Association Between Defibrillation Using LIFEPAK 15 or ZOLL X Series and Survival Outcomes in Out-of-Hospital Cardiac Arrest: A Nationwide Cohort Study.

BACKGROUND: Defibrillation is essential for achieving return of spontaneous circulation (ROSC) following out-of-hospital cardiac arrest (OHCA) with shockable rhythms. This study aimed to investigate if the type of defibrillator used was associated with ROSC in OHCA. METHODS AND RESULTS: This study included adult patients with OHCA from the Danish Cardiac Arrest Registry from 2016 to 2021 with at least 1 defibrillation by the emergency medical services. We used multivariable logistic regression and a difference-in-difference analysis, including all patients with or without emergency medical services shock to assess the causal inference of using the different defibrillator models (LIFEPAK or ZOLL) for OHCA defibrillation. Among 6516 patients, 77% were male, the median age (quartile 1; quartile 3) was 70 (59; 79), and 57% achieved ROSC. In total, 5514 patients (85%) were defibrillated using LIFEPAK (ROSC: 56%) and 1002 patients (15%) were defibrillated using ZOLL (ROSC: 63%). Patients defibrillated using ZOLL had an increased adjusted odds ratio (aOR) for ROSC compared with LIFEPAK (aOR, 1.22 [95% CI, 1.04-1.43]). There was no significant difference in 30-day mortality (aOR, 1.11 [95% CI, 0.95-1.30]). Patients without emergency medical services defibrillation, but treated by ZOLL-equipped emergency medical services, had a nonsignificant aOR for ROSC compared with LIFEPAK (aOR, 1.10 [95% CI, 0.99-1.23]) and the difference-in-difference analysis was not statistically significant (OR, 1.10 [95% CI, 0.91-1.34]). CONCLUSIONS: Defibrillation using ZOLL X Series was associated with increased odds for ROSC compared with defibrillation using LIFEPAK 15 for patients with OHCA. However, a difference-in-difference analysis suggested that other factors may be responsible for the observed association.

Sleep apnea, the risk of out-of-hospital cardiac arrest, and potential benefits of continuous positive airway pressure therapy: A nationwide study.

OBJECTIVE: Patients with sleep apnea (SA) are at increased cardiovascular risk. However, little is known about the risk of out-of-hospital cardiac arrest (OHCA) in patients with SA. Therefore, we studied the relation between SA patients who did and did not receive continuous positive airway pressure (CPAP) therapy with OHCA in the general population. METHODS: Using nationwide databases, we conducted a nested case-control study with OHCA-cases of presumed cardiac causes and age/sex/OHCA-date matched non-OHCA-controls from the general population. Conditional logistic regression models with adjustments for well-known OHCA risk factors were performed to generate odds ratio (OR) of OHCA comparing patients with SA receiving and not receiving CPAP therapy with individuals without SA. RESULTS: We identified 46,578 OHCA-cases and 232,890 matched non-OHCA-controls [mean: 71 years, 68.8% men]. Compared to subjects without SA, having SA without CPAP therapy was associated with increased odds of OHCA after controlling for relevant confounders (OR:1.20, 95%-Cl:1.06-1.36), while having SA with CPAP therapy was not associated with OHCA (OR:1.04, 95%-Cl:0.93-1.36). Regardless of CPAP therapy, age and sex did not significantly influence our findings. Our findings were confirmed in: (I) patients with neither ischemic heart disease nor heart failure (untreated SA, OR:1.24, 95%-CI:1.04-1.47; SA with CPAP, OR:1.08, 95%-CI:0.93-1.25); and (II) in patients without cardiovascular disease (untreated SA, OR:1.33, 95%-CI:1.07-1.65; SA with CPAP, OR:1.14, 95%-CI:0.94-1.39). CONCLUSION: SA not treated with CPAP was associated with OHCA, while no increased risk of OHCA was found for SA patients treated with CPAP.

