Resuscitation - Articles in Press

Causes of in-hospital cardiac arrest and influence on outcome - Accepted Manuscript

2012-05-16

Abstract: Aim of the study: To evaluate the relationship between cause and outcome of in-hospital cardiac arrest.Methods: Retrospective analysis of resuscitation data, causes of cardiac arrest and outcome with a follow-up to 6 months of a cardiac arrest registry in an emergency department of a tertiary care hospital, covering a 17.5-year period.Results: Of 1041 patients, 653 were male (63%), the median age was 64 years (IQR 53 -73), 51% suffered cardiac arrest in the emergency department. The ﬁrst recorded rhythm showed PEA in 432 (41%), ventricular ﬁbrillation in 404 (39%) and asystole in 205 (20%) patients. Cardiac arrest of cardiac origin occurred in 63% of all patients, with 35% of them due to acute myocardial infarction. Non-cardiac causes were mostly due to pulmonary causes (15% of all patients). Aortic dissection/rupture, exsanguination, intoxication and adverse drug reactions, metabolic, cerebral, sepsis and accidental hypothermia each ranged between 1 and 4% of the cohort. Of all patients, 376 (36%) were discharged in good neurologic condition. Overall, patients with cardiac causes had a significantly better outcome than those with non-cardiac causes (44 vs. 23%, p<0.01). Patients with pulmonary causes survived in 24%. The other subgroups showed widely divergent survival results (3 to 65%). Patients who had suffered cardiac arrest in the emergency department had a better outcome then patients of the regular ward or radiology department.Conclusion: In hospital cardiac arrest is caused mainly by cardiac and pulmonary causes, outcome depends on the cause, with a big variability

Safe campus using wireless managed automated external defibrillator(AED) - Accepted Manuscript

Hyunggoo Kang — 2012-05-14

COMPARISON OF TIMES OF INTERVENTION DURING PEDIATRIC CPR MANOEUVERS USING ABC AND CAB SEQUENCES: A RANDOMISED TRIAL - Accepted Manuscript

2012-05-10

Abstract: Background: the proposed introduction of the CAB (circulation, airway, breathing) sequence for cardiopulmonary resuscitation has raised some perplexity within the pediatric community. We designed a randomized trial intended to verify if and how much timing of intervention in pediatric cardiopulmonary resuscitation is affected by the use of the CAB vs. the ABC (airway, breathing, circulation) sequence.Patients and Methods: 340 volunteers, paired into 170 two-person teams, performed 2-rescuer healthcare provider BLS with both a CAB and ABC sequence. Their performances were audio-video recorded and times of intervention in the two scenarios, cardiac and respiratory arrest, were monitored.Results: the CAB sequence compared to ABC prompts quicker recognition of respiratory (CAB vs. ABC=17.48±2.19 vs. 19.17±2.38sec; p< 0.05) or cardiac arrest (CAB vs. ABC=17.48±2.19 vs. 41.67±4.95; p< 0.05) and faster start of ventilatory maneuvers (CAB vs. ABC=19.13±1.47sec vs. 22.66±3.07; p< 0.05) or chest compressions (CAB vs. ABC=19.27±2.64 vs. 43.40±5.036; p< 0.05)Conclusions: compared to ABC the CAB sequence prompts shorter time of intervention both in diagnosing respiratory or cardiac arrest and in starting ventilation or chest compression. However this does not necessarily entail prompter resumption of spontaneous circulation and significant reduction of neurological sequelae, an issue that requires further studies.

A Low Tilt Waveform in the Transthoracic Defibrillation of Ventricular Arrhythmias during Cardiac Arrest - Accepted Manuscript

2012-05-10

Abstract: Aims: Most commercially available defibrillators utilise a high tilt waveform. Work in atrial fibrillation has shown improved defibrillation success using low tilt waveforms. We hypothesise that a novel low tilt biphasic waveform will be non-inferior to a standard tilt waveform whilst delivering lower energy for the defibrillation of ventricular arrhythmiasMethods: Patients in cardiac arrest who experienced ventricular arrhythmias received shocks from a novel low tilt waveform defibrillator at 120J or a standard tilt waveform defibrillator at 150J. Resuscitation guidelines were followed as per Resuscitation Council UK, 2005. A shock was successful when the ventricular arrhythmia was terminated for ≥5seconds following shock delivery.Results: A total of 113 cardiac arrest cases were included. The low tilt device was used for 56 cases and the standard tilt device for 57 cases. The presenting rhythm was ventricular fibrillation (VF) in 71.7% (81/113), pulseless electrical activity (PEA) in 15.9% (18/113), ventricular tachycardia (VT) in 9.7% (11/113), asystole in 1.8% (2/113) and narrow complex rhythm in 0.9% (1/113). The low tilt device resulted in first shock success in 86% (48/56 cases) versus the standard tilt device first shock success of 77% (44/57 cases). There was no significant difference in first shock success between the two devices (p=0.36).Conclusion: The low tilt waveform used in this study demonstrated first shock success rates in keeping with a commercially available high tilt defibrillator which could result in less myocardial damage due to reduced energy requirements

Reply to letter: Aksu et al., Balanced vs. unbalanced crystalloid resuscitation in a near-fatal model of hemorrhagic shock and the effects on renal oxygenation, oxidative stress, and inflammation - Uncorrected Proof

Ugur Aksu, Rick Bezemer, Can Ince — 2012-05-07

We would like to thank Dr. Gatz for his interest in our study on the effects of balanced and unbalanced crystalloid resuscitation in hemorrhagic shock. We agree with the point raised by Dr. Gatz that Plasmalyte is indeed not optimally balanced. However, the term “balanced” should be considered in its context; i.e., obviously Plasmalyte is more balanced than isotonic saline. Although Dr. Gatz is theoretically right that Plasmalyte resuscitation could have led to a significantly increased SID level, we did not find this in our study. Perhaps more volume would be required to create this? This leads us to the second point raised by Dr. Gatz regarding the finding that less Plasmalyte than isotonic saline was required for resuscitation to specified target MAP. Our explanation is that Plasmalyte is probably better confined in the circulation than isotonic saline as it contains larger molecules such as gluconate and acetate. We thank Dr. Gatz for underscoring the clinical relevance of this finding.

