discrimination of APACHE II score in all cardiac arrest patients increased in stepwise fashion from 0-h to 72-h follow-up (AUC: 0-h: 0.62; 24-h: 0.75; 48-h: 0.82; 72-h: 0.86). CONCLUSIONS: APACHE II score is a poor predictor of outcome at time zero for out-of-hospital cardiac arrest (OHCA) post-arrest patients consistent with the original development of the score in the critically ill. For in-hospital cardiac arrest (IHCA) at time zero and for both IHCA and OHCA at 24h and beyond, the APACHE II score was a modest indicator of illness severity and predictor of mortality/neurologic morbidity.

Coenzyme Q10 levels are low and associated with increased mortality in post-cardiac arrest patients.

AIM: Survival after cardiac arrest (CA) is limited by the profound neurologic insult from ischemia-reperfusion injury. Therapeutic options are limited. Previous data suggest a benefit of coenzyme Q(10) (CoQ(10)) in post-arrest patients. We hypothesized that plasma CoQ(10) levels would be low after CA and associated with poorer outcomes. METHODS: Prospective observational study of post-arrest patients presenting to a tertiary care center. CoQ(10) levels were drawn 24h after return of spontaneous circulation (ROSC) and compared to healthy controls. Levels of inflammatory cytokines and biomarkers were analyzed. Primary endpoints were survival to discharge and neurologic status at time of discharge. RESULTS: 23 CA subjects and 16 healthy controls were enrolled. CoQ(10) levels in CA patients (0.28 µmol L(-1), inter-quartile range (IQR): 0.22-0.39) were significantly lower than in controls (0.75 µmol L(-1), IQR: 0.61-1.08, p<0.0001). The mean CoQ(10) level in CA patients who died was significantly lower than in those who survived (0.27 vs 0.47 µmol L(-1), p = 0.007). There was a significant difference in median CoQ(10) level between patients with a good vs poor neurological outcome (0.49 µmol L(-1), IQR: 0.30-0.67 vs 0.27 µmol L(-1), IQR: 0.21-0.30, p = 0.02). CoQ(10) was a statistically significant predictor of poor neurologic outcome (adjusted p = 0.02) and in-hospital mortality (adjusted p = 0.026). CONCLUSION: CoQ(10) levels are low in human subjects with ROSC after cardiac arrest as compared to healthy controls. CoQ(10) levels were lower in those who died, as well as in those with a poor neurologic outcome.

Rapid rewarming of hypothermic patient using arctic sun device.

There are multiple commercially made devices currently available for inducing hypothermia in patients with postcardiac arrest, but whether these devices can be used successfully for rewarming patients suffering from accidental hypothermia remains largely unexplored. We describe a case in which a patient with severe accidental hypothermia secondary to environmental exposure was successfully, safely, and rapidly warmed using a temperature regulation device traditionally used for therapeutic hypothermia (TH) in patients with postcardiac arrest. Clinicians may wish to consider the use of these devices when attempting to warm patients suffering from severe environmental hypothermia.

The development and implementation of cardiac arrest centers.

In the last decade, many regionalized centers for the care of post-cardiac arrest patients (cardiac arrest centers) have all independently developed with a common goal of providing multi-disciplinary and organized care plans for this patient population. The American Heart Association recently issued support for regionalized and organized comprehensive care for post-arrest patients through a position paper as well as the 2010 American Heart Association BLS/ACLS guidelines. This paper outlines the formation, structure, and implementation of four cardiac arrest centers, and also discusses a statewide model of post-arrest center care. This paper may assist other potential clinical sites that are considering or actively developing cardiac arrest centers of their own.