Resuscitation - Articles in Press

Use of beta-blockers for the Treatment of Cardiac Arrest due to Ventricular Fibrillation/Pulseless Ventricular Tachycardia: a Systematic Review. - Accepted Manuscript

2012-02-03

Abstract: Introduction: Advanced Life Support guidelines recommend the use of epinephrine during Cardiopulmonary Resuscitaion (CPR), as to increase coronary blood flow and perfusion pressure through its alpha-adrenergic peripheral vasoconstriction, allowing minimal rises in coronary perfusion pressure to make defibrillation possible. Contrasting to these alpha-adrenergic effects, epinephrine's beta-stimulation may have deleterious effects through an increase in myocardial oxygen consumption and a reduction of subendocardial perfusion, leading to postresuscitation cardiac dysfunction. Objective: The present paper consists of a systematic review of the literature regarding the use of beta-blockade in cardiac arrest due to ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT). Methods: Studies were identified through MEDLINE electronic databases research and were included those regarding the use of beta-blockade during CPR. Results: Beta-blockade has been extensively studied in animal models of CPR. These studies not only suggest that beta-blockade could reduce myocardial oxygen requirements and the number of shocks necessary for defibrillation, but also improve postresuscitation myocardial function, diminish arrhythmia recurrences and prolong survival. A few case reports described successful beta-blockade use in patients, along with two prospective human studies, suggesting that it could be safe and effectively used during cardiac arrest in humans. Conclusion: Even though the existing literature points towards a beneficial effect of beta-blockade in patients presenting with cardiac arrest due to VF/pulseless VT, high quality human trials are still lacking to answer this question definitely.

Comparison of Methods for the Determination of Cardiopulmonary Resuscitation Chest Compression Fraction - Accepted Manuscript

2012-02-03

Abstract: Objective: While cardiopulmonary resuscitation (CPR) chest compression fraction (CCF) is associated with out-of-hospital cardiac arrest (OHCA) outcomes, there is no standard method for the determination of CCF. We compared nine methods for calculating CCF.Methods: We studied consecutive adult OHCA patients treated by Alabama Emergency Medical Services (EMS) agencies of the Resuscitation Outcomes Consortium (ROC) during Jan. 1, 2010 - Oct. 28, 2010. Paramedics used portable cardiac monitors with real-time chest compression detection technology (LifePak 12, Physio-Control, Redmond, Washington). We performed both automated CCF calculation for the entire care episode as well as manual review of CPR data in 1-minute epochs, defining CCF as the proportion of each treatment interval with active chest compressions. We compared the CCF values resulting from 9 calculation methods: 1) mean CCF for the entire patient care episode (automated calculation by manufacturer software), 2) mean CCF for first 3minutes of patient care, 3) mean CCF for first 5minutes, 4) mean CCF for first 10minutes, 5) mean CCF for the entire episode except first 5minutes, 6) mean CCF for last 5minutes, 7) mean CCF from start to first shock, 8) mean CCF for the first half of resuscitation, 9) mean CCF for the second half of resuscitation. We compared CCF for Methods 2-9 with Method 1 using paired t-tests with a Bonferroni-adjusted p-value of 0.006 (99.5% confidence intervals).Results: Among 102 adult OHCA, patient demographics were: mean age 60.3 years (SD 20.8 years), African American 56.9%, male 63.7%, and shockable ECG rhythm 23.5%. Mean CPR duration was 728seconds (95% CI: 647-809seconds). Mean CCF for the 9 CCF calculation methods were: 1) 0.587; 2) 0.526; 3) 0.541; 4) 0.566; 5) 0.562; 6) 0.597; 7) 0.530; 8) 0.550; 9) 0.590%. Compared with Method 1, Method 7 CCF (start to first shock) was slightly lower (-0.057; 99.5% CI: -0.100–(-0.014)). There were no other statistically significant CCF differences (range:-0.054-0.013). Correlation between CCF 2-9 and CCF varied (ρ=0.48-0.85).Conclusion: CCF varies minimally with different calculation methods. Automated CCF determination may prove sufficient for evaluating CPR quality.

Emergency Physician-Initiated Extracorporeal Cardiopulmonary Resuscitation - Accepted Manuscript

2012-02-03

Abstract: Context: Extracorporeal cardiopulmonary resuscitation (ECPR) refers to emergent percutaneous veno-arterial cardiopulmonary bypass to stabilize and provide temporary support of patients who suffer cardiopulmonary arrest. Initiation of ECPR by emergency physicians with meaningful long-term patient survival has not been demonstrated.Objective: To determine whether emergency physicians could successfully incorporate ECPR into the resuscitation of patients who present to the emergency department (ED) with cardiopulmonary collapse refractory to traditional resuscitative efforts.Design: A three-stage algorithm was developed for ED ECPR in patients meeting inclusion/exclusion criteria. We report a case series describing our experience with this algorithm over a one-year period.Results: 42 patients presented to our ED with cardiopulmonary collapse over the one-year study period. Of these, 18 patients met inclusion/exclusion criteria for the algorithm. 8 patients were admitted to the hospital after successful ED ECPR and 5 of those patients survived to hospital discharge neurologically intact. 10 patients were not started on bypass support because either their clinical conditions improved or resuscitative efforts were terminated.Conclusion: Emergency physicians can successfully incorporate ED ECPR in the resuscitation of patients who suffer acute cardiopulmonary collapse. More studies are necessary to determine the true efficacy of this therapy.

Perturbation of the Endothelial Glycocalyx in Post Cardiac Arrest Syndrome - Accepted Manuscript

2012-02-03

Abstract: Background: The prognosis of immediate survivors of cardiac arrest remains poor, as the majority of these patients develops an inflammatory disorder known as the post-cardiac arrest syndrome (PCAS). Recently, the endothelial glycocalyx has been shown to be a key modulator of vascular permeability and inflammation, but its role in PCAS remains unknown.Methods: Plasma levels of the glycocalyx components syndecan-1, heparan sulfate and hyaluronic acid were measured in 25 patients after immediate survival of cardiac arrest during different phases of PCAS. Twelve hemodynamically stable patients with acute coronary syndrome served as controls.Results: Cardiac arrest resulted in a significant increase in syndecan-1, heparan sulfate and hyaluronic acid levels compared to controls, indicating a shedding of the endothelial glycocalyx as a pathophysiological component of the post cardiac arrest syndrome. The time course differed between the individual glycocalyx components, with a higher increase of syndecan-1 in the early phase of PCAS (2.8-fold increase vs. controls) and a later peak of heparan sulfate (1.7-fold increase) and hyaluronic acid (2-fold increase) in the intermediate phase. Only the plasma levels of syndecan-1 correlated positively with the duration of CPR and negatively with the glycocalyx-protective protease inhibitor antithrombin III. Plasma levels of both syndecan-1 and heparan sulfate were higher in eventual non-survivors than in survivors of cardiac arrest.Conclusion: Our data for the first time demonstrates a perturbation of the endothelial glycocalyx in immediate survivors of cardiac arrest and indicate a potential important role of this endothelial surface layer in the development of post-cardiac arrest syndrome.

Long-term prognosis following resuscitation from out-of-hospital cardiac arrest: role of aetiology and presenting arrest rhythm - Accepted Manuscript

Florence Dumas, Thomas D. Rea — 2012-02-03

Abstract: Objective: Little is known about long-term prognosis following resuscitation from out-of-hospital cardiac arrest, especially as it relates to the presenting rhythm or arrest aetiology. We investigated long-term survival among those discharged alive following resuscitation according to presenting rhythm and arrest aetiology.Methods: We conducted a cohort investigation of all non-traumatic adult out-of-hospital cardiac arrest patients resuscitated and discharged alive from hospital between January 1, 2001 and December 31, 2009 in a large metropolitan emergency medical service system. Information about demographics, circumstances, presenting arrest rhythm and aetiology was collected using the dispatch, EMS, and hospital records. Long-term vital status was ascertained using state death records and the Social Security Death Index through 31st Dec 2010. We used Kaplan Meier to evaluate survival.Results: During the study period, a total of 1001/5958 (17%) persons were resuscitated and discharged alive, of whom 313/1001 (31%) presented with a non-shockable rhythm and 210/1001 (21%) had a non-cardiac aetiology. Overall median survival was 9.8 years with 64% surviving >5 years. Five-year survival was 43% for non-shockable rhythms compared to 73% for shockable rhythms, and 45% for non-cardiac aetiology compared to 69% for cardiac aetiology (p<0.001 respectively).Conclusion: Cardiac arrest due to non-shockable rhythm or non-cardiac aetiology comprises a substantial proportion of those who survive to hospital discharge. Although long-term survival in these groups is less than their shockable or cardiac aetiology counterparts, nearly half are alive 5 years following discharge. The findings support efforts to improve resuscitation care for those with non-shockable rhythms or non-cardiac cause.