Correlation between coronary perfusion pressure and quantitative ECG waveform measures during resuscitation of prolonged ventricular fibrillation - Uncorrected Proof

Joshua C. Reynolds, David D. Salcido, James J. Menegazzi — 2012-05-07

Abstract: Introduction: The ventricular fibrillation (VF) waveform is dynamic and predicts defibrillation success. Quantitative waveform measures (QWMs) quantify these changes. Coronary perfusion pressure (CPP), a surrogate for myocardial perfusion, also predicts defibrillation success. The relationship between QWM and CPP has been preliminarily explored. We sought to further delineate this relationship in our porcine model and to determine if it is different between animals with/without ROSC (return of spontaneous circulation).Hypothesis: A relationship exists between QWM and CPP that is different between animals with/without ROSC.Methods: Utilizing a prior experiment in our porcine model of prolonged out-of-hospital VF cardiac arrest, we calculated mean CPP, cumulative dose CPP, and percent recovery of three QWM during resuscitation before the first defibrillation: amplitude spectrum area (AMSA), median slope (MS), and logarithm of the absolute correlations (LAC). A random effects linear regression model with an interaction term CPP*ROSC investigated the association between CPP and percent recovery QWM and how this relationship changes with/without ROSC.Results: For 12 animals, CPP and QWM measures (except LAC) improved during resuscitation. A linear relationship existed between CPP and percent recovery AMSA (coefficient 0.27; 95%CI 0.23, 0.31; p<0.001) and percent recovery MS (coefficient 0.80; 95%CI 0.70, 0.90; p<0.001). A linear relationship existed between cumulative dose CPP and percent recovery AMSA (coefficient 2.29; 95%CI 2.0, 2.56; p<0.001) and percent recovery MS (coefficient 6.68; 95%CI 6.09, 7.26; p<0.001). Animals with ROSC had a significantly “steeper” dose–response relationship.Conclusions: There is a linear relationship between QWM and CPP during chest compressions in our porcine cardiac arrest model that is different between animals with/without ROSC.

Association of lactate levels with outcome after in-hospital cardiac arrest - Uncorrected Proof

2012-05-07

Prognostication post cardiac arrest (CA) remains very difficult, especially the first 24h after return of spontaneous circulation (ROSC). Previous studies reported that lactate levels may be a reliable prognostic factor of outcome during the first hours after ROSC. These studies examined only patients which suffered out-of-hospital cardiac arrest (OHCA). However, there are many differences between in-hospital cardiac arrest (IHCA) and OHCA which may affect outcome.

Video recording and feedback of resuscitation - Uncorrected Proof

2012-05-07

We read with great interest the study of Chen et al., ‘Improving cardiopulmonary resuscitation in the emergency department by real-time video recording and regular feedback learning’. They presented a method to monitor and improve cardiopulmonary resuscitation quality using video recording and feedback. We support the use of real-time video to identify real problems in our daily cardiopulmonary resuscitation. In our university emergency department experience, real-time video recording and regular feedback learning do improve team members’ performance in resuscitation. We have a few comments for the paper.

Reply to Letter: Video recording and feedback of resuscitation - Uncorrected Proof

Jiang Cheng, Zhao Yan — 2012-05-07

We are grateful for the opportunity to reply to the helpful comments about our study made by Dr Ma and colleagues. In our series of cardiac arrests, a total of 16 cases which were caused by haemorrhage (trauma, extrauterine pregnancy, cerebral haemorrhage). The treatment protocols for traumatic arrests include not just the ABCs, but also specific surgical interventions and coordinated team work. However, the aim of our study was to describe how recording of CPR performed in our emergency department (including all the adult cases) with real-time video and regular feedback learning may improve CPR – our emphasis was the quality of CPR. We still contend that we can improve the outcome of resuscitation from traumatic cardiac arrest by using video feedback.

Use of mobile phones to stimulate interest and aid concentration for teaching resuscitation in schools - Uncorrected Proof

Hyunggoo Kang, Jaehoon Oh, Taeho Lim, Youngsuk Cho, Sangmo Je — 2012-05-04

Bohn et al., reported that annual resuscitation training provided by trained teachers is effective and adequate for children aged 10 years. We would like to applaud these authors because they assessed teaching cardiopulmonary resuscitation (CPR) in schools over four years and considered a number of criteria (effect of CPR course, training frequency, age, facilitator, and self-image). We have also taught CPR to the same age group with success. However, we would like to suggest some complementary approaches to annual training be considered.

Engaging a whole community in resuscitation - Uncorrected Proof

Anne Møller Nielsen, Dan Lou Isbye, Freddy Knudsen Lippert, Lars Simon Rasmussen — 2012-05-04

Abstract: Background: Survival after out-of-hospital cardiac arrest (OHCA) is influenced by each link in the chain of survival. On the Danish island of Bornholm (population 42,000, area 588km2) none survived an OHCA in 2001–2003. Therefore, we designed a multifaceted community-based approach aiming at strengthening each link in the chain of survival.The purpose of this study was to evaluate the effect of implementation of the intervention on bystander basic life support (BLS) rates and survival to hospital discharge after OHCA.Methods: Laypersons completed 24-min DVD-based-self-instruction BLS courses in schools and workplaces or 4-h BLS/automated external defibrillator (AED) courses. The local television station had broadcasts about resuscitation. The ambulance personnel were trained and the staff at the island hospital completed BLS courses or more advanced courses.Results: During 2 years 9226 people (22% of the population) completed the short course and 2453 (6% of the population) completed the 4-h course. The number of AEDs increased from 3 to 147. The bystander BLS rate for OHCAs with a presumed cardiac aetiology (N=96, incidence 114/100,000 person-years) was 47% [95% CI 30–50] and for witnessed OHCAs (N=35) it increased significantly from 22% (2004) to 74% [95% CI 58–86]. The AEDs were deployed in 9 cases. Survival to discharge for all-rhythms OHCA was 5.4% [95% CI 2–12], and for witnessed ventricular fibrillation (N=17) 18% [95% CI 5–42].Conclusion: Strengthening all links in the chain of survival was associated with significant increases in bystander BLS rates and survival after OHCA on a rural island.