Prodromal complaints and 30-day survival after emergency medical services-witnessed out-of-hospital cardiac arrest.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is a frequent and lethal condition with a yearly incidence of approximately 5000 in Denmark. Thirty-day survival is associated with the patient's prodromal complaints prior to cardiac arrest. This paper examines the odds of 30-day survival dependent on the reported prodromal complaints among OHCAs witnessed by the emergency medical services (EMS). METHODS: EMS-witnessed OHCAs in the Capital Region of Denmark from 2016-2018 were included. Calls to the emergency number 1-1-2 and the medical helpline for out-of-hours were analyzed according to the Danish Index; data regarding the OHCA was collected from the Danish Cardiac Arrest Registry. We performed multiple logistic regression to calculate the odds ratio (OR) of 30-day survival with adjustment for sex and age. RESULTS: We identified 311 eligible OHCAs of which 79 (25.4%) survived. The most commonly reported complaints were dyspnea (n = 209, OR 0.79 [95% CI 0.46: 1.36]) and 'feeling generally unwell' (n = 185, OR 1.07 [95% CI 0.63: 1.81]). Chest pain (OR 9.16 [95% CI 5.09:16.9]) and heart palpitations (OR 3.15 [95% CI 1.07:9.46]) had the highest ORs, indicating favorable odds for 30-day survival, while unresponsiveness (OR 0.22 [95% CI 0.11:0.43]) and blue skin or lips (OR 0.30, 95% CI 0.09, 0.81) had the lowest, indicating lesser odds of 30-day survival. CONCLUSION: Experiencing chest pain or heart palpitations prior to EMS-witnessed OHCA was associated with higher 30-day survival. Conversely, complaints of unresponsiveness or having blue skin or lips implied reduced odds of 30-day survival.

Volunteer Responder Interventions in Out-of-Hospital Cardiac Arrest in Urban, Suburban, and Rural Areas.

BACKGROUND: Patients with out-of-hospital cardiac arrest (OHCA) in rural areas experience longer emergency response times and have lower survival rates compared with patients in urban areas. Volunteer responders might improve care and outcomes for patients with OHCA specifically in rural areas. Therefore, we investigated volunteer responder interventions based on the degree of urbanization. METHODS AND RESULTS: We included 1310 OHCAs from 3 different regions in Denmark where volunteer responders had arrived at the OHCA location. The location was classified as urban, suburban, or rural according to the Eurostat Degree of Urbanization Tool. A logistic regression model was used to examine associations between the degree of urbanization and volunteer responder arrival before emergency medical services, cardiopulmonary resuscitation, or defibrillation. We found the odds for volunteer responder arrival before emergency medical services more than doubled in rural areas (odds ratio [OR], 2.60 [95% CI, 1.91-3.53]) and suburban areas (OR, 2.05 [95% CI, 1.56-2.69]) compared with urban areas. In OHCA cases where volunteer responders arrived first, odds for bystander cardiopulmonary resuscitation was tripled in rural areas (OR, 3.83 [95% CI, 1.64-8.93]) and doubled in suburban areas (OR, 2.27 [95% CI, 1.17-4.41]) compared with urban areas. Bystander defibrillation was more common in suburban areas (OR, 1.53 [95% CI, 1.02-2.31]), where almost 1 out of 4 patients received bystander defibrillation, compared with urban areas. CONCLUSIONS: Volunteer responders are significantly more likely to arrive before emergency medical services in rural and suburban areas than in urban areas. Patients with OHCA received more cardiopulmonary resuscitation in rural and suburban areas and more defibrillation in suburban areas than in urban areas.

The ROCK trial-a multidisciplinary Rehabilitation intervention for sudden Out-of-hospital Cardiac arrest survivors focusing on return-to-worK: a pragmatic randomized controlled trial protocol.

INTRODUCTION: Most cardiac arrest survivors are classified with mild to moderate cognitive impairment; roughly, 50% experience long-term neurocognitive impairment. Postarrest challenges complicate participation in society and are associated with social issues such as failure to resume social activities and impaired return to work. The effectiveness of rehabilitation interventions for out-of-hospital cardiac arrest survivors are sparsely described, but the body of evidence describes high probabilities of survivors not returning to work, returning to jobs with modified job descriptions, returning to part-time employment, and often in combination with extensive unmet rehabilitation needs. Hence, there is a need to develop and test a pragmatic individual targeted intervention to facilitate return to work (RTW) in survivors of OHCA. The overall aim of the ROCK trial is to evaluate the effectiveness of a comprehensive individually tailored multidisciplinary rehabilitation intervention for survivors of OHCA on RTW compared to usual care. METHODS AND ANALYSIS: The ROCK trial is a two-arm parallel group multicentre investigator-initiated pragmatic randomized controlled superiority trial with primary endpoint measured 12 months after the cardiac arrest. Adult survivors who were part of the labour force prior to the OCHA and had at least 2 years until they are qualified to receive retirement state pensions are eligible for inclusion. Survivors will be randomized 1:1 to usual care group or usual care plus a comprehensive tailored rehabilitation intervention focusing on supporting RTW. After comprehensive assessment of individual rehabilitation needs, the intervention is ongoingly coordinated within a multidisciplinary rehabilitation team, and the intervention can be delivered for up until 12 months. Data for the primary outcome will be obtained from the national register on social transfer payments. The primary outcome will be analysed using logistic regression assessing RTW status at 12 months adjusting for the intervention and age at OHCA, sex, marital status, and occupation prior to OHCA. DISCUSSION: The ROCK trial is the first RCT to investigate the effectiveness of a rehabilitation intervention focusing on return to work after cardiac arrest. TRIAL REGISTRATION: ClinicalTrials.gov NCT05173740. Registered on May 2018.

