Intracranial Intraosseous Catheter Placement to Temporize an Epidural Hematoma.

Acute epidural hematomas can lead to rapid neurologic decompensation and death. Epidural hematomas may require emergency surgical clot removal, but many patients live far away from a trauma center. This case report describes a pediatric patient with an acute epidural hematoma with significant neurologic compromise who initially presented to a nontrauma center. The emergency department (ED) had no neurosurgeon or equipment to perform burr hole craniostomy. The emergency physician at the nontrauma ED inserted an intraosseous catheter intracranially to temporarily decompress the hematoma due to long transport times. The patient survived with complete neurologic recovery. This is the youngest known patient in whom an intraosseous catheter was used to drain an intracranial hematoma.

Interhospital variability in Out-of-Hospital cardiac arrest survival in a large metropolitan area.

Background: Out-of-hospital cardiac arrest (OHCA) survival varies widely across the United States. The impact of hospital OHCA volume and ST-elevation myocardial infarction (STEMI) Receiving Center (SRC) designation on survival is not fully understood. Methods: This was a retrospective analysis of adult OHCA who survived to hospital admission reported to the Chicago Cardiac Arrest Registry to Enhance Survival (CARES) database from May 1, 2013 to December 31, 2019. Hierarchical logistic regression models were generated and adjusted by hospital characteristics. Survival to hospital discharge (SHD) and cerebral performance category (CPC) 1-2 at each hospital were calculated after adjusting for arrest characteristics. Hospitals were assigned quartiles (Q1-Q4) based on total arrest volume to allow for comparison of SHD and CPC 1-2 between quartiles. Results: 4,020 patients met inclusion criteria. 21 of the 33 Chicago hospitals included in this study were designated SRCs. Adjusted SHD and CPC 1-2 rates ranged from 27.3% to 37.0% and from 8.9% to 25.1%, respectively, by hospital. SRC designation did not significantly affect SHD (OR 0.96; 95% CI, 0.71-1.30) nor CPC 1-2 (OR 1.17; 95% CI, 0.74-1.84). OHCA volume quartiles did not significantly affect SHD (Q2: OR 0.94; 95% CI, 0.54-1.60; Q3: OR 1.30; 95% CI, 0.78-2.16; Q4: OR 1.25; 95% CI, 0.74-2.10) nor CPC 1-2 (Q2: OR 0.75; 95% CI, 0.36-1.54; Q3: OR 0.94; 95% CI, 0.48-1.87; Q4: OR 0.97; 95% CI, 0.48-1.97). Conclusion: Interhospital variability in both SHD and CPC 1-2 cannot be explained by hospital arrest volume nor SRC status. Further research is warranted to explore reasons for interhospital variability.

A comparison between sudden cardiac arrest on military bases and non-military settings.

INTRODUCTION: Out-of-hospital cardiac arrests contribute to significant morbidity and mortality in both non-military/civilian and military populations. Early CPR and AED use have been linked with improved outcomes. There is public health interest in identifying communities with high rates of both with the hopes of creating generalizable tactics for improving cardiac arrest survival. METHODS: We examined a national registry of EMS activations in the United States (NEMSIS). Inclusion criteria were witnessed cardiac arrests from January 2020 to September 2022 where EMS providers documented the location of the arrest, whether CPR was provided prior to their arrival (yes/no), and whether an AED was applied prior to their arrival (yes/no). Cardiac arrests were then classified as occurring on a military base or in a non-military setting. RESULTS: A total of 60 witnessed cardiac arrests on military bases and 202,605 witnessed cardiac arrests in non-military settings met inclusion criteria. Importantly, the prevalence of CPR and AED use prior to EMS arrival was significantly higher on military bases compared to non-military settings. CONCLUSIONS: Reasons for the trends we observed may be a greater availability of CPR-trained individuals and AEDs on military bases, as well as a widespread willingness to provide aid to victims of cardiac arrest. Further research should examine cardiac arrests on military bases.

Utilizing community level factors to improve prediction of out of hospital cardiac arrest outcome using machine learning.

OBJECTIVES: To evaluate the impact of community level information on the predictability of out-of-hospital cardiac arrest (OHCA) survival. METHODS: We used the Cardiac Arrest Registry to Enhance Survival (CARES) to geocode 9,595 Chicago incidents from 2014 to 2019 into community areas. Community variables including crime, healthcare, and economic factors from public data were merged with CARES. The merged data were used to develop ML models for OHCA survival. Models were evaluated using Area Under the Receiver Operating Characteristic curve (AUROC) and features were analyzed using SHapley Additive exPansion (SHAP) values. RESULTS: Baseline results using CARES data achieved an AUROC of 84%. The final model utilizing community variables increased the AUROC to 88%. A SHAP analysis between high and low performing community area clusters showed the high performing cluster is positively impacted by good health related features and good community safety features positively impact the low performing cluster. CONCLUSION: Utilizing community variables helps predict neurologic outcomes with better performance than only CARES data. Future studies will use this model to perform simulations to identify interventions to improve OHCA survival.