Training hospital providers in basic CPR skills in Botswana: Acquisition, retention and impact of novel training techniques - Uncorrected Proof

2012-05-04

Abstract: Objective: Globally, one third of deaths each year are from cardiovascular diseases, yet no strong evidence supports any specific method of CPR instruction in a resource-limited setting. We hypothesized that both existing and novel CPR training programs significantly impact skills of hospital-based healthcare providers (HCP) in Botswana.Methods: HCP were prospectively randomized to 3 training groups: instructor led, limited instructor with manikin feedback, or self-directed learning. Data was collected prior to training, immediately after and at 3 and 6months. Excellent CPR was prospectively defined as having at least 4 of 5 characteristics: depth, rate, release, no flow fraction, and no excessive ventilation. GEE was performed to account for within subject correlation.Results: Of 214 HCP trained, 40% resuscitate ≥1/month, 28% had previous formal CPR training, and 65% required additional skills remediation to pass using AHA criteria. Excellent CPR skill acquisition was significant (infant: 32% vs. 71%, p<0.01; adult 28% vs. 48%, p<0.01). Infant CPR skill retention was significant at 3 (39% vs. 70%, p<0.01) and 6months (38% vs. 67%, p<0.01), and adult CPR skills were retained to 3months (34% vs. 51%, p=0.02). On multivariable analysis, low cognitive score and need for skill remediation, but not instruction method, impacted CPR skill performance.Conclusions: HCP in resource-limited settings resuscitate frequently, with little CPR training. Using existing training, HCP acquire and retain skills, yet often require remediation. Novel techniques with increased student: instructor ratio and feedback manikins were not different compared to traditional instruction.

Team performance in resuscitation teams: Comparison and critique of two recently developed scoring tools - Uncorrected Proof

2012-05-04

Abstract: Background and aim: Following high profile errors resulting in patient harm and attracting negative publicity, the healthcare sector has begun to focus on training non-technical teamworking skills as one way of reducing the rate of adverse events. Within the area of resuscitation, two tools have been developed recently aiming to assess these skills – TEAM and OSCAR. The aims of the study reported here were:Methods: The study consisted of two phases – reliability assessment; and content comparison, and correlation. Assessments were made by two resuscitation experts, who watched 24 pre-recorded resuscitation simulations, and independently rated team behaviours using both tools. The tools were critically appraised, and correlation between overall score surrogates was assessed.Results: Both OSCAR and TEAM achieved high levels of inter-rater reliability (in the form of adequate intra-class coefficients) and minor significant differences between Wilcoxon tests. Comparison of the scores from both tools demonstrated a high degree of correlation (and hence concurrent validity). Finally, critique of each tool highlighted differences in length and complexity.Conclusion: Both OSCAR and TEAM can be used to assess resuscitation teams in a simulated environment, with the tools correlating well with one another. We envisage a role for both tools – with TEAM giving a quick, global assessment of the team, but OSCAR enabling more detailed breakdown of the assessment, facilitating feedback, and identifying areas of weakness for future training.

Increased cytochrome c in rat cerebrospinal fluid after cardiac arrest and its effects on hypoxic neuronal survival - Uncorrected Proof

2012-05-01

Abstract: Cerebrospinal fluid (CSF) proteins may be useful biomarkers of neuronal death and ultimate prognosis after hypoxic–ischemic brain injury. Cytochrome c has been identified in the CSF of children following traumatic brain injury. Cytochrome c is required for cellular respiration but it is also a central component of the intrinsic pathway of apoptosis. Thus, in addition to serving as a biomarker, cytochrome c release into CSF may have an effect upon survival of adjacent neurons. In this study, we use Western blot and ELISA to show that cytochrome c is elevated in CSF obtained from pediatric rats following resuscitation from cardiac arrest. Using biotinylated human cytochrome c in culture media we show that cytochrome c crosses the cell membrane and is incorporated into mitochondria of neurons exposed to anoxia. Lastly, we show that addition of human cytochrome c to primary neuronal culture exposed to anoxia improves survival. To our knowledge, this is the first study to show cytochrome c is elevated in CSF following hypoxic ischemic brain injury. Results from primary neuronal culture suggest that extracellular cytochrome c is able to cross the cell membrane of injured neurons, incorporate into mitochondria, and promote survival following anoxia.

Shape and size of cardiopulmonary resuscitation trials to optimise impact of advanced life support interventions - Uncorrected Proof

Janett Kreutziger, Volker Wenzel — 2012-05-01

During a three-year period from 2006 to 2009, Dr. Ong and colleagues in Singapore randomised 727 cardiac arrest patients to be treated with either vasopressin (40IU) or adrenaline (1mg) intravenously during ongoing advanced life support (ALS) after admission to the emergency department (ED). This approach was necessary because emergency medical service (EMS) personnel in Singapore were not allowed to administer the study drugs. This study is remarkable, as vasopressin has no patent protection rendering commercial support of vasopressin trials extremely unlikely. In addition, guidelines for good clinical practice impose severe restrictions on any clinical investigation, which in turn reduce especially the number of academic prospective randomised clinical trials. Accordingly, the present data is extremely valuable and needs to be interpreted with great care in order to harvest maximum knowledge to improve both immediate patient care and future clinical trials. Vasopressin patients tended to have higher, but not statistically significant, survival rates (the Singapore researchers followed up survivors for one year) when compared with the adrenaline group. The busy reader may stop reading after determining this fact in the abstract because of the usual hopes to find dramatic results, but this would be a shame. First, experienced researchers overcame major obstacles to conduct this trial and worked extremely hard for more than three years to present us these data, thus they deserve our respect to invest time to read the entire article. Second, data like this is a gold mine that allows us to assist planning future trials. Third, there are very few prospective randomised clinical trials investigating specific drugs given during cardiopulmonary resuscitation (CPR), thus opportunities to learn from them are very rare. So what is up for grabs?

Reply: Balanced vs. unbalanced crystalloid resuscitation in a near-fatal model of hemorrhagic shock and the effects on renal oxygenation, oxidative stress, and inflammation [Aksu U, et al., Resuscitation 2011 December 2] - Corrected Proof

Paul Elbers, Rainer Gatz — 2012-04-27

We should like to add two considerations to the recently published article by Aksu et al. As has been theoretically and empirically demonstrated by Morgan et al. a truely balanced intravenous fluid has a concentration of 24mEq/l bicarbonate or metabolisable anions. In plasmalyte, though, the combined charge of these (acetate and gluconate) is 50mEq/l. This would not qualify as balanced, in our view. It leads to an increased strong ion difference, ultimately introducing a iatrogenic metabolic alkalosis.