Effect of prehospital high-dose glucocorticoid on hemodynamics in patients resuscitated from out-of-hospital cardiac arrest: a sub-study of the STEROHCA trial.

BACKGROUND: Following resuscitated out-of-hospital cardiac arrest (OHCA), inflammatory markers are significantly elevated and associated with hemodynamic instability and organ dysfunction. Vasopressor support is recommended to maintain a mean arterial pressure (MAP) above 65 mmHg. Glucocorticoids have anti-inflammatory effects and may lower the need for vasopressors. This study aimed to assess the hemodynamic effects of prehospital high-dose glucocorticoid treatment in resuscitated comatose OHCA patients. METHODS: The STEROHCA trial was a randomized, placebo-controlled, phase 2 trial comparing one prehospital injection of methylprednisolone 250 mg with placebo immediately after resuscitated OHCA. In this sub-study, we included patients who remained comatose at admission and survived until intensive care unit (ICU) admission. The primary outcome was cumulated norepinephrine use from ICU admission until 48 h reported as mcg/kg/min. Secondary outcomes included hemodynamic status characterized by MAP, heart rate, vasoactive-inotropic score (VIS), and the VIS/MAP-ratio as well as cardiac function assessed by pulmonary artery catheter measurements. Linear mixed-model analyses were performed to evaluate mean differences between treatment groups at all follow-up times. RESULTS: A total of 114 comatose OHCA patients were included (glucocorticoid: n = 56, placebo: n = 58) in the sub-study. There were no differences in outcomes at ICU admission. From the time of ICU admission up to 48 h post-admission, patients in the glucocorticoid group cumulated a lower norepinephrine use (mean difference - 0.04 mcg/kg/min, 95% CI - 0.07 to - 0.01, p = 0.02). Moreover, after 12-24 h post-admission, the glucocorticoid group demonstrated a higher MAP with mean differences ranging from 6 to 7 mmHg (95% CIs from 1 to 12), a lower VIS (mean differences from - 4.2 to - 3.8, 95% CIs from - 8.1 to 0.3), and a lower VIS/MAP ratio (mean differences from - 0.10 to - 0.07, 95% CIs from - 0.16 to - 0.01), while there were no major differences in heart rate (mean differences from - 4 to - 3, 95% CIs from - 11 to 3). These treatment differences between groups were also present 30-48 h post-admission but to a smaller extent and with increased statistical uncertainty. No differences were found in pulmonary artery catheter measurements between groups. CONCLUSIONS: Prehospital treatment with high-dose glucocorticoid was associated with reduced norepinephrine use in resuscitated OHCA patients. TRIAL REGISTRATION: EudraCT number: 2020-000855-11; submitted March 30, 2020. URL: https://www. CLINICALTRIALS: gov ; Unique Identifier: NCT04624776.

A multidisciplinary guideline-based approach to improving the sudden cardiac arrest care pathway: The Copenhagen framework.

Although recommended in the European Resuscitation Council (ERC) and European Society of Intensive Care Medicine (ESICM) Guidelines, a framework for delivering post-cardiac arrest care in a systematic manner in dedicated high-volume cardiac arrest centers is lacking in the existing literature. To our knowledge, the Copenhagen Framework is the only established framework of its kind. The framework comprises management of out-of-hospital cardiac arrest (OHCA) survivors, and follow-up, and rehabilitation. The framework also incorporates research projects on cardiac arrest survivors and their close family members. The overall aim of this paper is to describe a framework made in order to bridge the gaps between international recommendations and delivering high-quality post-resuscitation clinical care, improving the continuity of care for OHCA survivors, access to post-CA rehabilitation, a seamless transition to everyday life, and ultimately patient outcomes in the future.