A machine learning approach for modeling decisions in the out of hospital cardiac arrest care workflow.

BACKGROUND: A growing body of research has shown that machine learning (ML) can be a useful tool to predict how different variable combinations affect out-of-hospital cardiac arrest (OHCA) survival outcomes. However, there remain significant research gaps on the utilization of ML models for decision-making and their impact on survival outcomes. The purpose of this study was to develop ML models that effectively predict hospital's practice to perform coronary angiography (CA) in adult patients after OHCA and subsequent neurologic outcomes. METHODS: We utilized all (N = 2398) patients treated by the Chicago Fire Department Emergency Medical Services included in the Cardiac Arrest Registry to Enhance Survival (CARES) between 2013 and 2018 who survived to hospital admission to develop, test, and analyze ML models for decisions after return of spontaneous circulation (ROSC) and patient survival. ML classification models, including the Embedded Fully Convolutional Network (EFCN) model, were compared based on their ability to predict post-ROSC decisions and survival. RESULTS: The EFCN classification model achieved the best results across tested ML algorithms. The area under the receiver operating characteristic curve (AUROC) for CA and Survival were 0.908 and 0.896 respectively. Through cohort analyses, our model predicts that 18.3% (CI 16.4-20.2) of patients should receive a CA that did not originally, and 30.1% (CI 28.5-31.7) of these would experience improved survival outcomes. CONCLUSION: ML modeling effectively predicted hospital decisions and neurologic outcomes. ML modeling may serve as a quality improvement tool to inform system level OHCA policies and treatment protocols.

Large urban center improves out-of-hospital cardiac arrest survival.

BACKGROUND: Large cities pose unique challenges that limit the effectiveness of system improvement interventions. Successful implementation of integrated cardiac resuscitation systems of care can serve as a model for other urban centers. METHODS: This was a retrospective analysis of prospectively collected data of adult cases of non-traumatic cardiac arrest who received treatment by Chicago Fire Department EMS from September 1, 2013 through December 31, 2016. We measured temporal OHCA outcomes during implementation of system-wide initiatives including telephone-assisted and community CPR training programs; high performance CPR and team based simulation training; new post resuscitation care and destination protocols; and case review for EMS providers. Outcomes measured included bystander CPR rates, return of spontaneous circulation (ROSC), hospital admission and survival, and favorable neurologic outcomes (CPC 1-2). Relative risk was determined by logistic regression model where observed group-specific outcomes are expressed as odds ratios (OR). RESULTS: We included 6103 adult OHCA cases occurring outside of health care facilities from September 1, 2013 through December 31, 2016. Significantly improved outcomes (p < 0.05) were observed between 2013 and 2016 for bystander CPR (11.6% vs 19.4%), ROSC (28.6% vs 36.9%), hospital admission (22.5% vs 29.4%), survival (7.3% vs 9.9%), and CPC 1-2 (4.3% vs 6.4%). Utstein survival increased from 16.3%-35.4% and CPC 1-2 survival from 11.6%-29.1% (p < 0.05). After adjustment for OHCA characteristics, survival with CPC 1-2 increased over time (OR 1.15, p = 0.0277). CONCLUSIONS: Densely populated cities with low survival rates can overcome systematic challenges and improve OHCA survival.

Major League Soccer Provides a Captive Audience for Promoting Bystander CPR and AED Use Among Hispanics.

OBJECTIVE: Rates of bystander cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use are lower in Hispanic compared to non-Hispanic white communities. Novel instructional methods that focus on population subgroups most likely to benefit must be explored. The purpose of this study was to determine the feasibility, efficiency, and participant demographics of 10-minute educational intervention on bystander CPR and AED use delivered at a pre-match festival for Major League Soccer (MLS) fans. METHODS: Results are reported with descriptive statistics. The primary outcomes included: (1) Training efficiency index for cardiac arrest (TEICA) defined as persons trained/volunteer hours; (2) cardiac arrest training yield (CATY) defined as percent participation by the target audience; and (3) percent of participants of Hispanic origin. Our secondary outcome was average post intervention knowledge survey score. RESULTS: CATY was 16% and TEICA was 3.81. Survey participation was 48.3% and 38.9% of survey participants were Hispanic. Average knowledge score post training was 87.5%. CONCLUSION: Soccer matches may be a suitable setting for provision of CPR and AED training to Hispanics. This intervention gives insight into a novel way of providing health education to Hispanics that can be applied to other behaviors.

Implementing a STEMI system of care in urban Bangalore: Rationale and Study Design for heart rescue India.