Analysis of intraosseous samples using point of care technology—An experimental study in the anaesthetised pig - Uncorrected Proof

2012-04-26

Abstract: Background: Intraosseous access is an essential method in emergency medicine when other forms of vascular access are unavailable and there is an urgent need for fluid or drug therapy. A number of publications have discussed the suitability of using intraosseous access for laboratory testing. We aimed to further evaluate this issue and to study the accuracy and precision of intraosseous measurements.Methods: Five healthy, anaesthetised pigs were instrumented with bilateral tibial intraosseous cannulae and an arterial catheter. Samples were collected hourly for 6h and analysed for blood gases, acid base status, haemoglobin and electrolytes using an I-Stat® point of care analyser.Results: There was no clinically relevant difference between results from left and right intraosseous sites. The variability of the intraosseous sample values, measured as the coefficient of variance (CV), was maximally 11%, and smaller than for the arterial sample values for all variables except SO2. For most variables, there seems to be some degree of systematic difference between intraosseous and arterial results. However, the direction of this difference seems to be predictable.Conclusion: Based on our findings in this animal model, cartridge based point of care instruments appear suitable for the analysis of intraosseous samples. The agreement between intraosseous and arterial analysis seems to be good enough for the method to be clinically useful. The precision, quantified in terms of CV, is at least as good for intraosseous as for arterial analysis. There is no clinically important difference between samples from left and right tibia, indicating a good reproducibility.

Law, ethics and clinical judgment in end-of-life decisions—How do Norwegian doctors think? - Corrected Proof

Marianne K. Bahus, Petter Andreas Steen, Reidun Førde — 2012-04-26

Abstract: Aim: According to Norwegian law, an autonomous patient has the right to refuse life-prolonging treatment. If the patient is not defined as dying, however, health personnel are obliged to instigate life-saving treatment in an emergency situation even against the patient's wishes. The purpose of this study was to investigate how doctors’ attitudes and knowledge agree with these legal provisions, and how the statutory provision on emergency situations influences the principle of patient autonomy for severely ill, but not dying, patients.Method: A strategic sample of 1175 Norwegian doctors who are specialists in internal medicine, paediatrics, surgery, neurology and neurosurgery received a mail questionnaire about decisions on end-of-life care in hypothetical scenarios. The case presented concerns a 45-year-old autonomous patient diagnosed with end-stage ALS who declines ventilatory treatment. Recipients were randomly selected from the membership roster of the Norwegian Medical Association. 640 (54.5%) responded; of these, 406 had experience with end-of-life decisions.Results: 56.1% (221/394) stated that ALS patients in such situations can always refuse life-prolonging treatment, and 42.4% (167/394) were of the opinion that the patient can normally refuse life-prolonging treatment. 1.5% (6/394) stated that the patient cannot refuse life-prolonging treatment.Conclusions: The answers indicate that the respondents include patients’ refusal in an overall clinical judgement, and interpret patients’ right to decline life-saving treatment in different ways. This may reflect the complex legal situation in Norway regarding patient autonomy with respect to the right of severely ill, but not dying, patients’ right to decline acute life-saving treatment.

Near-infrared spectroscopy in post-cardiac arrest patients undergoing therapeutic hypothermia - Corrected Proof

2012-04-20

Abstract: Aims: To investigate the relationship between tissue oxygen saturation during a vascular occlusion test with systemic hemodynamics, central and peripheral skin temperature in patients resuscitated from cardiac arrest.Methods: This prospective, observational study included a convenience sample of 30 patients hospitalized in a multidisciplinary intensive care unit in a university hospital and treated with therapeutic hypothermia. Near infrared spectroscopy (NIRS) was used to measure thenar tissue oxygen saturation, desaturation rate and saturation recovery rate after the vascular occlusion test, conducted within 24h of hospital admission and within 12h of initiating re-warming. Measurements included heart rate (HR), mean arterial blood pressure (MAP), oxygen saturation, use of vasopressors and sedatives, core body (esophageal) and peripheral skin temperature and sequential organ failure assessment (SOFA) score.Results: Peripheral skin temperature was found to have a significant effect on StO2 deoxygenation and recovery slopes, resulting in lower rates at colder temperatures. This effect was independent of MAP, HR, and core temperature. NIRS-derived variables were not associated with SOFA score or use of vasopressors and did not predict mortality.Discussion: Colder peripheral skin temperatures resulting in lower StO2 desaturation rates may be explained by slower aerobic metabolism, thus lower extraction rate of oxygen, in the tissue beds. Lower recovery slopes at colder local temperatures may result from peripheral vasoconstriction during reactive hyperemia.Conclusion: We found that peripheral skin temperature in post-arrest critically ill patients undergoing TH strongly influences tissue oxygen desaturation and reoxygenation rates. In additional, changes in NIRS derived variables were independent of measures of shock, vasopressor use or illness severity.

Immediate cardiac arrest resuscitation skills are acquired in 8th grade students during normal class hours with a low-cost, short-term, self-instruction video - Corrected Proof

2012-04-20

Sudden cardiac arrest (CA) is a leading cause of death throughout the world. The majority of events take place outside of the hospital. Early effective cardiac resuscitation manoeuvres provided by casual bystanders improves survival of CA victims and extended community cardiac resuscitation training increases the chance of survival. In this reason, cardiopulmonary resuscitation (CPR) education is extremely important because the survival rate of out of hospital CA remains extremely low and the promotion of this skill from elementary schools could have a favourable impact in the outcome of individuals who suffer a CA in the outpatient setting. The aim of this study was to assess knowledge and competences associated to the immediate effect of a 15-min self-instruction video of CPR in 8th grade schoolchildren.