Prediction of the neurological outcome with intrathecal high mobility group box 1 and S100B in cardiac arrest victims: A pilot study - Accepted Manuscript

2012-02-03

Abstract: Objectives: To investigate whether high mobility group box 1 (HMGB1) and S100B in cerebrospinal fluid (CSF) and the serum predict the neurological outcome in patients resuscitated from out-of-hospital cardiac arrest (OHCA).Materials and methods: This study was designed as a prospective observational study. Twenty-five patients, who received standard cardiopulmonary resuscitation and post-resuscitation intensive care, were enrolled in this study. The patients were divided into two groups according to Glasgow-Pittsburgh Cerebral Performance categories (CPCs) at 6 months after return of spontaneous circulation (ROSC), Group G (n=7, CPC 1 or 2) and Group P (n=18, CPC ≥ 3). Their blood samples were taken at 6, 24, and 48hours after ROSC. The patients, whose CSF was sampled at 48hours, were also divided into either sub-Group G (n=6) or sub-Group P (n=8) at 6 months after ROSC.Results: HMGB1 and S100B in CSF in sub-Group P were significantly higher than those in sub-Group G (HMGB1,<1.0 vs. 12.4ng/ml, P=0.009; S100B, 2.68 vs. 84.2ng/ml, P=0.007, respectively). HMGB1 in CSF was strongly correlated with S100B (σ=0.81, P=0.001). HMGB1 was elevated in serum at 6hours and normalized within 48hours after ROSC without any significant differences between the two groups. Serum S100B in Group P was significantly higher than that in Group G at each time point.Conclusions: The significant elevations of HMGB1 and S100B in CSF, and S100B in serum are associated with the neurologically poor outcome in OHCA patients.

Eleven years of experience with extracorporeal cardiopulmonary resuscitation for pediatric patients with in-hospital cardiac arrest - Accepted Manuscript

2012-02-03

Abstract: Purpose: To describe 11 years of experience with extracorporeal cardiopulmonary resuscitation (ECPR) for in-hospital pediatric cardiac arrest in a university affiliated tertiary care hospital.Methods: Pediatric patients who received extracorporeal membrane oxygenation (ECMO) during active cardiopulmonary resuscitation (ECPR) at our center from 1999 to 2009 were included in this retrospective study. The results from three different cohorts (1999-2001, 2002-2005, 2006-2009) were compared. Survival rates and neurological outcomes were analyzed. Favorable neurological outcome was defined as Pediatric Cerebral Performance Categories (PCPC) 1, 2, and 3.Results: We identified 54 ECPR events. The survival rate to hospital discharge was 46% (25/54), and 21 (84%) of the survivors had favorable neurological outcomes.The duration of cardiopulmonary resuscitation (CPR) was 39+/-17minutes in the survivors and 52+/- 45minutes in the non-survivors (p=N.S). The patients with pure cardiac causes of cardiac arrest had a similar survival rate to patients with non-cardiac causes (47% [18/38] vs 44% [7/16], p=NS)The non-survivors had higher serum lactate levels prior to ECPR (13.4+/-6.4 vs 8.8+/-5.1mmol/L, p<0.01) and more renal failure after ECPR (66% [19/29] vs 20% [5/25], p<0.01).The patients resuscitated between 2006 and 2009 had shorter durations of CPR (34+/- 13min vs 78+/- 76min, p=0.032), and higher rates of survival (55% (16/29) vs 0% (0/8), p=0.017) than those resuscitated between 1999 and 2002.Conclusions: In our single center experience with ECPR for pediatric in-hospital cardiac arrest, the duration of CPR has become shorter and outcomes have improved in recent years. Higher pre-ECPR lactate levels and the presence of post-ECPR renal failure were associated with increased mortality. The presence of non-cardiac causes of cardiac arrest did not preclude successful ECPR outcomes. The duration of CPR was not significantly associated with poor outcomes in this study.

Estimating the Impact of Off-Balancing Forces upon Cardiopulmonary Resuscitation during Transport of Out-of-Hospital Cardiac Arrest - Accepted Manuscript

Michael Christopher Kurz, Siddhartha A Dante, Brian J Puckett — 2012-02-03

Abstract: Title: Estimating the Impact of Off-Balancing Forces upon Cardiopulmonary Resuscitation during Ambulance TransportIntroduction: Survival from out-of-hospital cardiac arrest (OOH-CA) remains poor, especially when patients are transported with CPR in progress. Previous investigations suggest that CPR quality erodes during transport due to the austere environment. We sought to determine how frequently ambulance personnel are exposed to off-balancing forces during transport of OOH-CA patients and to estimate the potential impact on CPR and coronary perfusion pressure (CPP).Methods: An onboard monitoring system was utilized to record acceleration data during the transport of 50 OOH-CA patients. Acceleration vectors were calculated for every second of drive time (speed>0mph). A model was constructed to estimate the potential impact of these vectors upon CPR and CPP. These data were then compared to a case-control cohort of 102 matched non-urgent transports.Results: A total of 5.8hours of drive time was analyzed in the cardiac arrest cohort. Mean transport time was 8min 53sec with a mean drive time of 6min 58sec. Critical acceleration threshold was exceeded 60% of transport time (202.42min, mean 4.05min/per transport) yielding a potential hands-off ratio of 0.42 with a CPP<15mmHg 62% of drive time. Ambulance speed was inversely related to the magnitude of off-balancing forces. Comparison to 14.1hours of control cohort yielded similar off-balancing forces and relationships despite lower speeds and no “lights and siren” use.Conclusion: Critical acceleration forces occur frequently during transport of OOH-CA patients and may directly affect both CPR quality and thereby CPP. These force vectors are stronger and more frequent at slower speeds, comprising the majority of ambulance drive time. Reducing speed or transporting OOH-CA patients without lights and sirens does little to mitigate these forces.

Supraglottic Airway Device Preference and insertion speed in F1 doctors - Accepted Manuscript

Michael Adlam, Dan Purnell — 2012-02-02

The Development and Assessment of an Evaluation Tool for Pediatric Resident Competence in Leading Simulated Pediatric Resuscitations - Accepted Manuscript

2012-01-30

Abstract: Introduction: It is critical that competency in pediatric resuscitation is achieved and assessed during residency or post graduate medical training. The purpose of this study was to create and evaluate a tool to measure all elements of pediatric resuscitation team leadership competence.Methods: An initial set of items, derived from a literature review and a brainstorming session, were refined to a 26 item assessment tool through the use of Delphi methodology. The tool was tested using videos of standardized resuscitations. A psychometric assessment of the evidence for instrument validity and reliability was undertaken.Results: The performance of 30 residents on two videotaped scenarios was assessed by 4 pediatricians using the tool, with 12 items assessing ‘leadership and communication skills’ (LCS) and 14 items assessing ‘knowledge and clinical skills’ (KCS). The instrument showed evidence of reliability; the Cronbach's alpha and generalizability co-efficients for the overall instrument were α=0.818 and Ep2=0.76, for LCS were α=0.827 and Ep2=0.844, and for KCS were α=0.673 and Ep2=0.482. While validity was initially established through literature and brainstorming by the panel of experts, it was further built through the high strength of correlation between global scores and scores for overall performance (r=0.733), LCS (r=0.718) and KCS (r=0.662) as well as the factor analysis which accounted for 40.2% of the variance.Conclusion: The results of the study demonstrate that the instrument is a valid and reliable tool to evaluate pediatric resuscitation team leader competence.

