A National Survey Assessing the Variability in the Management of Traumatic Cardiac Arrest.

BACKGROUND: Resuscitation of traumatic cardiac arrest (TCA) is variable, with approaches that overlap Advanced Trauma Life Support (ATLS) and Advanced Cardiac Life Support (ACLS) algorithms. There is no standard algorithm for TCA, with some withholding ACLS protocols given abysmal outcomes. This study aims to assess surgeon practices and attitudes toward resuscitation practices in TCA. MATERIALS AND METHODS: A 16-question web-based survey was distributed to the membership of a national trauma association. Respondent demographics and management of TCA were analyzed. Chi-squared tests determined statistical significance. Open-ended responses were coded and analyzed inductively. RESULTS: Two hundred and three surveys were completed. 73.4% of respondents reported utilizing ACLS, while 26.6% reported they never utilized ACLS. A statistically significant difference in the performance of ACLS was found based on number of years in practice (P = .025) and the state of practice (P = .006). There was no significant difference in self-reported survival rates or legal, ethical, or interpersonal conflicts. Qualitative data highlighted themes of interpersonal conflict and futility. DISCUSSION: This study shows that one-quarter of respondents never utilize ACLS in TCA. Of those that utilize ACLS, there was variability in the technique, indication, and duration of resuscitation. Despite significant variability in technique, there appears to be similar survival rates and incidence of conflict. The association between years in practice and ACLS use suggests this may represent an emerging change in practice. The low response rate limits generalizability; however, there is significant variability in practice, highlighting a need for evidence-based guidelines.

Early Extracorporeal CPR for Refractory Out-of-Hospital Cardiac Arrest.

BACKGROUND: Extracorporeal cardiopulmonary resuscitation (CPR) restores perfusion and oxygenation in a patient who does not have spontaneous circulation. The evidence with regard to the effect of extracorporeal CPR on survival with a favorable neurologic outcome in refractory out-of-hospital cardiac arrest is inconclusive. METHODS: In this multicenter, randomized, controlled trial conducted in the Netherlands, we assigned patients with an out-of-hospital cardiac arrest to receive extracorporeal CPR or conventional CPR (standard advanced cardiac life support). Eligible patients were between 18 and 70 years of age, had received bystander CPR, had an initial ventricular arrhythmia, and did not have a return of spontaneous circulation within 15 minutes after CPR had been initiated. The primary outcome was survival with a favorable neurologic outcome, defined as a Cerebral Performance Category score of 1 or 2 (range, 1 to 5, with higher scores indicating more severe disability) at 30 days. Analyses were performed on an intention-to-treat basis. RESULTS: Of the 160 patients who underwent randomization, 70 were assigned to receive extracorporeal CPR and 64 to receive conventional CPR; 26 patients who did not meet the inclusion criteria at hospital admission were excluded. At 30 days, 14 patients (20%) in the extracorporeal-CPR group were alive with a favorable neurologic outcome, as compared with 10 patients (16%) in the conventional-CPR group (odds ratio, 1.4; 95% confidence interval, 0.5 to 3.5; P = 0.52). The number of serious adverse events per patient was similar in the two groups. CONCLUSIONS: In patients with refractory out-of-hospital cardiac arrest, extracorporeal CPR and conventional CPR had similar effects on survival with a favorable neurologic outcome. (Funded by the Netherlands Organization for Health Research and Development and Maquet Cardiopulmonary [Getinge]; INCEPTION ClinicalTrials.gov number, NCT03101787.).

Comparison of two strategies for managing in-hospital cardiac arrest.

In-hospital cardiac arrest (IHCA) is associated with poor outcomes. There are currently no standards for cardiac arrest teams in terms of member composition and task allocation. Here we aimed to compare two different cardiac arrest team concepts to cover IHCA management in terms of survival and neurological outcomes. This prospective study enrolled 412 patients with IHCA from general medical wards. From May 2014 to April 2016, 228 patients were directly transferred to the intensive care unit (ICU) for ongoing resuscitation. In the ICU, resuscitation was extended to advanced cardiac life support (ACLS) (Load-and-Go [LaG] group). By May 2016, a dedicated cardiac arrest team provided by the ICU provided ACLS in the ward. After return of spontaneous circulation (ROSC), the patients (n = 184) were transferred to the ICU (Stay-and-Treat [SaT] group). Overall, baseline characteristics, aetiologies, and characteristics of cardiac arrest were similar between groups. The time to endotracheal intubation was longer in the LaG group than in the SaT group (6 [5, 8] min versus 4 [2, 5] min, p = 0.001). In the LaG group, 96% of the patients were transferred to the ICU regardless of ROSC achievement. In the SaT group, 83% of patients were transferred to the ICU (p = 0.001). Survival to discharge did not differ between the LaG (33%) and the SaT (35%) groups (p = 0.758). Ultimately, 22% of patients in the LaG group versus 21% in the SaT group were discharged with good neurological outcomes (p = 0.857). In conclusion, we demonstrated that the cardiac arrest team concepts for the management of IHCA did not differ in terms of survival and neurological outcomes. However, a dedicated (intensive care) cardiac arrest team could take some load off the ICU.