Fluoroquinolones do not provide added risk of out-of-hospital cardiac arrest: a nationwide study.

AIM: Conflicting results have been reported regarding the association between fluoroquinolones (FQs) and the risk of out-of-hospital cardiac arrest (OHCA). In particular, it has not become clear whether OHCA in FQ users is related to the inherent comorbidities or whether there is a direct pro-arrhythmic effect of FQs. Therefore, we studied the relation between FQs and OHCA in the general population. METHODS: Through Danish nationwide registries, we conducted a nested case-control study with OHCA cases of presumed cardiac causes and age/sex/OHCA date-matched non-OHCA controls from the general population. Conditional logistic regression models with adjustments for well-known risk factors of OHCA were employed to estimate the OR with 95% CI of OHCA comparing FQs with amoxicillin. RESULTS: The study population consisted of 46 578 OHCA cases (mean: 71 years (SD: 14.40), 68.8% men) and 232 890 matched controls. FQ was used by 276 cases and 328 controls and conferred no increase in the odds of OHCA compared with amoxicillin use after controlling for the relevant confounders (OR: 0.91 (95% CI: 0.71 to 1.16)). The OR of OHCA associated with FQ use did not vary significantly by age (OR≤65: 0.96 (95% CI: 0.53 to 1.74), OR>65: 0.88 (95% CI: 0.67 to 1.16), p value interaction=0.7818), sex (ORmen: 0.96 (95% CI: 0.70 to 1.31), ORwomen: 0.80 (95% CI: 0.53 to 1.20), p value interaction=0.9698) and pre-existing cardiovascular disease (ORabsent: 1.02 (95% CI: 0.57 to 1.82), ORpresent: 0.98 (95% CI: 0.75 to 1.28), p value interaction=0.3884), including heart failure (ORabsent: 0.93 (95% CI: 0.72 to 1.22), ORpresent: 1.11 (95% CI: 0.61 to 2.02), p value interaction=0.7083) and ischaemic heart disease (ORabsent: 0.85 (95% CI: 0.64 to 1.12), ORpresent: 1.38 (95% CI: 0.86 to 2.21), p value interaction=0.6230). CONCLUSION: Our findings do not support an association between FQ exposure and OHCA in the general population. This lack of association was consistent in men and women, in all age categories, and in the presence or absence of cardiovascular disease.

2023 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 engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using 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. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

Association between mortality and phone-line waiting time for non-urgent medical care: a Danish registry-based cohort study.

BACKGROUND AND IMPORTANCE: Telephone calls are often patients' first healthcare service contact, outcomes associated with waiting times are unknown. OBJECTIVES: Examine the association between waiting time to answer for a medical helpline and 1- and 30-day mortality. DESIGN, SETTING AND PARTICIPANTS: Registry-based cohort study using phone calls data (January 2014 to December 2018) to the Capital Region of Denmark's medical helpline. The service refers to hospital assessment/treatment, dispatches ambulances, or suggests self-care guidance. EXPOSURE: Waiting time was grouped into the following time intervals in accordance with political service targets for waiting time in the Capital Region: <30 s, 0:30-2:59, 3-9:59, and ≥10 min. OUTCOME MEASURES AND ANALYSIS: The association between time intervals and 1- and 30-day mortality per call was calculated using logistic regression with strata defined by age and sex. MAIN RESULTS: In total, 1 244 252 callers were included, phoning 3 956 243 times, and 78% of calls waited <10 min. Among callers, 30-day mortality was 1% (16 560 deaths). For calls by females aged 85-110 30-day mortality increased with longer waiting time, particularly within the first minute: 9.6% for waiting time <30 s, 10.8% between 30 s and 1 minute and 9.1% between 1 and 2 minutes. For calls by males aged 85-110 30-day mortality was 11.1%, 12.9% and 11.1%, respectively. Additionally, among calls with a Charlson score of 2 or higher, longer waiting times were likewise associated with increased mortality. For calls by females aged 85-110 30-day mortality was 11.6% for waiting time <30 s, 12.9% between 30 s and 1 minute and 11.2% between 1 and 2 minutes. For calls by males aged 85-110 30-day mortality was 12.7%, 14.1% and 12.6%, respectively. Fewer ambulances were dispatched with longer waiting times (4%/2%) with waiting times <30 s and >10 min. CONCLUSION: Longer waiting times for telephone contact to a medical helpline were associated with increased 1- and 30-day mortality within the first minute, especially among elderly or more comorbid callers.