Ischemic postconditioning at the initiation of cardiopulmonary resuscitation facilitates functional cardiac and cerebral recovery after prolonged untreated ventricular fibrillation - Corrected Proof

2012-04-20

Abstract: Objectives: Ischemic postconditioning (PC) with “stuttering” reintroduction of blood flow after prolonged ischemia has been shown to offer protection from ischemia reperfusion injury to the myocardium and brain. We hypothesized that four 20-s pauses during the first 3min of standard CPR would improve post resuscitation cardiac and neurological function, in a porcine model of prolonged untreated cardiac arrest.Methods: 18 female farm pigs, intubated and isoflurane anesthetized had 15min of untreated ventricular fibrillation followed by standard CPR (SCPR). Nine animals were randomized to receive PC with four, controlled, 20-s pauses, during the first 3min of CPR (SCPR+PC). Resuscitated animals had echocardiographic evaluation of their ejection fraction after 1 and 4h and a blinded neurological assessment with a cerebral performance category (CPC) score assigned at 24 and 48h. All animals received 12h of post resuscitation mild therapeutic hypothermia.Results: SCPR+PC animals had significant improvement in left ventricular ejection fraction at 1 and 4h compared to SCPR (59±11% vs 35±7% and 55±8% vs 31±13% respectively, p<0.01). Neurological function at 24h significantly improved with SCPR+PC compared to SCPR alone (CPC: 2.7±0.4 vs 3.8±0.4 respectively, p=0.003). Neurological function significantly improved in the SCPR+PC group at 48h and the mean CPC score of that group decreased from 2.7±0.4 to 1.7±0.4 (p<0.00001).Conclusions: Ischemic postconditioning with four 20-s pauses during the first 3min of SCPR improved post resuscitation cardiac function and facilitated neurological recovery after 15min of untreated cardiac arrest in pigs.

The influence of rewarming after therapeutic hypothermia on outcome after cardiac arrest - Corrected Proof

2012-04-20

Abstract: Introduction: Treatment with hypothermia has been shown to improve outcome after cardiac arrest (CA). Current consensus is to rewarm at 0.25–0.5°C/h and avoid fever. The aim of this study was to investigate whether active rewarming, the rate of rewarming or development of fever after treatment with hypothermia after CA was correlated with poor outcome.Methods: This retrospective cohort study included adult patients treated with hypothermia after CA and admitted to the intensive care unit between January 2006 and January 2009. The average rewarming rate from end of hypothermia treatment (passive rewarming) or start active rewarming until 36°C was dichotomized in a high (≥0.5°C/h) or normal rate (<0.5°C/h). Fever was defined as >38°C within 72h after admission. Poor outcome was defined as death, vegetative state, or severe disability after 6months.Results: From 128 included patients, 56% had a poor outcome. Actively rewarmed patients (38%) had a higher risk for poor outcome, OR 2.14 (1.01–4.57), p<0.05. However, this effect disappeared after adjustment for the confounders age and initial rhythm, OR 1.51 (0.64–3.58). A poor outcome was found in 15/21 patients (71%) with a high rewarming rate, compared to 54/103 patients (52%) with a normal rewarming rate, OR 2.61 (0.88–7.73), p=0.08. Fever was not associated with outcome, OR 0.64 (0.31–1.30), p=0.22.Conclusions: This study showed that patients who needed active rewarming after therapeutic hypothermia after CA did not have a higher risk for a poor outcome. In addition, neither speed of rewarming, nor development of fever had an effect on outcome.

Seizures and status epilepticus in post cardiac arrest syndrome: Therapeutic opportunities to improve outcome or basis to withhold life sustaining therapies? - Uncorrected Proof

Romergryko G. Geocadin, Eva K. Ritzl — 2012-04-17

Acute coma and disorders of consciousness continue to be among the most challenging problems in patients who are successfully resuscitated with post-cardiac arrest syndrome (PCAS). It is widely acknowledged that therapeutic hypothermia has shifted the outcome paradigm by improving survival and enhancing the functional outcome. The realization that therapeutic hypothermia can ameliorate acute neurologic injury has improved research into other possible neuroprotective strategies in the post-cardiac arrest period. At the bedside, there is a growing awareness of the need to diagnose and treat the neurologic pathologies in the hope of further improving clinical outcomes. Of the many etiologies of acute coma, seizures, especially non-convulsive seizures are common and effective control may result in improved outcomes. Despite the growing awareness, the diagnosis and management of seizures and status epilepticus (SE) continues to be a major problem in PCAS.

Comparative performance of direct and indirect laryngoscopes for emergency intubation under cervical stabilization - Corrected Proof

F.S. Xue, Y. Cheng, R.P. Li, X. Liao — 2012-04-17

In a randomized, controlled crossover trial on a standard airway manikin with cervical stabilization, Wetsch et al. showed that when used by experienced anaesthesiologists, none of five indirect laryngoscopes could facilitate emergency intubation in a faster or more secure way than the Macintosh direct laryngoscope. Just as the authors had indicated in discussion, their findings were in strong contrast to results of previously several studies comparing performance of the same devices in a similar scenario (their Refs. [31,33–35,37]). By reading these articles, we noted that in the pre-study training sessions of previous studies, other than a demonstration of the intubation technique with each device, all participants were also allowed to practice the intubation with each device 2–5 times or for 5min or until each performed one successful intubation with each device. Before the beginning of this study, however, participant was not allowed to practice the intubation with each of the devices being tested. In designing this study, the authors may ignore an important issue, namely, experience and competence with any of the new devices are critical for their successful use, especially when using a difficult airway.

Experience is not the only consideration in video laryngoscopy - Corrected Proof

2012-04-17

We sincerely thank Xue et al. for the interest in our results and for the careful reading of our article as well as for their repetitive valuable comments in one of our studies. However, some of their statements need clarification and interpretation.

Hospital care after resuscitation from out-of-hospital cardiac arrest: The emperor's new clothes? - Corrected Proof

Dion Stub, Graham Nichol — 2012-04-16

The large regional variation in outcome after treatment for out-of-hospital cardiac arrest (OHCA) has led to efforts to develop and implement cardiac resuscitation systems of care that include interconnected community, emergency medical services (EMS) and hospital efforts to measure and improve the process and outcome of care for this population. Implicit assumptions of these efforts are that care provided for patients with OHCA is better at some hospitals that receive such patients than others, and that resuscitated patients should be preferentially transported to higher-performing hospitals.