Magnetically targeted drug delivery during cardiopulmonary resuscitation and post-resuscitation period - Accepted Manuscript

2012-01-30

Abstract: Treatment with pharmacological agents is frequently required during cardiopulmonary resuscitation efforts and almost always during the post-resuscitation period. However, the lack of scientific evidence, the potent side effects, and the association of resuscitation drugs with poor outcome act as a disincentive for their use. The use of magnetic nanoparticles in medicine has great potential. Magnetically targeted drug-delivery may be an ideal method of pharmaceutical treatment during the resuscitation efforts and post-resuscitation period. In addition, there is evidence that magnetic nanotechnology may be used in the detection of post-cardiac arrest brain injury. In the light of poor survival of cardiac arrest victims, research in cardiopulmonary resuscitation should focus on this promising technology as soon as possible.

Sodium nitroprusside ameliorates systemic but not pulmonary HBOC-201-induced vasoconstriction: an exploratory study in a swine controlled haemorrhage model - Accepted Manuscript

2012-01-30

Abstract: Background: Vasoconstriction is a side effect that may prevent the use of haemoglobin based oxygen carrier (HBOC) as blood substitute. Therefore, we tested the hypothesis that the NO donor, sodium nitroprusside (SNP), would mitigate systemic and pulmonary hypertension associated with HBOC-201 in a simple controlled haemorrhage swine modelMethods: After 55% estimated blood volume withdrawal through a venous catheter, invasively anesthetized and instrumented animals were resuscitated with three 10ml/kg infusions of either HBOC-201 or Hextend (HEX) with or without 0.8μg/kg/min SNP (infused concomitantly via different lines). Haemodynamics, direct and indirect measures of tissue oxygenation, and coagulation were measured for 2hours.Results: Haemorrhage caused a state of shock manifested by hypotension and base deficit. HBOC-201 resuscitation resulted in higher systemic (p<0.0001) and pulmonary (p<0.002) blood pressure than with HEX. Elevation of systemic (p<0.0001) but not pulmonary (p>0.05) arterial pressure was attenuated by co-infusion of SNP, without significant group differences in haemodynamics, tissue oxygenation, platelet function, coagulation, methaemoglobin, or survival (p>0.05).Conclusion: In swine with haemorrhagic shock, co-administration of the NO donor, SNP, effectively and safely reduces HBOC-201-related systemic but not pulmonary vasoactivity. Interestingly, co-administration of the vasodilator SNP with HEX had no deleterious effects in comparison with HEX alone.

Teaching resuscitation in schools: annual tuition by trained teachers is effective starting at age 10. A four-year prospective cohort study - Accepted Manuscript

2012-01-30

Abstract: Aims: Evaluation of school pupils’ resuscitation performance after different types of training relative to the effects of training frequency (annually vs. biannually), starting age (10 vs. 13 years) and facilitator (emergency physician vs. teacher).Methods: Prospective longitudinal study investigating 433 pupils in training and control groups. Outcome criteria were chest compression depth, compression frequency, ventilation volume, ventilation frequency, self-image and theoretical knowledge. In the training groups, 251 pupils received training annually or biannually either from emergency physicians or CPR-trained teachers. The control group without any training consisted of 182 pupils.Results: Improvements in training vs. control groups were observed in chest compression depth (38 vs. 24mm), compression frequency (74 vs. 42/min), ventilation volume (734ml vs. 21ml) and ventilation frequency (9/min vs. 0/min). Numbers of correct answers in a written test improved by 20%, vs. 5% in the control group. Pupils starting at age 10 showed practical skills equivalent to those starting at age 13. Theoretical knowledge was better in older pupils. Self-confidence grew in the training groups. Neither more frequent training nor training by emergency physicians led to better performance among the pupils.Conclusions: Pupils starting at age 10 are able to learn cardiopulmonary resuscitation with one annual training course only. After a 60-minute CPR-training update, teachers are able to provide courses successfully. Early training reduces anxieties about making mistakes and markedly increases participants’ willingness to help. Courses almost doubled the confidence of pupils that what they had learned would enable them to save lives.

Cannabinoid 1 (CB1) Receptor Mediates WIN55, 212-2 Induced Hypothermia and Improved Survival in a Rat Post-Cardiac Arrest Model - Accepted Manuscript

Yinlun Weng, Shijie Sun, Jeonghyun Park, Sen Ye, Max Harry Weil, Wanchun Tang — 2012-01-30

Abstract: Aim: The nonselective cannabinoid (CB) receptor agonist, WIN55, 212-2, was demonstrated to induce hypothermia and improve post-resuscitation outcomes in a rat post- cardiac arrest model. The present study was to explore the potential mechanisms of WIN55, 212-2 on thermoregulation following resuscitation and to investigate which class of CB receptors was involved in WIN55, 212-2-induced hypothermia.Methods: Ventricular fibrillation (VF) was induced and untreated for 6min in 20 male Sprague-Dawley rats. Defibrillation was attempted after 8min of Cardiopulmonary resuscitation (CPR). Five min post-resuscitation, resuscitated animals were randomized to receive an intramuscular injection of selective CB1 receptors antagonist, SR141716A (5 mg·kg−1); selective CB2 receptors antagonist SR144528 (5 mg·kg−1); or placebo. Thirty min after injection, animals received continuous intravenous infusion of WIN55, 212-2 (1.0 mg·kg−1·hr−1) for 4h while control animals received placebo. The identical temperature environment was maintained in all animals.Results: In animals treated with WIN55, 212-2, blood temperatures decreased progressively from 37°C to 34°C within 4h. This hypothermic effect was completely blocked by CB1 but not CB2 antagonist. Accordingly, significantly better cardiac output, ejection fraction and myocardial performance index, reduced neurological deficit scores, improved microcirculation and longer duration of survival were observed in WIN55, 212-2-treated animals, which were also completely abolished by pretreatment with CB1 antagonist.Conclusions: Pharmacologically induced hypothermia with WIN55, 212-2 improved post-resuscitation myocardial and cerebral function, associated with a significantly increased duration of survival in a rat post-cardiac arrest model. The hypothermic and resulted beneficial effects of WIN55, 212-2 were mediated through CB1 receptors.

A New Age-Based Formula for Estimating Weight of Korean Children - Accepted Manuscript

2012-01-30

Abstract: Objectives: The objective of this study was to develop and validate a new age-based formula for estimating body weights of Korean children.Methods: We obtained body weight and age data from a survey conducted in 2005 by the Korean Pediatric Society that was performed to establish normative values for Korean children. Children aged 0 to 14 were enrolled, and they were divided into three groups according to age; infants (<12 months), preschool-aged (1-4 years) and school-aged children (5-14 years). Seventy-five percent of all subjects were randomly selected to make a derivation set. Regression analysis was performed in order to produce equations that predict the weight from the age for each group. The linear equations derived from this analysis were simplified to create a weight estimating formula for Korean children. This formula was then validated using the remaining 25% of the study subjects with mean percentage error and absolute error. To determine whether a new formula accurately predicts actual weights of Korean children, we also compared this new formula to other weight estimation methods (APLS, Shann formula, Leffler formula, Nelson formula and Broselow tape) in order to determine whether it accurately predicted the actual weights of Korean children.Results: A total of 124,095 children's data were enrolled, and 19,854 (16.0%), 40,612 (32.7%) and 63,629 (51.3%) were classified as infants, preschool-aged, and school-aged groups, respectively. Three equations, (age in months+9)/2, 2×(age in years)+9 and 4×(age in years) - 1 were derived for infants, pre-school and school-aged groups, respectively. When these equations were applied to the validation set, the actual average weight of those children was 0.4kg heavier than our estimated weight (95% CI=0.37 to 0.43, p<0.001). The mean percentage error of our model (+0.9%) was lower than APLS (-11.5%), Shann formula (-8.6%), Leffler formula (-1.7%), Nelson formula (-10.0%), Best Guess formula (+5.0%) and Broselow tape (-4.8%) for all age groups.Conclusion: We developed and validated a simple formula to estimate body weight from the age of Korean children and found that this new formula was more accurate than other weight estimating methods. However, care should be taken when applying this formula to older children because of a large standard deviation of estimated weight.