COVID-19 Rapid Antigen Tests With Self-Collected vs Health Care Worker-Collected Nasal and Throat Swab Specimens: A Randomized Clinical Trial.

Importance: Self- or health care worker (HCW)-collected nasal swab specimens are the preferred sampling method to perform rapid antigen testing for COVID-19, but it is debated whether throat specimens can improve test sensitivity. Objective: To compare the diagnostic accuracy of self- and HCW-collected nasal vs throat swab specimens for COVID-19 rapid antigen testing. Design, Setting, and Participants: This per-protocol multicenter randomized clinical trial was conducted from February 15 through March 25, 2022. The participants, individuals aged 16 years or older requesting a COVID-19 test for diagnostic or screening purposes, had 4 specimens collected for individual testing at 1 of 2 urban COVID-19 outpatient test centers in Copenhagen, Denmark. Interventions: Participants were randomized 1:1 to self-collected or HCW-collected nasal and throat swab specimens for rapid antigen testing. Additional HCW-collected nasal and throat swab specimens for reverse transcriptase-polymerase chain reaction (RT-PCR) were used as the reference standard. Main Outcomes and Measures: The primary outcome was sensitivity to diagnose COVID-19 of a self- vs HCW-collected nasal and throat specimen for rapid antigen testing compared with RT-PCR. Results: Of 2941 participants enrolled, 2674 (90.9%) had complete test results and were included in the final analysis (1535 [57.4%] women; median age, 40 years [IQR, 28-55 years]); 1074 (40.2%) had COVID-19 symptoms, and 827 (30.9%) were positive for SARS-CoV-2 by RT-PCR. Health care worker-collected throat specimens had higher mean sensitivity than HCW-collected nasal specimens for rapid antigen testing (69.4% [95% CI, 65.1%-73.6%] vs 60.0% [95% CI, 55.4%-64.5%]). However, a subgroup analysis of symptomatic participants found that self-collected nasal specimens were more sensitive than self-collected throat specimens for rapid antigen testing (mean sensitivity, 71.5% [95% CI, 65.3%-77.6%] vs 58.0% [95% CI, 51.2%-64.7%]; P < .001). Combining nasal and throat specimens increased sensitivity for HCW- and self-collected specimens by 21.4 and 15.5 percentage points, respectively, compared with a single nasal specimen (both P < .001). Conclusions and Relevance: This randomized clinical trial found that a single HCW-collected throat specimen had higher sensitivity for rapid antigen testing for SARS-CoV-2 than a nasal specimen. In contrast, the self-collected nasal specimens had higher sensitivity than throat specimens for symptomatic participants. Adding a throat specimen to the standard practice of collecting a single nasal specimen could improve sensitivity for rapid antigen testing in health care and home-based settings. Trial Registration: ClinicalTrials.gov Identifier: NCT05209178.

Pre-hospital pulse glucocorticoid therapy in patients with ST-segment elevation myocardial infarction transferred for primary percutaneous coronary intervention: a randomized controlled trial (PULSE-MI).

BACKGROUND: Inflammation in ST-segment elevation myocardial infarction (STEMI) is an important contributor to both acute myocardial ischemia and reperfusion injury after primary percutaneous coronary intervention (PCI). Methylprednisolone is a glucocorticoid with potent anti-inflammatory properties with an acute effect and is used as an effective and safe treatment of a wide range of acute diseases. The trial aims to investigate the cardioprotective effects of pulse-dose methylprednisolone administered in the pre-hospital setting in patients with STEMI transferred for primary PCI. METHODS: This trial is a randomized, blinded, placebo-controlled prospective clinical phase II trial. Inclusion will continue until 378 patients with STEMI have been evaluated for the primary endpoint. Patients will be randomized 1:1 to a bolus of 250 mg methylprednisolone intravenous or matching placebo over a period of 5 min in the pre-hospital setting. All patients with STEMI transferred for primary PCI at Rigshospitalet, Copenhagen University Hospital, Denmark, will be screened for eligibility. The main eligibility criteria are age ≥ 18 years, acute onset of chest pain with < 12 h duration, STEMI on electrocardiogram, no known allergy to glucocorticoids or no previous coronary artery bypass grafting, previous acute myocardial infarction in assumed culprit, or a history with previous maniac/psychotic episodes. Primary outcome is final infarct size measured by late gadolinium enhancement on cardiac magnetic resonance (CMR) 3 months after STEMI. Secondary outcomes comprise key CMR efficacy parameters, clinical endpoints at 3 months, the peak of cardiac biomarkers, and safety. DISCUSSION: We hypothesize that pulse-dose methylprednisolone administrated in the pre-hospital setting decreases inflammation and thus reduces final infarct size in patients with STEMI treated with primary PCI. TRIAL REGISTRATION: EU-CT number: 2022-500762-10-00; Submitted May 5, 2022. CLINICALTRIALS: gov Identifier: NCT05462730; Submitted July 7, 2022, first posted July 18, 2022.