Association of the duration of on-scene advanced life support with good neurological recovery in out-of-hospital cardiac arrest.

BACKGROUND: As advanced life support (ALS) provided by emergency medical services (EMS) on scene becomes more common, the scene time interval (STI) for which EMS providers stay on scene tends to lengthen. We investigated the relationship between the STI and neurological outcome of patients at hospital discharge when ALS was provided by EMS on scene. METHODS: We conducted a retrospective analysis of prospectively collected out-of-hospital cardiac arrest (OHCA) data between August 2015 and December 2018. A restricted cubic spline curve was used to investigate the relationship between the STI and neurologic outcome, and patients were divided into two groups based on the cut-off value obtained through receiver operating characteristic (ROC) analysis. Comparisons of outcomes between the two groups were performed before and after propensity score matching. RESULTS: 4548 patients were included in the analysis. In ROC analysis, the optimal cut-off value for STI was 19 min. For the group with an STI <19 min, survival admission, survival discharge, and good neurologic outcome at hospital discharge were all higher than for the group with STI ≥19 min before and after propensity score matching. The multivariable model also showed that the STI ≥19 min was significantly associated with poor neurologic outcome at hospital discharge compared with the STI <19 min (adjusted odds ratio, 2.00; 95% CI, 1.40-2.88). CONCLUSIONS: A duration of on-scene ALS more than 19 min was associated with a poor neurologic outcome of patients at hospital discharge in OHCA.

Optimizing airway management and ventilation during prehospital advanced life support in out-of-hospital cardiac arrest: A narrative review.

Airway management and ventilation are essential components of cardiopulmonary resuscitation to achieve oxygen delivery in order to prevent hypoxic injury and increase the chance of survival. Weighing the relative benefits and downsides, the best approach is a staged strategy; start with a focus on high-quality chest compressions and defibrillation, then optimize mask ventilation while preparing for advanced airway management with a supraglottic airway device. Endotracheal intubation can still be indicated, but has the largest downsides of all advanced airway techniques. Whichever stage of airway management, ventilation and chest compression quality should be closely monitored. Capnography has many advantages and should be used routinely. Optimizing ventilation strategies, harmonizing ventilation with mechanical chest compression devices, and implementation in complex and stressful environments are challenges we need to face through collaborative innovation, research, and implementation.

Impact of the modified SESAME ultrasound protocol implementation on patients with cardiac arrest in the emergency department.

INTRODUCTION: Point-of-care (POC) ultrasound protocols are commonly used for the initial management of patients with cardiac arrest in the emergency department (ED). However, there is little published evidence regarding any mortality benefit. We compared and studied the effect of implementation of the modified SESAME protocol in terms of clinical outcomes and resuscitation management. METHODS: This was a single-center retrospective observational study. We conducted a pre- and post-intervention study to evaluate changes in patient outcomes and management after educating emergency medicine residents and the faculty about the modified SESAME protocol. The pre-intervention period lasted from March 2018 to February 2019, and the post-intervention period lasted from May 2019 to April 2020. The modified SESAME protocol education was initiated in March 2019. Multivariate logistic regression analyses were performed to examine the associations between independent variables and outcomes. RESULTS: A total of 334 patients were included in this study during a 24-month period. We found no significant differences between the two groups for the primary outcome of survival to hospital admission (pre-intervention group 28.9% versus post-intervention group 28.6%; P = 0.751), survival to hospital discharge (12.1% vs. 12.4%; P = 0.806), and good neurologic outcome at discharge (6.0% vs. 8.1%; P = 0.509). The proportion of resuscitation procedures of thrombolysis, emergency transfusion, tube thoracotomy, and pericardiocentesis during resuscitation increased from 0.6% in the pre-intervention period to 4.9% in the post-intervention period (P = 0.016). CONCLUSION: We did not discover any significant survival benefits associated with the implementation of the modified SESAME protocol; however, early diagnosis of specific pathologies (pericardial effusion, possible pulmonary embolism, tension pneumothorax, and hypovolemia) and accordingly a direct increase in the resuscitation management were seen in this study. Future studies with larger sample sizes are required to examine the clinical outcomes as well as to identify the most effective POC ultrasonography protocols for non-traumatic cardiac arrests.

Does second EMS unit response time affect outcomes of OHCA in multi-tiered system? A nationwide observational study.