Life support techniques related to survival after out-of-hospital cardiac arrest in infants - Accepted Manuscript

Takeru Abe, Takashi Nagata, Manabu Hasegawa, Akihito Hagihara — 2012-01-30

Abstract: Aim of the study: The incidence rate of out-of-hospital cardiac arrest (OHCA) among infants is high; however, little is known about effective life-support for this group. Thus, we examined factors related to 1-month survival after OHCA among infants.Methods: All infant OHCA cases occurring between 2005 and 2008 in Japan were extracted from the National Utstein Registry. Split-half random sampling and signal detection analysis were used to identify the effective factors on1-month survival after OHCA.Results: The mutual interaction of life support techniques and other factors were identified and used to divide the study population into five subgroups. A witness to the cardiac arrest, rescue breathing administered by a bystander, and less than 18min to hospital arrival or a witness to the arrest, no rescue breathing and less than 7min for the ambulance to arrive at the scene were found to be related to higher survival after OHCA in infants. The survival proportions for these subgroups were 44.83% (95% CI: 25.58-64.08) and 19.18% (95% CI: 14.64-23.72), respectively.Conclusion: The probability of survival after OHCA in infants may be improved by a bystander witnessing the arrest and providing the rescue breathing at the first sight of arrest.

Peer-led training and assessment in basic life support for healthcare students: synthesis of literature review and fifteen years practical experience - Accepted Manuscript

P.R. Harvey, C.V. Higenbottam, A. Owen, J. Hulme, J.F. Bion — 2012-01-27

Abstract: Background: In 1995, the University of Birmingham, UK, School of Medicine and Dentistry replaced lecture-based basic life support (BLS) teaching with a peer-led, practical programme. We present our 15-yr experience of peer-led healthcare undergraduate training and examination with a literature review.Methods: A literature review of healthcare undergraduate peer-led practical skills teaching was performed though Pubmed.The development of the Birmingham course is described, from its inception in 1995 to 2011. Training methods include peer-led training and assessment by senior students who complete an European Resuscitation Council-endorsed instructor course. Student assessors additionally undergo training in assessment and communication skills. The course has been developed by parallel research evaluation and peer-reviewed publication.1,2 Course administration is by an experienced student committee with senior clinician support. Anonymous feedback from the most recent courses and the current annual pass rates are reported.Results: The literature review identified 369 publications of which 28 met our criteria for inclusion. Largely descriptive, these are highly positive about peer involvement in practical skills teaching using similar, albeit smaller, courses to that described below.Currently approximately 600 first year healthcare undergraduates complete the Birmingham course; participant numbers increase annually. Successful completion is mandatory for students to proceed to the second year of studies. First attempt pass rate is 86%, and close to 100% (565/566 students, 99.8%) following re-assessment the same day. 97% of participants enjoyed the course, 99% preferred peer-tutors to clinicians, 99% perceived teaching quality as “good” or “excellent”, and felt they had sufficient practice. Course organisation was rated “good” or “excellent” by 91%. Each year 3-4 student projects have been published or presented internationally. The annual cost of providing the course is currently £15 594.70 (Eur 18 410), or approximately £26 (Eur 30) per student.Conclusions: This large scale, peer-led BLS course demonstrates that such programmes can have excellent outcomes with outstanding participant satisfaction. Peer-tutors and assessors are competent, more available and less costly than clinical staff. Student instructors develop skills in teaching, assessment and appraisal, organisation and research. Sustainability is possible given succession-planning and consistent leadership.

Survival and outcome prediction using the Apache III and the out-of-hospital cardiac arrest (OHCA) score in patients treated in the intensive care unit (ICU) following out-of-hospital, in-hospital or ICU cardiac arrest - Uncorrected Proof

M.B. Skrifvars, B. Varghese, M.J. Parr — 2012-01-27

Abstract: Background: There are few data comparing outcome and the utility of severity of illness scoring systems following intensive care after out-of-hospital (OHCA), in-hospital (IHCA) and intensive care unit (ICUCA) cardiac arrest. We investigated survival, factors associated with survival and the correlation and accuracy of general and specific scoring systems, including the Apache III score and the OHCA score in OHCA, IHCA and ICUCA patients.Material and methods: Prospective analysis of data on all cardiac arrest patients treated in a tertiary hospital between August 1st 2008 and July 30th 2010. Collected data included resuscitation and post-resuscitation care data as defined by the Utstein Guidelines, Apache III on admission and the OHCA score on admission in OHCA and IHCA patients and after the arrest in ICUCA patients. Statistical methods were used to identify factors associated with outcome and the predictive ability and correlation of the aforementioned scores.Results: Of a total of 3931 patients treated in the ICU, 51 were admitted following OHCA, 50 following IHCA and 22 suffered an ICUCA and had sustained return of spontaneous circulation (ROSC). Survival at 30 days was highest among ICUCAs (67%) followed by IHCAs (38%) and OHCAs (29%). Using multivariate analysis delay ROSC was the only independent predictor of survival. The OHCA score performed with moderate accuracy for predicting 30-day mortality (area under the curve 0.77 [0.69–0.86] and was slightly better than the Apache III score 0.71 (0.61–0.80). Using multiple logistic regression the Apache III and the OHCA score were both independent predictors of hospital survival and correlation between these two scores was weak (correlation coefficient of 0.244).Conclusions: Latency to ROSC seems to be the most important determinant of survival in patients following ICU care after a cardiac arrest in this single center trial. The OHCA score and the Apache III score offer moderate predictive accuracy in ICU cardiac arrest patients but correlated weakly with each other. Illness severity adjustment for cardiac arrest patients in ICU should include features of both these scoring systems.

Quantitative response of volumetric variables measured by a new ultrasound dilution method in a juvenile model of hemorrhagic shock and resuscitation - Uncorrected Proof

2012-01-27

Abstract: Objective: New volumetric variables of preload, such as total end-diastolic volume index (TEDVI) and active circulation volume index (ACVI) and central blood volume index (CBVI), may represent good indicators of preload and predictors of fluid responsiveness. During acute changes of intravascular volume these variables would allow a more accurate intervention.Aim: The aim of the present study was to investigate the changes in TEDVI, ACVI, CBVI in a juvenile model of hemorrhagic shock and resuscitation.Methods: Twelve anaesthetized ponies (3–8months of age) were studied at normovolaemia (BASE), after blood withdrawal to mean arterial pressure (MAP) of 40mmHg (HEMO), after infusion of norepinephrine to reach a MAP of ±10% of baseline (HE-NE), and after retransfusion of shed blood (RESU). TEDVI, ACVI, CBVI were measured by Ultrasound Dilution (UD) technology with CoStatus device. Data were analyzed using 1-way (ANOVA) followed by Bonferroni's multiple pairwise comparisons. Evaluation of dependence between CoStatus volumetric variables and stroke volume index (SVI) were performed using the linear regression analysis and calculating the r2 coefficient of determination.Results: TEDVI and ACVI changed significantly during HEMO and RESU status. NE administration induced MAP and CVP significant changes, whereas TEDVI and ACVI remained unchanged. CBVI showed high variability and seemed to be inconsistent on the identification of the volume status. In the correlation analysis, only TEDVI consistently correlated with SVI and volume induced SVI changes.Conclusions: In this animal model, TEDVI and ACVI were superior to CBVI in consistently reflecting hemorrhage. TEDVI but not ACVI and CBVI correlated with volume-induced changes in SVI. NE administration did not affect this correlation.

Prediction protocol for neurological outcome for survivors of out-of-hospital cardiac arrest treated with targeted temperature management - Uncorrected Proof

2012-01-27

Abstract: Aim: To identify patients who can obtain the full benefit from targeted temperature management (TTM) after out-of-hospital cardiac arrest.Methods: We performed a retrospective observational study of comatose patients treated with TTM after an out-of-hospital cardiac arrest from January 2006 to February 2011. Neurological outcome was evaluated with the Glasgow-Pittsburgh Cerebral Performance category (CPC) at discharge and predictors were determined.Results: Of 66 patients studied, 40 (60.6%) survived to neurologically intact discharge (CPC 1 or 2). According to multivariate analysis, predictors of good neurological outcome included arrest-to-first cardiopulmonary resuscitation attempt interval ≤5min, ventricular fibrillation or ventricular tachycardia in the first monitored rhythm, absence of re-arrest before leaving the emergency department, arrest-to-return of spontaneous circulation interval ≤30min and recovery of pupillary light reflex, which were identifiable in the emergency department. Based on this analysis, we developed a seven-point score (5-R score). If the score was ≥5, it predicted good neurological outcome with a sensitivity of 82.5% (95% confidence interval [CI], 67.2–92.7%) and specificity of 92.3% (95% CI, 74.9–99.1%). The negative predictive value of a score ≥4 was 100% (95% CI, 81.5–100%). Our prediction model was validated internally by a bootstrapping technique.Conclusions: The prediction protocol using the 5-R score was associated with good neurological outcome of patients treated with TTM. Therefore, it could be helpful in clinical decision making on whether to initiate cooling.