Prehospital high-dose methylprednisolone in resuscitated out-of-hospital cardiac arrest patients (STEROHCA): a randomized clinical trial.

PURPOSE: Patients who are successfully resuscitated following out-of-hospital cardiac arrest (OHCA) are still at a high risk of neurological damage and death. Inflammation and brain injury are components of the post-cardiac arrest syndrome, and can be assessed by systemic interleukin 6 (IL-6) and neuron-specific enolase (NSE). Anti-inflammatory treatment with methylprednisolone may dampen inflammation, thereby improving outcome. This study aimed to determine if prehospital high-dose methylprednisolone could reduce IL-6 and NSE in comatose OHCA patients. METHODS: The STEROHCA trial was a randomized, blinded, placebo-controlled, phase II prehospital trial performed at two cardiac arrest centers in Denmark. Resuscitated comatose patients with suspected cardiac etiology were randomly assigned 1:1 to a single intravenous injection of 250 mg methylprednisolone or placebo. The co-primary outcome was reduction of IL-6 and NSE-blood levels measured daily for 72 h from admission. The main secondary outcome was survival at 180 days follow-up. RESULTS: We randomized 137 patients to methylprednisolone (n = 68) or placebo (n = 69). We found reduced IL-6 levels (p < 0.0001) in the intervention group, with median (interquartile range, IQR) levels at 24 h of 2.1 pg/ml (1.0; 7.1) and 30.7 pg/ml (14.2; 59) in the placebo group. We observed no difference between groups in NSE levels (p = 0.22), with levels at 48 h of 18.8 ug/L (14.4; 24.6) and 14.8 ug/L (11.2; 19.4) in the intervention and placebo group, respectively. In the intervention group, 51 (75%) patients survived and 44 (64%) in the placebo group. CONCLUSION: Prehospital treatment with high-dose methylprednisolone to resuscitated comatose OHCA patients, resulted in reduced IL-6 levels after 24 h, but did not reduce NSE levels.

2023 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 engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using 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. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

Drone delivery of automated external defibrillators compared with ambulance arrival in real-life suspected out-of-hospital cardiac arrests: a prospective observational study in Sweden.

BACKGROUND: A novel approach to improve bystander defibrillation for out-of-hospital cardiac arrests is to dispatch and deliver an automated external defibrillator (AED) directly to the suspected cardiac arrest location by drone. The aim of this study was to investigate how often a drone could deliver an AED before ambulance arrival and to measure the median time benefit achieved by drone deliveries. METHODS: In this prospective observational study, five AED-equipped drones were placed within two separate controlled airspaces in Sweden, covering approximately 200 000 inhabitants. Drones were dispatched in addition to standard emergency medical services for suspected out-of-hospital cardiac arrests and flight was autonomous. Alerts concerning children younger than 8 years, trauma, and emergency medical services-witnessed cases were not included. Exclusion criteria were air traffic control non-approval of flight, unfavourable weather conditions, no-delivery zones, and darkness. Data were collected from the dispatch centres, ambulance organisations, Swedish Registry for Cardiopulmonary Resuscitation, and the drone operator. Core outcomes were the percentage of cases for which an AED was delivered by a drone before ambulance arrival, and the median time difference (minutes and seconds) between AED delivery by drone and ambulance arrival. Explorative outcomes were percentage of attached drone-delivered AEDs before ambulance arrival and the percentage of cases defibrillated by a drone-delivered AED when it was used before ambulance arrival. FINDINGS: During the study period (from April 21, 2021 to May 31, 2022), 211 suspected out-of-hospital cardiac arrest alerts occurred, and in 72 (34%) of those a drone was deployed. Among those, an AED was successfully delivered in 58 (81%) cases, and the major reason for non-delivery was cancellation by dispatch centre because the case was not an out-of-hospital cardiac arrest. In cases for which arrival times for both drone and ambulance were available (n=55), AED delivery by drone occurred before ambulance arrival in 37 cases (67%), with a median time benefit of 3 min and 14 s. Among these cases, 18 (49%) were true out-of-hospital cardiac arrests and a drone-delivered AED was attached in six cases (33%). Two (33%) had a shockable first rhythm and were defibrillated by a drone-delivered AED before ambulance arrival, with one person achieving 30-day survival. No adverse events occurred. AED delivery (not landing) was made within 15 m from the patient or building in 91% of the cases. INTERPRETATION: AED-equipped drones dispatched in cases of suspected out-of-hospital cardiac arrests delivered AEDs before ambulance arrival in two thirds of cases, with a clinically relevant median time benefit of more than 3 min. This intervention could potentially decrease time to attachment of an AED, before ambulance arrival. FUNDING: Swedish Heart Lung Foundation.