Akt or phosphoinositide-3-kinase inhibition reverses cardio-protection in Toll-like receptor 2 deficient mice - Corrected Proof

2012-04-16

Abstract: Aim: Absence or inhibition of Toll-like receptor 2 (TLR2) signalling during murine myocardial ischaemia/reperfusion (MI/R) decreases myocardial necrosis and inflammation, thereby ameliorating cardiac dysfunction and improving survival. In the present study, we provide evidence for the involvement of the phosphoinositide-3-kinase/Akt pathway in TLR2-dependent reperfusion injury.Methods: Adult male wild-type (WT) and TLR2−/− mice were subjected to myocardial ischaemia (30min) and reperfusion (4h). Animals were treated with phosphoinositide-3-kinase inhibitor wortmannin, Akt inhibitor V (triciribine), or vehicle 1h prior to MI/R. Protein expression levels of Akt1 and phosphoinositide-3-kinase and their respective phosphorylated forms were determined by Western blot analysis. Myocardial necrosis was quantified after staining with the tetrazolium method and by troponin T plasma levels.Results: TLR2−/− mice displayed significantly increased Akt and phospho-Akt levels compared to WT mice, whilst no significant difference in phosphoinositide-3-kinase expression and phosphorylation could be observed. TLR2−/− mice also showed a blunted myocardial necrosis, the extent of which inversely correlated with Akt expression and degree of phosphorylation. Pharmacological inhibition of both, phosphoinositide-3-kinase or Akt, reversed the cardioprotection observed in TLR2−/− mice, whilst no effect could be observed in WT mice.Conclusion: Akt is an important mediator of cardioprotection in TLR2−/− animals during MI/R. The effect is, however, likely mediated by its genomic overexpression in the heart of TLR2−/− animals whilst Akt activation by phosphoinositide-3-kinase is unaltered.

Capnography during cardiopulmonary resuscitation - Uncorrected Proof

Edward Scarth, Tim Cook — 2012-04-16

Use of waveform capnography during cardiac arrest was recommended in the 2010 International Consensus on Cardiopulmonary Resuscitation (CPR) Science with Treatment Recommendations. A primary benefit includes confirmation that a tracheal tube (or other airway device) has been placed correctly and is providing ventilation of the lungs. Capnography is considerably more reliable than either clinical assessment by auscultation or observation of chest wall movement. The recent 4th National Audit Project of The Royal College of Anaesthetists and Difficult Airway Society examined Major Complications of Airway Management in the UK. It did not focus on airway management during cardiac arrest, but it included 11 instances where failure to use or correctly interpret capnography led to unrecognised oesophageal intubations during cardiac arrest, most of which led to avoidable death or brain injury. We can assume that the incidence of unrecognised oesophageal intubation is higher when waveform capnography is not used during cardiac arrest. There is strong evidence to support the use of waveform capnography in this situation (CPR will generate an attenuated, but not absent, end-tidal CO2 trace), with data demonstrating 100% sensitivity and 100% specificity in identifying correct tracheal tube placement. In contrast to waveform capnography, studies of alternative devices to determine correct tube placement (such as colorimetric end-tidal CO2 detectors, syringe aspiration oesophageal detector, self-inflating bulb oesophageal detector and non-waveform end-tidal capnometers) have been shown to have accuracy that is not substantially better than clinical assessment.

Circulating cell-free mitochondrial DNA: A better early prognostic marker in patients with out-of-hospital cardiac arrest - Corrected Proof

F. Arnalich, R. Codoceo, E. López-Collazo, C. Montiel — 2012-04-09

In a well-designed study of 42 patients who achieve return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA), Huang et al. reported that plasma cell-free DNA concentrations within 2h after ROSC were much higher in the group of 25 patients who died than in those who survived. A plasma concentration higher than 1170GE/ml was associated with higher 90 days mortality. These results confirm our findings in a cohort of 85 consecutive patients with OHCA showing that plasma DNA concentration early after ROSC was twofold higher in patients who died at 24h compared to those in survivors, and were independently associated with in-hospital mortality ().

Out-of-hospital cardiac arrest outcomes stratified by rhythm analysis - Corrected Proof

2012-04-09

Abstract: Background: Survival data for out-of-hospital cardiac arrest (OHCA) victims initially in PEA or asystole who convert to a shockable rhythm during attempted resuscitation, relative to an initial shockable rhythm, have never been previously reported. This study was done to assess OHCA outcomes among a large cohort of adults in the CARES dataset stratified by three rhythm categories: initial shockable (IS), converted shockable (CS), and never shockable (NS).Methods: The study was IRB approved. All adult index events at participating sites (2005–2010) were study eligible. All patient data elements were provided. Odds ratios of CS and NS status for survival to hospital discharge were calculated via multivariate logistic regression that adjusted for demographics, site, resuscitation initiators, AED use, and other covariates.Results: There were 40,274 OHCA records submitted to the CARES registry during the study period. After exclusions, our final sample size was 30,939 (7404 IS [23.9%], 3225 CS [10.4%], 20,310 NS [65.7%]). Raw survival rates of CS and NS patients were similar (4.7% vs. 4.1%, respectively; p=0.08) but significantly lower than IS patients (26.9%; p<0.001). The adjusted OR of survival to hospital discharge for CS was 0.17 (95%CI: 0.14, 0.20) and for NS it was 0.17 (95%CI: 0.15, 0.18) with IS as the referent.Conclusion: After OHCA, the survival rate for CS victims is significantly lower than for IS patients. These findings suggest that CS and IS are different entities and that alternatives to existing resuscitation algorithm tailored to patients with CS should be investigated.

Letter in response to: Tadie JM, Heming N, Serve E, et al. Drowning associated pneumonia: a descriptive cohort. Resuscitation (2011), doi:10.1016/j.resuscitation.2011.08.023 - Corrected Proof

Joseph Y. Ting — 2012-04-06

Tadie et al. are to be commended for their microbiological characterisation of non-ventilator-associated pneumonia in adults requiring mechanical ventilation after out-of-hospital cardiac arrest related to submersion in the River Seine between 2002 and 2010. Tadie used highly reliable tracheal aspirates (TA) and bronchoalveolar lavage (BAL) sampling in their patient cohort. Both sampling methods have been found to be similarly high performing in the detection of difficult to diagnose ventilator-associated pneumonia in adults receiving mechanical ventilation. In a multicenter randomised comparative trial conducted by the Canadian Critical Care Trials Group, clinical outcomes and use of antibiotics did not differ between 740 critically ill patients allocated either TA or BAL surveillance.