Technical factors weaken the clinical relevance of manikin measurements of mechanical chest compression depth - Uncorrected Proof

Anders Nilsson, Fred W. Chapman — 2012-01-24

The recent study by Blomberg et al. used measurements from a CPR training manikin to compare the timing and depth of chest compressions during CPR delivered manually and with a mechanical compression device. The study showed the LUCAS™2 Chest Compression System was applied quickly, without delaying the first defibrillation, and without increasing interruption in compressions compared to manual CPR. However, compressions delivered by LUCAS were reported to be too shallow. Important technical factors must be considered when evaluating whether these depth measurements are clinically relevant.

A randomized trial of compression first or analyze first strategies in patients with out-of-hospital cardiac arrest: Results from an Asian community - Uncorrected Proof

2012-01-24

Abstract: Background: It is still under debate whether a period of cardiopulmonary resuscitation should be performed prior to rhythm analysis for defibrillation for out of hospital cardiac arrests (OHCA). This study compared outcomes of OHCA treated by “compression first” (CF) versus “analyze first” (AF) strategies in an Asian community with low rates of shockable rhythms.Methods: This randomized trial was conducted in Taipei City between February 2008 and December 2009. Dispatches of suspected OHCA that activated advanced life support teams were randomized into the CF and AF strategies. Patients assigned to CF strategy received 10 cycles of CPR prior to analysis by automatic external defibrillator. The primary outcome was sustained (>2h) return of spontaneous circulation (ROSC) and secondary outcome was survival to hospital discharge.Results: We included 289 cases in the final analysis after exclusion by pre-specified criteria, 141 were allocated to CF strategy and 148 to AF strategy. Baseline characteristics were similar. Thirty-seven (26.2%) of those receiving CF strategy and 49 (33.1%) of the AF strategy achieved sustained ROSC (p=0.25). In a post-hoc analysis of patients who achieved ROSC, those that received CF strategy were more likely to be discharged alive from the hospital (16/37=43.2% vs. 11/49=22.4%, p=0.02).Conclusion: In this study population of low rates of shockable rhythms, there was no difference in ROSC for CF or AF strategies. Considering the EMS operation situations, a period of paramedic-administered CPR for up to 10 cycles prior to rhythm analysis could be a feasible strategy in this community.

Increased incidence of CPR-related rib fractures in infants – Is it related to changes in CPR technique? - Uncorrected Proof

2012-01-24

The article entitled “Increased incidence of CPR-related rib fractures in infants – Is it related to changes in CPR technique?” is a valuable addition to the clinical and forensic literature, assessing the causes of infant rib fractures. We would value further clarification of a number of points, however.

Resuscitation of Non-postcardiotomy Cardiogenic Shock or Cardiac Arrest with Extracorporeal Life Support: The Role of Bridging to Intervention - Accepted Manuscript

2012-01-24

Abstract: Background: : To investigate the predictors of adverse outcomes of extracorporeal life support (ECLS) in rescuing adult non-postcardiotomy cardiogenic shock or cardiac arrest (non-PC CS/CA).Materials and Methods: : This retrospective study included 60 adult patients receiving ECLS for non-PC CS/CA in a single institution between June 2003 and June 2010. The exclusion criteria were (1) pre-ECLS cardiac surgeries in the same admission, and (2) age <18 years. Pre-ECLS and ECLS characteristics were compared in patients surviving to hospital discharge and those who did not. Mortalities after hospital discharge were also investigated.Results: : Of the 38 patients weaned from ECLS, 32 survived to discharge. Acute myocardial infarction (AMI) and myocarditis were the most common etiologies in this study. Forty patients experienced pre-ECLS conventional cardiopulmonary resuscitation (C-CPR) and 29 required an ECLS-assisted CPR (E-CPR). Thirteen patients that received E-CPR had profound anoxic encephalopathy later. In-hospital mortality was similar in AMI patients who underwent emergent coronary artery bypass grafting (CABG) after a failed percutaneous coronary intervention (PCI, 43%, 5/11) and those who underwent PCI only (58%, 7/12). Etiologies other than myocarditis [odds ratio (OR) 11.0, 95% confidence interval (CI) 1.5–78.5], requirement for E-CPR (OR 5.6, 95% CI 1.5–22.0), and profound anoxic encephalopathy (OR 8.9, 95% CI 2.0–40.5) were predictors of in-hospital mortality. No risk factors of mortality after hospital discharge were identified.Conclusion: : ECLS was effective in bridging adults with non-PC CS/CA to definite treatments. Their prognosis depended on the cause of collapse and the severity of the post-cardiac arrest syndrome.

Response to Letter: Increased incidence of CPR-related rib fractures in infants – Is it related to changes in CPR technique? - Uncorrected Proof

Jeanette A. Reyes, Gino R. Somers, Glenn P. Taylor, David A. Chiasson — 2012-01-24

We appreciate the Letter to the Editor by Martin et al., and welcome the opportunity to respond. Identification of the study population was based upon the cause of the fractures, as determined from autopsy findings and information gathered by the Coroner and police investigators. None of the study cases had a history of accidental trauma; nor was there any circumstantial or pathological evidence of inflicted trauma/abuse. Incidences of acute posterior segment rib fractures were not identified. Microscopic examination confirmed the lack of a cellular inflammatory reaction at the fracture site, in keeping with an immediate peri-mortem event.

Regarding “Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial” - Uncorrected Proof

Scott T. Youngquist, James T. Niemann — 2012-01-20

As the only randomised, controlled, double-blind trial of adrenaline vs. placebo for out-of-hospital cardiac arrest, the study by Jacobs et al. represents the most rigorously obtained data on this topic to date. A frequentist interpretation of the data requires the admission that we are unable to reject the null hypothesis of no effect on survival to hospital discharge rate because the P value is 0.15 (and correspondingly, the 95% confidence intervals crosses unity). However, such an all-or-nothing interpretation has been widely criticised by methodologists for promoting “the P value fallacy, the mistaken idea that a single number can capture both the long-run outcomes of an experiment and the evidential meaning of a single result.” (Goodman SN, Ann Intern Med. 1999;130:995–1004.)

Comparison of historical anatomic landmarks vs. ultrasound guidance for the selection of a needle insertion site for jugular central venous access - Uncorrected Proof

2012-01-20

Ultrasound (US) has revolutionised central venous access. Historical anatomic landmarks have been progressively abandoned as ultrasound guidance has shown it improved central venous access. Nevertheless, US devices are not always available. Therefore, historical anatomic landmarks are still used. The aim of this study was to compare needle insertion sites (NIS) provided by anatomic landmarks or ultrasound guidance for internal jugular venous access.

Reply to Letter: Regarding “Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial” - Uncorrected Proof

2012-01-20

We thank the authors for their comments regarding our study and proposing an alternative approach to the analysis and interpretation of the data. While a frequentist interpretation of the data is what most researchers and readers of the literature are familiar with, it is reasonable that a Bayesian approach be considered.