Is dispatcher-assisted cardiopulmonary resuscitation affected by a bystander's emotional stress state in out-of-hospital cardiac arrest?

AIM: The study aimed to investigate whether a bystander's emotional stress state affects dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) in out-of-hospital cardiac arrest (OHCA). The primary outcome was initiation of chest compressions (Yes/No). Secondarily we analysed time until chest compressions were initiated and assessed how dispatchers instructed CPR. METHOD: The study was a retrospective, observational study of OHCA emergency calls from the Capital Region of Denmark. Recorded calls were evaluated by five observers using a pre-defined code catalogue regarding the variables wished investigated. RESULTS: Included were 655 OHCA emergency calls, of which 211 callers were defined as emotionally stressed. When cardiac arrest was recognized, chest compressions were initiated in, respectively, 76.8% of cases with an emotionally stressed caller and 73.9% in cases with a not emotionally stressed caller (2.18 (0.80-7.64)). Cases with an emotionally stressed caller had a longer time until chest compressions were initiated compared to cases with a not emotionally stressed caller, however non-significant (164 s. vs. 146 s.; P = 0.145). The dispatchers were significantly more likely to be encouraging and motivating, and to instruct on speed and depth of chest compressions in cases with an emotionally stressed caller compared to cases with a not emotionally stressed caller (1.64 (1.07-2.56); 1.78 (1.13-2.88)). Barriers to CPR were significantly more often reported in cases with an emotionally stressed caller compared to cases with a not emotionally stressed caller (1.83 (1.32-2.56)). CONCLUSION: There was no significant difference in initiation of chest compressions or in time until initiation of chest compressions in the two groups. However, the dispatchers were overall more encouraging and motivating, and likely to instruct on speed and depth of chest compressions when the caller was emotionally stressed. Furthermore, barriers to CPR were more often reported in cases with an emotionally stressed caller compared to cases with a not emotionally stressed caller. TRIAL REGISTRATION: We applied for ethical approval from The Danish National Committee on Health Research Ethics, but formal approval was waived. We received permission for storage of data and to use these for research of OHCAs in the Capital Region of Denmark by Danish Data Protection Agency (P-2021-670) and Danish Health Authorities (R-2,005,114). The study is registered at ClinicalTrials (NTC05113706).

Association of intraosseous and intravenous access with patient outcome in out-of-hospital cardiac arrest.

Here we report the results of a study on the association between drug delivery via intravenous route or intraosseous route in out-of-hospital cardiac arrest. Intraosseous drug delivery is considered an alternative option in resuscitation if intravenous access is difficult or impossible. Intraosseous uptake of drugs may, however, be compromised. We have performed a retrospective cohort study of all Danish patients with out-of-hospital cardiac arrest in the years 2016-2020 to investigate whether mortality is associated with the route of drug delivery. Outcome was 30-day mortality, death at the scene, no prehospital return of spontaneous circulation, and 7- and 90-days mortality. 17,250 patients had out-of-hospital cardiac arrest. 6243 patients received no treatment and were excluded. 1908 patients had sustained return of spontaneous circulation before access to the vascular bed was obtained. 2061 patients were unidentified, and 286 cases were erroneously registered. Thus, this report consist of results from 6752 patients. Drug delivery by intraosseous route is associated with increased OR of: No spontaneous circulation at any time (OR 1.51), Death at 7 days (OR 1.94), 30 days (2.02), and 90 days (OR 2.29). Intraosseous drug delivery in out-of-hospital cardiac arrest is associated with overall poorer outcomes than intravenous drug delivery.