BACKGROUND: A system of care designed to measure and improve process measures such as symptom recognition, emergency response, and hospital care has the potential to reduce mortality and improve quality of life for patients with ST-elevation myocardial infarction (STEMI). OBJECTIVE: To document the methodology and rationale for the implementation and impact measurement of the Heart Rescue India project on STEMI morbidity and mortality in Bangalore, India. STUDY DESIGN: A hub and spoke STEMI system of care comprised of two interventional, hub hospitals and five spoke hospitals will build and deploy a dedicated emergency response and transport system covering a 10 Km. radius area of Bangalore, India. High risk patients will receive a dedicated emergency response number to call for symptoms of heart attack. A dedicated operations center will use geo-tracking strategies to optimize response times including first responder motor scooter transport, equipped with ECG machines to transmit ECG's for immediate interpretation and optimal triage. At the same time, a dedicated ambulance will be deployed for transport of appropriate STEMI patients to a hub hospital while non-STEMI patients will be transported to spoke hospitals. To enhance patient recognition and initiation of therapy, school children will be trained in basic CPR and signs and symptom of chest pain. Hub hospitals will refine their emergency department and cardiac catheterization laboratory protocols using continuous quality improvement techniques to minimize treatment delays. Prior to hospital discharge, secondary prevention measures will be initiated to enhance long-term patient outcomes.

Pay It Forward: High School Video-based Instruction Can Disseminate CPR Knowledge in Priority Neighborhoods.

INTRODUCTION: The implementation of creative new strategies to increase layperson cardiopulmonary resuscitation (CPR) and defibrillation may improve resuscitation in priority populations. As more communities implement laws requiring CPR training in high schools, there is potential for a multiplier effect and reach into priority communities with low bystander-CPR rates. METHODS: We investigated the feasibility, knowledge acquisition, and dissemination of a high school-centered, CPR video self-instruction program with a "pay-it-forward" component in a low-income, urban, predominantly Black neighborhood in Chicago, Illinois with historically low bystander-CPR rates. Ninth and tenth graders followed a video self-instruction kit in a classroom setting to learn CPR. As homework, students were required to use the training kit to "pay it forward" and teach CPR to their friends and family. We administered pre- and post-intervention knowledge surveys to measure knowledge acquisition among classroom and "pay-it-forward" participants. RESULTS: Seventy-one classroom participants trained 347 of their friends and family, for an average of 4.9 additional persons trained per kit. Classroom CPR knowledge survey scores increased from 58% to 93% (p < 0.0001). The pay-it-forward cohort saw an increase from 58% to 82% (p < 0.0001). CONCLUSION: A high school-centered, CPR educational intervention with a "pay-it-forward" component can disseminate CPR knowledge beyond the classroom. Because schools are centrally-organized settings to which all children and their families have access, school-based interventions allow for a broad reach that encompasses all segments of the population and have potential to decrease disparities in bystander CPR provision.

Save-a-life at the ballpark: 10-min spectator training achieves proficiency in cardiac arrest response.

OBJECTIVE: To determine immediate recall, feasibility, and efficiency of a brief out-of-hospital cardiac arrest (OHCA) bystander response training session at a large sporting event. We introduce two new measures of efficiency for training: (i) cardiac arrest training yield (CATY), i.e., number trained/number of spectators, and (ii) the training efficiency index for cardiac arrest (TEICA), i.e., persons trained per volunteer hours. METHODS: A convenience sample of baseball fans participated in a 10-min training on OHCA recognition, CPR and automatic external defibrillator (AED) use and completed post-training knowledge surveys. RESULTS: Out of 20,000 spectators, 198 participated for a CATY of 1%. Seventy-five volunteers over 3h of training generated a TEICA of 0.88. 90% of respondents identified the proper rate of chest compressions. 90% of respondents recognized an AED's function; 98% recognized it was easy to use. 83% recognized chest compressions as the next step after calling 911 and 62% included AED as part of the OHCA response. CONCLUSIONS: A 10-min training session is feasible and can achieve good recall in cardiac arrest response. However, participant recruitment dominated most of our volunteer effort. Our results can serve as a framework in the development of future health promotion campaigns.

The effects of cold-water immersion on power output and heart rate in elite cyclists.

The purpose of this study was to examine the effects of cold-water immersion on power output, heart rate, and time to peak power in 10 well-trained cyclists. The Compu-trainer Professional Model 8001 computerized stationary trainer was used to evaluate maximum power, average power, and time to peak power during a simulated cycling sprint. The heart rate was measured using a Polar heart rate monitor. Subjects performed 2 maximum-effort sprints (for approximately 30 seconds) separated by either an experimental condition (15 minutes of cold-water immersion at 12 degrees C up to the level of the iliac crest) or a control condition (15 minutes of quiet sitting). All subjects participated under both control and experimental conditions in a counterbalanced design in which 5 subjects performed the experimental condition first and the other 5 subjects performed the control condition first. Each condition was separated by at least 2 days. The time to peak power was not different between the 2 conditions. Maximum and average powers declined by 13.7 and 9.5% for the experimental condition but only by 4.7 and 2.3% for the control condition, respectively. The results also demonstrated a significantly greater decline in maximum heart rate after cold-water immersion (8.1%) than under the control condition (2.4%). Average heart rate showed a decrease of 4.2% under the experimental condition, as compared with an increase of 1.5% under the control condition. The major findings of this study suggest that a relatively brief period of cold-water immersion can manifest significant physiological effects that can impair cycling performance.