Conceptual models of coronary perfusion pressure and their relationship to defibrillation success in a porcine model of prolonged out-of-hospital cardiac arrest - Uncorrected Proof

Joshua C. Reynolds, David D. Salcido, James J. Menegazzi — 2012-01-20

Abstract: Introduction: The amount of myocardial perfusion required for successful defibrillation after cardiac arrest is unknown. Coronary perfusion pressure (CPP) is a surrogate for myocardial perfusion. One limited clinical study identifies a threshold of 15mmHg required for return of spontaneous circulation (ROSC). Our exploration of threshold and dose models of CPP during the initial bout of CPR indicates higher levels than previously demonstrated are required. CPP required for shock success throughout on-going resuscitation is unknown and other conceptual models of CPP have not been explored.Hypothesis: An array of conceptual models of CPP is associated with and predicts defibrillation success throughout resuscitation.Methods: Data from 6 porcine cardiac arrest studies were pooled. Mean and area under the curve (AUC) CPP were derived for 30-s epochs. Five conceptual models of CPP were analyzed: threshold, delta, cumulative delta, dose, and cumulative dose. Comparative statistics were performed with one-way ANOVA and two-tailed t-test. Regression models assessed CPP trends and prediction of ROSC.Results: For 316 defibrillation attempts in 124 animals, those resulting in ROSC (n=75) had significantly higher threshold, delta, cumulative delta, dose, and cumulative dose CPP than those without. All conceptual models except delta CPP had significantly different values across successive defibrillation attempts and all five models were significant predictors of ROSC, along with experimental design.Conclusions: Threshold, delta, cumulative delta, dose, and cumulative dose CPP predict individual defibrillation success throughout resuscitation.

Neonatal resuscitation: In pursuit of evidence gaps in knowledge - Corrected Proof

2012-01-16

Abstract: Guidelines for the techniques of resuscitating newly born infants have undergone major revisions over the past 25 years. The International Liaison Committee on Resuscitation (ILCOR) is committed to “periodically developing and publishing a consensus on resuscitation science” every five years with the most recent Consensus on Science and Treatment Recommendations (CoSTR) statement published in 2010. The CoSTR document is used as a basis for developing specific resuscitation guidelines felt to be appropriate for implementation in respective countries. A “gaps in knowledge” summary is created at the conclusion of a cycle. It is a goal that identification of these knowledge gaps will stimulate investigators to pursue more targeted studies to help close the gaps. The current document is based on the “gaps in knowledge” summary for neonatal resuscitation that was created at the conclusion of the 2005–2010 ILCOR cycle.

Is the Modified Early Warning Score (MEWS) superior to clinician judgement in detecting critical illness in the pre-hospital environment? - Corrected Proof

2012-01-16

Abstract: Aim: Physiological track and trigger scores have an established role in enhancing the detection of critical illness in hospitalized patients. Their potential to identify individuals at risk of clinical deterioration in the pre-hospital environment is unknown. This study compared the predictive accuracy of the Modified Early Warning Score (MEWS) with current clinical practice.Methods: A retrospective observational cohort study of consecutive adult (≥16 yrs) emergency department attendances to a single centre over a two-month period. The outcome of interest was the occurrence or not of an adverse event within 24h of admission. Hospital pre-alerting was used as a measure of current critical illness detection and its accuracy compared with MEWS scores calculated from pre-hospital observations.Results: 3504 patients were included in the study. 76 (2.5%) suffered an adverse event within 24h of admission. Paramedics pre-alerted the hospital in 224 cases (7.3%). Clinical judgement demonstrated a sensitivity of 61.8% (95% CI 51.0–72.8%) with a specificity of 94.1% (95% CI 93.2–94.9%). MEWS was a good predictor of adverse outcomes and hence critical illness detection (AUC 0.799, 95% CI 0.738–0.856). Combination systems of MEWS and clinical judgement may be effective MEWS ≥4+clinical judgement: sensitivity 72.4% (95% CI 62.5–82.7%), specificity 84.8% (95% CI 83.52–86.1%).Conclusions: Clinical judgement alone has a low sensitivity for critical illness in the pre-hospital environment. The addition of MEWS improves detection at the expense of reduced specificity. The optimal scoring system to be employed in this setting is yet to be elucidated.

Molecular mechanisms of therapeutic hypothermia on neurological function in a swine model of cardiopulmonary resuscitation - Uncorrected Proof

2012-01-13

Abstract: Objective: To explore the molecular mechanisms by which mild hypothermia following resuscitation improves neurological function in a porcine model of cardiac arrest.Methods: Thirty-three inbred Chinese Wuzhishan (WZS) minipigs were used. After 8min of untreated ventricular fibrillation (VF), the surviving animals (n=29) were randomly divided into two groups including serum group (n=16) and molecular group (n=13). Serum group animals were used to measure porcine-specific tumour necrosis factor (TNF)-α, interleukin (IL)-6, IL-10, matrix metalloproteinase (MMP9), Aquaporin-4 (AQP4), tissue inhibitor to metalloproteinase-1 (TIMP1), neuron-specific enolase (NSE) and S100B at 0.5h, 6h, 12h, 24h and 72h recovery by enzyme-linked immunosorbent assay (ELISA). Molecular group animals were used to measure cerebral cortex messenger RNA (mRNA) and protein expression of nuclear factor-κB (NF-κB), MMP9 and AQP4 by real-time (RT) quantitative polymerase chain reaction (PCR) and Western blotting at 24h and 72h recovery. Animals were further divided into either normothermia or hypothermia groups. Hypothermia (33°C) was maintained for 12h using an endovascular cooling device. Swine neurologic deficit scores (NDS) were used to evaluate neurological function at 24-h and 72-h recovery.Results: Twenty-nine of the 33 (87.9%) animals were successfully resuscitated. The hypothermia group exhibited higher survival rates at 24h (75%) and 72h (62.5%) compared to the normothermia group (37.5% and 25%, respectively). Hypothermia markedly inhibited expression of NF-κB, TNF-α, MMP9 and NSE, and promoted expression of TIMP1 (P<0.01). The mean NDS at 24-h and 72-h recovery was 112.5 and 61, respectively, in the hypothermic group, and 230 and 207.5, respectively, in the normothermia group.Conclusion: Brain protection induced by hypothermia involves inhibition of inflammatory and brain edema pathways.

Marked variation in newborn resuscitation practice: A national survey in the UK - Corrected Proof

2012-01-13

Abstract: Background: Although international newborn resuscitation guidance has been in force for some time, there are no UK data on current newborn resuscitation practices.Objective: Establish delivery room (DR) resuscitation practices in the UK, and identify any differences between neonatal intensive care units (NICU), and other local neonatal services.Methods: We conducted a structured two-stage survey of DR management, among UK neonatal units during 2009–2010 (n=192). Differences between NICU services (tertiary level) and other local neonatal services (non-tertiary) were analysed using Fisher's exact and Student's t-tests.Results: There was an 89% response rate (n=171). More tertiary NICUs institute DR CPAP than non-tertiary units (43% vs. 16%, P=0.0001) though there was no significant difference in frequency of elective intubation and surfactant administration for preterm babies. More tertiary units commence DR resuscitation in air (62% vs. 29%, P<0.0001) and fewer in 100% oxygen (11% vs. 41%, P<0.0001). Resuscitation of preterm babies in particular, commences with air in 56% of tertiary units. Significantly more tertiary units use DR pulse oximeters (58% vs. 29%, P<0.01) and titrate oxygen based on saturations. Almost all services use occlusive wrapping to maintain temperature for preterm infants.Conclusions: In the UK, there are many areas of good evidence based DR practice. However, there is marked variation in management, including between units of different designation, suggesting a need to review practice to fulfil new resuscitation guidance, which will have training and resource implications.

Comment on “Epidemiology and outcomes of poisoning-induced out-of-hospital cardiac arrest” - Uncorrected Proof

Hossein Sanaei-Zadeh — 2012-01-13

We read with interest the study conducted by Sang Do Shin et al., published on-line in your journal entitled: “Epidemiology and outcomes of poisoning-induced out-of-hospital cardiac arrest”. The authors have evaluated a total of 52,467 out-of-hospital cardiac arrests (OHCA). Of these, 900 were due to poisoning (poisoning-induced OHCA; POHCA). Diagnosis of poisoning had been confirmed on the basis of history taken from a neighbor or relatives, physical examination, and clinical signs and symptoms. We would like to ask few questions from the authors and also, we have a suggestion for them.

Reply to Letter: Comments on “Epidemiology and outcomes of poisoning-induced out-of-hospital cardiac arrest” [Hossein Sanaei-Zadeh] - Uncorrected Proof

Sang Do Shin — 2012-01-13

Using a nationwide out-of-hospital cardiac arrest (OHCA) registry, we found that poisonings were responsible for 4.4% of OHCAs of a non-cardiac aetiology. Ingestion of insecticides including organophosphate and carbamate was associated with more favourable survival to discharge rate (9.9% vs. other poisons (0.0–3.3%).