Assessing optimal methods for transferring machine learning models to low-volume and imbalanced clinical datasets: experiences from predicting outcomes of Danish trauma patients.

Introduction: Accurately predicting patient outcomes is crucial for improving healthcare delivery, but large-scale risk prediction models are often developed and tested on specific datasets where clinical parameters and outcomes may not fully reflect local clinical settings. Where this is the case, whether to opt for de-novo training of prediction models on local datasets, direct porting of externally trained models, or a transfer learning approach is not well studied, and constitutes the focus of this study. Using the clinical challenge of predicting mortality and hospital length of stay on a Danish trauma dataset, we hypothesized that a transfer learning approach of models trained on large external datasets would provide optimal prediction results compared to de-novo training on sparse but local datasets or directly porting externally trained models. Methods: Using an external dataset of trauma patients from the US Trauma Quality Improvement Program (TQIP) and a local dataset aggregated from the Danish Trauma Database (DTD) enriched with Electronic Health Record data, we tested a range of model-level approaches focused on predicting trauma mortality and hospital length of stay on DTD data. Modeling approaches included de-novo training of models on DTD data, direct porting of models trained on TQIP data to the DTD, and a transfer learning approach by training a model on TQIP data with subsequent transfer and retraining on DTD data. Furthermore, data-level approaches, including mixed dataset training and methods countering imbalanced outcomes (e.g., low mortality rates), were also tested. Results: Using a neural network trained on a mixed dataset consisting of a subset of TQIP and DTD, with class weighting and transfer learning (retraining on DTD), we achieved excellent results in predicting mortality, with a ROC-AUC of 0.988 and an F2-score of 0.866. The best-performing models for predicting long-term hospitalization were trained only on local data, achieving an ROC-AUC of 0.890 and an F1-score of 0.897, although only marginally better than alternative approaches. Conclusion: Our results suggest that when assessing the optimal modeling approach, it is important to have domain knowledge of how incidence rates and workflows compare between hospital systems and datasets where models are trained. Including data from other health-care systems is particularly beneficial when outcomes are suffering from class imbalance and low incidence. Scenarios where outcomes are not directly comparable are best addressed through either de-novo local training or a transfer learning approach.

Dispatcher Stroke/TIA Recognition in Emergency Medical Call Center and Out-of-Hours Service Calls in Copenhagen, Denmark.

Background and Objectives: Recognition of stroke/TIA symptoms by emergency medical services (EMS) is instrumental in providing timely recanalization treatments. We assessed the recognition of stroke/TIA by EMS via the emergency medical call center (EMCC) dispatchers and out-of-hours health service (OOHS) dispatchers. Methods: In a registry study, based on 2015-2020 data from the Copenhagen EMS, we calculated sensitivity, positive predictive value (PPV), specificity, and negative predictive value (NPV) of dispatcher suspicion of stroke or transient ischemic attack (TIA) and compared against discharge diagnosis. Results: We included 462,029 contacts to EMCC and 2,573,865 contacts to OOHS. In total, 19,798 contacts had a stroke or TIA diagnosis at hospital discharge. Sensitivity was 0.64 for EMCC dispatchers and 0.25 for OOHS. PPV was 0.28 for EMCC and 0.22 for OOHS; specificity was 0.96 for EMCC and >0.99 for OOHS, and NPV was 0.99 for EMCC and >0.99 for OOHS. Sensitivity improved over the period of the study from 0.62 to 0.68 for EMCC and from 0.20 to 0.25 for OOHS. PPV did not change over the period for EMCC and decreased from 0.26 to 0.19 for OOHS. Both EMCC and OOHS more frequently overlooked stroke in women, in patients calling more than 3 hours after symptom onset, and for more severe strokes. For OHHS, advanced age correlated with lower recognition. Discussion: As the first study reporting on OOHS setting dispatcher stroke/TIA recognition, we find a need for the improvement of stroke/TIA recognition both in EMCC and in OOHS. Solutions may include specific training of dispatchers, public awareness campaigns, and new technological solutions.