Reply letter to: Drowning associated pneumonia: A descriptive cohort. - Corrected Proof

Nicholas Heming, Jean-Marc Tadié — 2012-04-06

Dr. Ting points out that the microbiological pattern found in a cohort of adult patients suffering from out of hospital cardiac arrest related to submersion in the River Seine is not necessarily due to aspiration of a volume of contaminated river water but could be due to aspiration of a preexisting enteric or oropharyngeal organism during resuscitation or contamination by the breathing circuit of the ventilator. We would like to point out that the microbiological pattern we describe is different from the pattern usually observed in patients suffering from acute neurological injuries, including out of hospital cardiac arrests. We acknowledge that aspiration of a preexisting enteric or oropharyngeal organism during resuscitation attempts is however a possibility.

Corrected Proof

Jenny Tuckey — 2012-04-05

The editor of this concise book relating to contemporary issues and controversies suggests that it is aimed at trainees in obstetric anaesthesia, obstetric nurses and midwives, as well providing an update on recent concepts and advances. It certainly succeeds in this task as far as the anaesthetic personnel are concerned. The book does not pretend to be a comprehensive text relating to all matters of obstetric anaesthesia, but contains a selection of topics which are current and often controversial, as there is not always definitive evidence upon which to base practice.

Antecedent bradycardia and in-hospital cardiopulmonary arrest mortality in telemetry-monitored patients outside the ICU - Corrected Proof

2012-04-05

Abstract: Background Patients with in-hospital cardiopulmonary arrest (IHCA) precipitated by respiratory insufficiency often exhibit bradycardia before the arrest. We hypothesized that bradycardia frequently occurs in the 10min preceding IHCA and is associated with poor outcomes when IHCA occurs outside the intensive care unit (ICU).Objectives: To determine the prevalence and association of antecedent bradycardia with outcome in adult patients with IHCA occurring outside the ICU.Methods We performed a retrospective cohort study among telemetry monitored adults with IHCA outside the ICU in a two-hospital health system between 2008 and 2010 with follow-up until their discharge or death in-hospital.We defined (1) IHCA as >1min of chest compressions or trans-thoracic defibrillation, (2) Antecedent bradycardia as at least 2min of continuous heart rate between 1 and 59 beats per minute in the 10min preceding IHCA, and (3) ventricular tachyarrhythmia arrests as presence of sustained ventricular tachyarrhythmia for >20s in the 10min preceding IHCA.Results: Of 98 IHCAs, 39 (39.8%) survived to hospital discharge. Of 98 IHCAs, 53 (54.1%) had antecedent bradycardia. After adjusting for potential confounders, antecedent bradycardia was associated with death prior to hospital discharge (adjusted OR=3.80, 95%CI: 1.47–9.81, p=0.006). Among patients with ventricular tachyarrhythmia arrests, antecedent bradycardia was associated with a higher risk of death (OR=13.1, 95%CI 1.92–89.5, p=0.009).Conclusions: Antecedent bradycardia occurred frequently and was associated with death prior to hospital discharge in non-ICU hospitalized adults on telemetry monitoring who developed IHCA.

Chest compression quality management and return of spontaneous circulation: A matched-pair registry study - Corrected Proof

2012-04-05

Abstract: Aims: Investigating the effects of any intervention during cardiac arrest remains difficult. The ROSC after cardiac arrest score was introduced to facilitate comparison of rates of return of spontaneous circulation (ROSC) between different ambulance services. To study the influence of chest compression quality management (including training, real-time feedback devices, and debriefing) in comparison with conventional cardiopulmonary resuscitation (CPR), a matched-pair analysis was conducted using data from the German Resuscitation Registry, with the calculated ROSC after cardiac arrest score as the baseline.Methods and results: Matching for independent ROSC after cardiac arrest score variables yielded 319 matched cases from the study period (January 2007–March 2011). The score predicted a 45% ROSC rate for the matched pairs. The observed ROSC increased significantly with chest compression quality management, to 52% (P=0.013; 95% CI, 46–57%). No significant differences were seen in the conventional CPR group (47%; 95% CI, 42–53%). The difference between the observed ROSC rates was not statistically significant.Conclusions: Chest compression quality management leads to significantly higher ROSC rates than those predicted by the prognostic score (ROSC after cardiac arrest score). Matched-pair analysis shows that with conventional CPR, the observed ROSC rate was not significantly different from the predicted rate. Analysis shows a trend toward a higher ROSC rate for chest compression quality management in comparison with conventional CPR. It is unclear whether a single aspect of chest compression quality management or the combination of training, real-time feedback, and debriefing contributed to this result.

The Los Angeles public access defibrillator (PAD) program: Ten years after - Corrected Proof

Marc Eckstein — 2012-04-05

Abstract: Background: Public access automated external defibrillator (PAD) programs have been shown to be successful in several municipalities. This study sought to determine the usage of and survival rate from a large, urban PAD program in the first 10years since its implementation.Methods: This was a prospective, longitudinal, observational study from January 2002–2012 conducted in Los Angeles, California, a city with a population of 3.8 million. An incremental rollout resulted in a current total of 1300 automated external defibrillators (AEDs) in place in city-owned buildings and other public places, including all 3 area airports, golf-courses, and public pools. All instances where an AED was applied were included in the study.Results: There were 59 incidents of cardiac arrest with a public access AED applied, of which 42 (71%) occurred at an airport. 51 (86%) of the patients were male, with a median age of 64years (interquartile range, 56.5 to 70years). A shockable rhythm was detected and shocks were applied in 39 (66%) patients, with 30 (77%) of these patients achieving a return of spontaneous circulation (ROSC). Of those patients who received shock(s) by public access AED, 27 (69%) survived to hospital discharge. The youngest survivors were a 25year old male and a 34year old female.Conclusion: While the majority of PAD cases occurred at an airport, there were also survivors from other public locations. AEDs deployed as part of a large PAD program resulted in a very high survival rate for patients with cardiac arrest.