Paediatric chest compressions, can we practice what we teach? - Corrected Proof

Margaret F. Everett, Gary M. Weiner — 2012-01-13

The 2010 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) include updated recommendations for paediatric chest compressions (CCs). The 2005 AHA paediatric guidelines for infants and pre-pubertal children recommended only a relative CC depth (one-third to one-half the anterior–posterior diameter (APD) of the chest), while the updated guidelines include both a relative and absolute depth target (at least one-third the chest APD or 50mm (2in.)). The recommended CC depth for post-pubertal adolescents follows the adult guidelines and has increased from 38 to 51mm to a minimum of 50mm. These guidelines are based on anthropometric measurements, computed tomography, and mathematical calculations. There are few published data measuring the quality of actual chest compressions during paediatric CPR.

Laryngeal mask airway and newborn resuscitation - Corrected Proof

Vincenzo Zanardo, Massimo Micaglio, Matteo Parotto, Daniele Trevisanuto — 2012-01-13

We read Dr. Zhu et al.’s thought provoking article with great interest. The authors maintain that use of the LMA in neonatal resuscitation is effective and safe, but nonetheless reported that vomiting and regurgitation were more frequent in the LMA-infants with an Apgar score of 7–8 at 1min. While they recommend LMA for all neonates in need of resuscitation, they suggest that bag-mask ventilation (BMV) “might be a better choice” if pharyngo-laryngeal reflexes are still present. They maintain that inserting a LMA might cause reflux, regurgitation, and/or vomiting. We feel that these comments could lead to fewer attempts to insert LMA in neonates needing resuscitation, a procedure included in the International Guidelines for Neonatal Resuscitation since 2000.

Reply to Letter: “Laryngeal Mask Airway and newborn resuscitation” [Vincenzo Zanardo] - Uncorrected Proof

Bingchun Lin, Xiaoyu Zhu — 2012-01-13

We thank you and Dr. Zanardo very much for his comments. Currently, the laryngeal mask airway (LMA) is widely used in adult anaesthesia and cardiopulmonary resuscitation. It has been shown to be effective in neonatal resuscitation. Recently, international guidelines for neonatal resuscitation have recommended its use when bag-mask ventilation (BMV) is ineffective and/or endotracheal intubation (ETI) is unsuccessful.

Ultrasound-guided evaluation of lung sliding for widespread use? - Uncorrected Proof

Raoul Breitkreutz, Armin Seibel, Peter M. Zechner — 2012-01-13

There are new concepts for ultrasound-based airway evaluation in emergencies and observation of lung sliding seems to play a crucial role. In a first international lung ultrasound consensus conference main artefacts and clinical situations were defined. Lung sliding, detected by real-time ultrasonography is now the current consensus term, which previously was also named gliding, pleura sliding or else. Lung sliding is the ultrasonographic observation of the movement of the visceral pleura (VP) against the parietal pleura (PP). Lung sliding depends on the compliance and tidal volume and can be used for continuous monitoring of ventilation. On an ultrasound image, the PP appears as a bright echoic line but the VP is anatomically thin and hardly detectable. However, when the ultrasound beam passes through subcutaneous and intercostal muscle tissue and reaches the VP and aerated lung tissue, there is a high difference in the impedance, which causes total reflection. Thus, the VP appears echoic as well. Lung sliding can be seen clearly and enables diagnostic interpretation. Moreover, when fluid is in the intrapleural space, detection of both PP and VP is facilitated. Lung sliding can be seen with almost every transcutaneous probe (linear, convex or sector) and by B- and M-Mode ultrasonography and even more clearly with colour- and power-Doppler technology. While B-Mode 2D-imaging can resolve movement of the VP within inspiration and expiration, the M-Mode resolves this movement against time as the ‘sea-shore’ sign with ‘sky, ocean and beach’, the latter an irregular grid pattern resembling a 3D-barcode. At a respiratory rate of 10min−1, lung sliding can be seen in both hemithoraces within 30s. Taken together, lung sliding is a simple real-time diagnostic ultrasound evaluation to show lung movement, which virtually everybody could perform with very little training.

BML-111, a lipoxin receptor agonist, protects haemorrhagic shock-induced acute lung injury in rats - Corrected Proof

Jie Gong, Si Guo, Hong-Bin Li, Shi-Ying Yuan, You Shang, Shang-Long Yao — 2012-01-13

Abstract: Objectives: The main pathogenesis of acute lung injury induced by haemorrhagic shock is inflammation. BML-111, a lipoxinA4-receptor agonist, promotes acute inflammatory resolution. We sought to elucidate whether BML-111 protects haemorrhagic shock-induced acute lung injury in rats.Methods: Thirty two adult male rats were randomized to sham group (sham), haemorrhagic shock/resuscitation (HS), HS plus BML-111 (BML-111), and HS plus BML-111 and BOC-2 (BOC-2). Haemorrhagic shock was induced by blood drawing, and then resuscitation was obtained by infusion of shed blood and two-fold volume saline.Results: Histological findings, as well as assays of neutrophilic infiltration (myeloperoxidase activity, ICAM-1 expression), inflammatory cytokines and pro-inflammatory factor (IκB-α and NF-κB p65) confirmed that haemorrhagic shock induced acute lung injury. BML-111 significantly mitigated acute lung injury induced by haemorrhagic shock. However, BOC-2, an antagonist of the lipoxinA4-receptor, partially reversed the protective effect of BML-111 on the haemorrhagic shock-induced the acute lung injury.Conclusion: BML-111 protects haemorrhagic shock-induced acute lung injury in rats.

A potential novel rule for therapeutic decision-making in the cardiocerebral resuscitation of patients with cardiac arrest on arrival - Uncorrected Proof

2012-01-12

To better utilize scarce health care resources, the prehospital termination-of-resuscitation (TOR) rules during basic life support (BLS) and advanced life support (ALS) for patients with refractory out-of-hospital cardiac arrest (OHCA) have been implemented in North America. However, identifying OHCA patients who have no realistic hope of meaningful neurologic recovery is still a major clinical challenge, and the development of an additional rule for cardiocerebral resuscitation is awaited. Recently, we reported “nondetectable cortical oxygen saturation (N-value): a regional cerebral oxygen saturation (rSO2) of ≤15%” as a strong predictor of poor neurological outcome in OHCA patients. We here proposed “the N-value rule: OHCA with an rSO2 of ≤15%” and examined whether the rule can be an independent predictor of neurological prognosis at hospital discharge in patients with cardiac arrest on arrival (CAOA).

Reply to Letter: Technical factors weaken the clinical relevance of manikin measurements of mechanical chest compression depth - Corrected Proof

Hans Blomberg, Jakob Johansson — 2012-01-12

The manufacturer of the LUCAS-device, Jolife AB, has raised concerns regarding the accuracy in the measurement of compression depths. Jolife AB kindly provided the manikin used in our study. The same manikin was used to ensure correct usage of LUCAS in an ongoing multicentre randomized trial. Prior to our study, Jolife AB stated that there was a measurement precision of ±0.1cm within a radius of 5cm. The stated precision was confirmed by Jolife AB, also after the preliminary analyses in our study. In a pilot study, preceding our study, the experimental set-up and the manikin were tested together with an engineer from Jolife AB. Adequate compression depths with manual as well as mechanical compressions were registered. Furthermore, when performing the study, the measurement of compression depth was calibrated and approved by the engineer from Jolife AB immediately before the start of the scenarios.

Spontaneous cooling and rewarming after cardiac arrest may not be therapeutic - Corrected Proof

Samuel A. Tisherman — 2012-01-12

Therapeutic temperature management has become standard care for comatose survivors of cardiac arrest. Intuitively, it is logical that the sooner the patients reach target temperature, the greater the effect of the hypothermia. Indeed, some studies have correlated time to target temperature with better outcomes. Some studies have had opposite findings, however. What has been missing from these studies has been consideration of the effect of the insult itself on temperature regulation.