OBJECTIVES: The time dependence of a multi-tier response for out-of-hospital cardiac arrest (OHCA) is unclear. The aim of this study was to evaluate the time-dependent effect of EMS response type in a multi-tiered system on the clinical outcomes of OHCA. METHODS: Adult EMS-treated OHCA of presumed cardiac etiology who were not witnessed by EMS between January 2015 and December 2017 were included. The main exposure was EMS response type: single-tier response, early multi-tier response (0-18 min from call to second EMS arrival), and late multi-tier response (19 min from call to second EMS arrival). The primary outcome was good neurologic recovery at the time of discharge from the hospital. Multivariate logistic regression analysis was performed, adjusting for patient-community and prehospital variables. RESULTS: Among 54,436 patients, 29,995 patients (55.1%), 21,552 patients (39.6%), and 2889 patients (5.3%) were treated by single-tiered EMS, early multi-tiered EMS, and late multi-tiered EMS, respectively. Good neurological recovery and survival to discharge were more frequent in the early multi-tiered response group (6.4% and 9.7%) than in the single-tiered response group (4.8% and 7.5%) or late multi-tiered response group (3.1% and 5.8%). Compared to the single-tiered response group, the early multi-tiered response group was more likely to have good neurological recovery (adjusted OR, 95% CI: 1.15 [1.06-1.26]), but the late multi-tiered response group was less likely to have good neurological recovery (adjusted OR, 95% CI: 0.76 [0.61-0.96]). CONCLUSION: In our basic to intermediate-tiered EMS system, early multi-tier response was associated with improved survival and good neurological recovery.

Singapore Advanced Cardiac Life Support Guidelines 2021.

Advanced cardiac life support (ACLS) emphasises the use of advanced airway management and ventilation, circulatory support and the appropriate use of drugs in resuscitation, as well as the identification of reversible causes of cardiac arrest. Extracorporeal cardiopulmonary resuscitation and organ donation, as well as special circumstances including drowning, pulmonary embolism and pregnancy are addressed. Resuscitation does not end with ACLS but must continue in post-resuscitation care. ACLS also covers the recognition and management of unstable pre-arrest tachy- and bradydysrhythmias that may deteriorate further.

After a century, Epinephrine's role in cardiac arrest resuscitation remains controversial.

BACKGROUND: Epinephrine is recommended in contemporary educational efforts by the American Heart Association (AHA) as central to adult Advanced Cardiac Life Support (ACLS). However, the International Liaison Committee on Resuscitation (ILCOR) 2019 recommendations update describes large evidentiary gaps for epinephrine use in cardiopulmonary resuscitation, highlighting that clinical and experimental evidence do not support the current AHA recommendations. OBJECTIVE: This controversies article was written as a response to updated AHA and ILCOR adult ACLS recommendations in late 2019. This report summarizes and evaluates the evidence surrounding epinephrine for cardiac arrest with a focus on the historical perspective of epinephrine research. DISCUSSION: According to the 2019 AHA ACLS guidelines, epinephrine is an integral component of adult out-of-hospital cardiac arrest resuscitation. Epinephrine improves rates of return of spontaneous circulation and might provide benefit at different doses or in select resuscitation scenarios, such asystole as an initial rhythm at onset of resuscitation efforts. However, evidence indicates potential harms with routine use of standard dose epinephrine (1 mg/10 mL), with no improvement in neurologic or long-term outcomes. CONCLUSIONS: Despite years of use and inclusion in resuscitation guidelines, epinephrine is not associated with improved neurologic outcomes. The AHA Emergency Cardiovascular Care committee should revise ACLS guidelines reflecting evidence that standard-dose epinephrine offers little benefit to successful patient recovery including neurologic outcomes. Future resuscitation guidelines should reflect this important consideration.

Effect of citywide enhancement of the chain of survival on good neurologic outcomes after out-of-hospital cardiac arrest from 2008 to 2017.

Improving outcomes after out-of-hospital cardiac arrests (OHCAs) requires an integrated approach by strengthening the chain of survival and emergency care systems. This study aimed to identify the change in outcomes over a decade and effect of citywide intervention on good neurologic outcomes after OHCAs in Daegu. This is a before- and after-intervention study to examine the association between the citywide intervention to improve the chain of survival and outcomes after OHCA. The primary outcome was a good neurologic outcome, defined as a cerebral performance category score of 1 or 2. After dividing into 3 phases according to the citywide intervention, the trends in outcomes after OHCA by primary electrocardiogram rhythm were assessed. Logistic regression analysis was used to analyze the association between the phases and outcomes. Overall, 6203 patients with OHCA were eligible. For 10 years (2008-2017), the rate of survival to discharge and the good neurologic outcomes increased from 2.6% to 8.7% and from 1.5% to 6.6%, respectively. Especially for patients with an initial shockable rhythm, these changes in outcomes were more pronounced (survival to discharge: 23.3% in 2008 to 55.0% in 2017, good neurologic outcomes: 13.3% to 46.0%). Compared with phase 1, the adjusted odds ratio (AOR) and 95% confidence intervals (CI) for good neurologic outcomes was 1.20 (95% CI: 0.78-1.85) for phase 2 and 1.64 (1.09-2.46) for phase 3. For patients with an initial shockable rhythm, the AOR for good neurologic outcomes was 3.76 (1.88-7.52) for phase 2 and 5.51 (2.77-10.98) for phase 3. Citywide improvement was observed in the good neurologic outcomes after OHCAs of medical origin, and the citywide intervention was significantly associated with better outcomes, particularly in those with initial shockable rhythm.

Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial.

BACKGROUND: Among patients with out-of-hospital cardiac arrest (OHCA) and ventricular fibrillation, more than half present with refractory ventricular fibrillation unresponsive to initial standard advanced cardiac life support (ACLS) treatment. We did the first randomised clinical trial in the USA of extracorporeal membrane oxygenation (ECMO)-facilitated resuscitation versus standard ACLS treatment in patients with OHCA and refractory ventricular fibrillation. METHODS: For this phase 2, single centre, open-label, adaptive, safety and efficacy randomised clinical trial, we included adults aged 18-75 years presenting to the University of Minnesota Medical Center (MN, USA) with OHCA and refractory ventricular fibrillation, no return of spontaneous circulation after three shocks, automated cardiopulmonary resuscitation with a Lund University Cardiac Arrest System, and estimated transfer time shorter than 30 min. Patients were randomly assigned to early ECMO-facilitated resuscitation or standard ACLS treatment on hospital arrival by use of a secure schedule generated with permuted blocks of randomly varying block sizes. Allocation concealment was achieved by use of a randomisation schedule that required scratching off an opaque layer to reveal assignment. The primary outcome was survival to hospital discharge. Secondary outcomes were safety, survival, and functional assessment at hospital discharge and at 3 months and 6 months after discharge. All analyses were done on an intention-to-treat basis. The study qualified for exception from informed consent (21 Code of Federal Regulations 50.24). The ARREST trial is registered with ClinicalTrials.gov, NCT03880565. FINDINGS: Between Aug 8, 2019, and June 14, 2020, 36 patients were assessed for inclusion. After exclusion of six patients, 30 were randomly assigned to standard ACLS treatment (n=15) or to early ECMO-facilitated resuscitation (n=15). One patient in the ECMO-facilitated resuscitation group withdrew from the study before discharge. The mean age was 59 years (range 36-73), and 25 (83%) of 30 patients were men. Survival to hospital discharge was observed in one (7%) of 15 patients (95% credible interval 1·6-30·2) in the standard ACLS treatment group versus six (43%) of 14 patients (21·3-67·7) in the early ECMO-facilitated resuscitation group (risk difference 36·2%, 3·7-59·2; posterior probability of ECMO superiority 0·9861). The study was terminated at the first preplanned interim analysis by the National Heart, Lung, and Blood Institute after unanimous recommendation from the Data Safety Monitoring Board after enrolling 30 patients because the posterior probability of ECMO superiority exceeded the prespecified monitoring boundary. Cumulative 6-month survival was significantly better in the early ECMO group than in the standard ACLS group. No unanticipated serious adverse events were observed. INTERPRETATION: Early ECMO-facilitated resuscitation for patients with OHCA and refractory ventricular fibrillation significantly improved survival to hospital discharge compared with standard ACLS treatment. FUNDING: National Heart, Lung, and Blood Institute.

Criterios de triaje para reanimación cardiopulmonar y soporte vital avanzado durante la epidemia COVID-19 / Triage criterio for cardiopulmonary resuscitation and advanced life support during the COVID-19 epidemic

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[Recommendations on cardiopulmonary resuscitation in patients with suspected or confirmed SARS-CoV-2 infection (COVID-19). Executive summary]. / Recomendaciones sobre reanimación cardiopulmonar en pacientes con sospecha o infección confirmada por SARS-CoV-2 (COVID-19). Resumen ejecutivo.

The SARS-CoV-2 pandemic has created new scenarios that require modifications to the usual cardiopulmonary resuscitation protocols. The current clinical guidelines on the management of cardiorespiratory arrest do not include recommendations for situations that apply to this context. Therefore, the National Cardiopulmonary Resuscitation Plan of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), in collaboration with the Spanish Group of Pediatric and Neonatal CPR and with the Teaching Life Support in Primary Care program of the Spanish Society of Family and Community Medicine (SEMFyC), have written these recommendations, which are divided into 5 parts that address the main aspects for each healthcare setting. This article consists of an executive summary of them.