Emergency airway management: The need to refine – And redefine – The “state of the art” - Corrected Proof

Henry E. Wang — 2012-01-12

Over 15 years ago, Ron Walls and colleagues launched the National Emergency Airway Registry (NEAR), a multicenter effort to characterize airway management practices in United States (US) Emergency Departments (ED). Data from NEAR helped to demonstrate the competence of emergency physicians in the most advanced airway management techniques and to spotlight emergent airway management as a defining intervention in the state-of-art practice of EM. NEAR played a pivotal role in the history of EM in the US, helping to cement the role of the emergency physician in the care of the critically ill.

Resuscitation science: A role for observation? - Corrected Proof

Thomas D. Rea, Florence Dumas — 2012-01-09

Resuscitation of cardiac arrest is exceptionally challenging, but can be achieved by successfully integrating the links in the chain of survival. Importantly, successful treatment requires cardiovascular resuscitation and brain recovery. Advanced cardiac life support is a core link and incorporates acute medication management with epinephrine (or vasopressin) as the primary drug treatment for shockable and non-shockable arrest. Given the dynamic nature of cardiac arrest and the formidable challenge of resuscitation, treatment decisions ideally would be supported by exhaustive evidence that establishes the optimal sequence, timing, and dose of epinephrine; and perhaps considers the individual patient's physiological status and their response to other therapies. Currently however we generally apply a uniform dose and timing of vasopressor therapy in pulseless patients based on modest supporting evidence, an approach that enables operational efficiency and directs clinical care but may or may not advance resuscitation.

Effects of variation in temperature management on cerebral performance category scores in patients who received therapeutic hypothermia post cardiac arrest - Corrected Proof

2012-01-09

Abstract: Aim: To assess differences in cerebral performance category (CPC) in patients who received therapeutic hypothermia post cardiac arrest by time to initiation, time to target temperature, and duration of therapeutic hypothermia (TH).Methods: A secondary data analysis was conducted using hospital-specific data from the international cardiac arrest registry (INTCAR) database. The analytic sample included 172 adult patients who experienced an out-of-hospital cardiac arrest and were treated in one Midwestern hospital. Measures included time from arrest to ROSC, arrest to TH, arrest to target temperature, and length of time target temperature was maintained. CPC was assessed at three points: transfer from ICU, discharge from hospital, and post discharge follow-up.Results: Average age was 63.6 years and 74.4% of subjects were male. Subjects had TH initiation a mean of 94.4min (SD 81.6) after cardiac arrest and reached target temperature after 309.0min (SD 151.0). In adjusted models, the odds of a poor neurological outcome increased with each 5min delay in initiating TH at transfer from ICU (OR=1.06, 95% C.I. 1.02–1.10). Similar results were seen for neurological outcomes at hospital discharge (OR=1.06, 95% C.I. 1.02–1.11) and post-discharge follow-up (OR=1.08, 95% C.I. 1.03–1.13). Additionally the odds of a poor neurological outcome increased for every 30min delay in time to target temperature at post-discharge follow-up (OR=1.17, 95% C.I. 1.01–1.36).Conclusion: In adults undergoing TH post cardiac arrest, delay in initiation of TH and reaching target temperature differentiated poor versus good neurologic outcomes. Randomized trials assessing the range of current recommended guidelines for TH should be conducted to establish optimal treatment protocols.

Early findings on brain computed tomography and the prognosis of post-cardiac arrest syndrome: Application of the score for stroke patients - Uncorrected Proof

2012-01-06

Abstract: Aim: To examine whether early findings of the brain computed tomography (CT) evaluated by the modified Alberta stroke programme early CT (m-ASPECT) score is useful for determining the prognosis of post-cardiac arrest syndrome (PCAS) patients or not.Materials: From 2003 through 2010, 149 consecutive PCAS patients: (1) with various aetiologies but neither from haemorrhagic stroke nor trauma, (2) who were 15years old or older and (3) whose brain CT was available were admitted to our intensive care unit. Early findings on all of their CT images were rated with the m-ASPECT scoring system by three raters, and an inter-rater comparison was conducted. Next, the images within 24h from arrest were collected from 133 patients (89 males, age 60.2±17.6years), and a relation of the scores with outcome at day 30 of the patients was analysed.Results: According to the inter-rater comparison based on a linear regression analysis, agreement between the raters was good (correlation coefficient 0.76–0.88). A receiver operating curve analysis revealed that the m-ASPECT scores within 24h were a good predictor of poor outcome (dead or vegetative state) with an area under the curve of 0.905. An m-ASPECT score ≤13 was 100% predictive of a poor outcome, with a negative predictive value of 0.57. The m-ASPECT score was the best predictor of poor outcome (odds ratio 45.62) among various factors including cause or duration of arrest.Conclusion: The m-APSECT score evaluated within 24h from arrest was found to be the most predictive factor for outcome at day 30.

Comparison of the T-piece resuscitator with other neonatal manual ventilation devices: A qualitative review - Corrected Proof

Colin Patrick Hawkes, C. Anthony Ryan, Eugene Michael Dempsey — 2012-01-06

Abstract: Aim: To review the literature surrounding various aspects of T-piece resuscitator use, with particular emphasis on the evidence comparing the device to other manual ventilation devices in neonatal resuscitation.Data sources: The Medline, EMBASE, Cochrane databases were searched in April 2011. Ongoing trials were identified using www.clinicaltrials.gov and www.controlled-trials.com. Additional studies from reference lists of eligible articles were considered. All studies including T-piece resuscitator use were eligible for inclusion.Results: Thirty studies were included. There were two randomised controlled trials in newborn infants comparing the devices, one of which addressed short and intermediate term morbidity and mortality outcomes and found no difference between the T-piece resuscitator and self inflating bag. From manikin studies, advantages to the T-piece resuscitator include the delivery of inflating pressures closer to predetermined target pressures with least variation, the ability to provide prolonged inflation breaths and more consistent tidal volumes. Disadvantages include a technically more difficult setup, more time required to adjust pressures during resuscitation, a larger mask leak and less ability to detect changes in compliance.Conclusions: There is a need for appropriately designed randomised controlled trials in neonates to highlight the efficacy of one device over another. Until these are performed, healthcare providers should be appropriately trained in the use of the device available in their departments, and be aware of its own limitations.

The effect of hyperoxia following cardiac arrest – A systematic review and meta-analysis of animal trials - Corrected Proof

2012-01-06

Abstract: Aim: There are conflicting findings from observational studies regarding the nature of the association between hyperoxia and risk of mortality in patients admitted to intensive care following cardiac arrest. This systematic review and meta-analysis evaluates animal data investigating the effect of administration of high concentrations of oxygen following cardiac arrest on neurological outcome and the clinical applicability of this data.Methods: A systematic search of Medline and Embase identified controlled animal studies modelling cardiac arrest with subsequent cardiopulmonary resuscitation that compared ventilation with 100% oxygen to lower concentrations following return of spontaneous circulation. Eligible studies were included in a meta-analysis in which the inverse variance weighted differences were calculated for the standardised mean difference of the primary outcome measure, the neurological deficit score.Results: Ten studies met the criteria for inclusion in the systematic review. In a meta-analysis of six studies, with 95 animals, treatment with 100% oxygen resulted in a significantly worse neurological deficit score than oxygen administered at lower concentrations, with a standardised mean difference of −0.64 (95% CI −1.06 to −0.22). In four of five studies, histological evidence of increased neuronal damage was present in animals that received 100% oxygen therapy.Conclusions: The administration of 100% oxygen therapy is associated with worse neurological outcome than lower oxygen concentrations in animal models of cardiac arrest. However, due to limitations in study design and poor generalisability of the animal models to the situation of post cardiac arrest resuscitation in humans, the clinical applicability of this data is uncertain.

Can post resuscitation electrocardiogram be a ‘stand alone’ criterion for patient selection for emergency angiography after recovery from out of hospital cardiac arrest? - Corrected Proof

Nikolaos I. Nikolaou, Sotirios P. Patsilinakos — 2012-01-06

We read with interest the paper: value of post resuscitation electrocardiogram (ECG) in the diagnosis of acute myocardial infarction (MI) in out of hospital cardiac arrest (OHCA) patients. In this study Sideris et al. evaluated 12-lead ECG for identification of acute coronary lesions (ACL) producing MI in patients with OHCA. Previous studies suggest that the presence of ST segment elevation on the ECG is highly specific for the presence of an ACL but a considerable number of OHCA patients without ST elevation may have an ACL.