King LTS-D use by EMT-intermediates in a rural prehospital setting without intubation availability - Corrected Proof

2012-04-05

Resuscitation guidelines suggest that rescuers with less airway experience utilize supraglottic airway devices, but the evidence characterizing prehospital use of these devices is limited. In Vermont, EMS staff are predominantly EMT-Intermediates (EMT-Is), mostly volunteers, without training in endotracheal intubation. Based on early reports of King-LT insertion success near 100%, in 2009 the EMS district serving our academic medical center (approximately 60,000 patients annually) approved a protocol for King-LTS-D (King Systems, Noblesville, IN) use by EMT-Is. The district serves a mostly rural population with ground transport of 45min from distant location without paramedic or intubation availability. The protocol specified King-LT use in cardiac arrest patients with apnea. EMT-Is received 3-h training with the device, followed by a 1-h refresher session after 6 months. In this letter, we characterize King-LT insertion performance by EMT-Is in our district.

A comparison of survival with and without extracorporeal life support treatment for severe poisoning due to drug intoxication - Corrected Proof

2012-04-02

Abstract: Background: The use of extracorporeal life support (ECLS) as a treatment for severe cardiovascular impairment due to poisoning is unclear. Therefore, we conducted a retrospective cohort analysis to compare survival among critically ill poisoned patients treated with or without ECLS.Methods: All consecutive patients admitted into 2 university hospitals in northwestern France over the past decade for persistent cardiac arrest or severe shock following poisoning due to drug intoxication were included. ECLS was preferentially performed in 1 of the 2 centers.Results: Sixty-two patients (39 women, 23 men; mean age 48±17 years) fulfilled inclusion criteria: 10 with persistent cardiac arrest and 42 with severe shock. Fourteen patients were treated with ECLS and 48 patients with conventional therapies. All subjects received vasopressor and fluid loading. Patients treated with or without ECLS at ICU admission had comparable drug ingestion histories, Simplified Acute Physiology Score (SAPS II score) (66±18), Sequential Organ Failure Assessment (SOFA) score (median: 11 [IQR, 9–13]), Glasgow Coma Scale score (median: 3 [IQR, 3–11]), need for ventilator support (n=56) and extra renal support (n=23). Thirty-five (56%) patients survived: 12/14 (86%) ECLS patients and 23/48 (48%) non-ECLS patients (p=0.02, by Fisher exact test). None of the patients with persistent cardiac arrest survived without ECLS support. Based on admission data, beta-blocker intoxication (p=0.02) was also associated with lower mortality. In multivariate analysis, adjusting for SAPS II and beta-blocker intoxication, ECLS support remained associated with lower mortality [Adjusted Odds Ratio, 0.18; 95% CI, 0.03–0.96; p=0.04].Conclusion: In the absence of response to conventional therapies, we consider that ECLS may improve survival in critically ill poisoned patients experiencing cardiac arrest and severe shock.

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

2012-03-29

Abstract: Aim: Survival after cardiac arrest (CA) is limited by the profound neurologic insult from ischemia–reperfusion injury. Therapeutic options are limited. Previous data suggest a benefit of coenzyme Q10 (CoQ10) in post-arrest patients. We hypothesized that plasma CoQ10 levels would be low after CA and associated with poorer outcomes.Methods: Prospective observational study of post-arrest patients presenting to a tertiary care center. CoQ10 levels were drawn 24h after return of spontaneous circulation (ROSC) and compared to healthy controls. Levels of inflammatory cytokines and biomarkers were analyzed. Primary endpoints were survival to discharge and neurologic status at time of discharge.Results: 23 CA subjects and 16 healthy controls were enrolled. CoQ10 levels in CA patients (0.28μmolL−1, inter-quartile range (IQR): 0.22–0.39) were significantly lower than in controls (0.75μmolL−1, IQR: 0.61–1.08, p<0.0001). The mean CoQ10 level in CA patients who died was significantly lower than in those who survived (0.27 vs 0.47μmolL−1, p=0.007). There was a significant difference in median CoQ10 level between patients with a good vs poor neurological outcome (0.49μmolL−1, IQR: 0.30–0.67 vs 0.27μmolL−1, IQR: 0.21–0.30, p=0.02). CoQ10 was a statistically significant predictor of poor neurologic outcome (adjusted p=0.02) and in-hospital mortality (adjusted p=0.026).Conclusion: CoQ10 levels are low in human subjects with ROSC after cardiac arrest as compared to healthy controls. CoQ10 levels were lower in those who died, as well as in those with a poor neurologic outcome.

Impairment of carotid artery blood flow by supraglottic airway use in a swine model of cardiac arrest - Corrected Proof

2012-03-29

Abstract: Objective: Supraglottic airway devices (SGDs) are often used as an alternative to endotracheal tube (ETT) during cardiopulmonary resuscitation (CPR). SGDs can be inserted ‘blindly’ and rapidly, without stopping compressions. These devices utilize pressurized balloons to direct air to the trachea and prevent esophagus insufflation. We hypothesize that the use of a SGD will compress the carotid artery and decrease carotid blood flow (CBF) during CPR in pigs.Methods: Ventricular fibrillation (VF) was induced in 9 female pigs (32±1kg) followed by 4min without compressions. CPR was then performed continuously for 3–6-min intervals. During each interval, an ETT was used for the first 3min, followed by 3min of each SGD (King LTS-D™, LMA Flexible™, Combitube™) in a random order. The primary endpoint was mean CBF (ml/min). Statistical comparisons among the 4 airway devices were performed by Wilcoxon Rank test. Post mortem carotid arteriographies were performed with SGDs in place.Results: CBF (median ml/min; 25/75 percentile) was significantly lower with each SGD [King (10; 6/41), LMA (10; 4/39), and Combitube (5; −0.4/15)] versus ETT (21; 14/46) (p<0.05 for each SGD compared with ETT). Arteriograms showed that with each SGD there was compression of the internal and external carotid vessels.Conclusion: The use of 3 different SGDs during CPR significantly decreased CBF in a porcine model of cardiac arrest. While the current study is limited to pigs, the findings suggest that further research on the effects of SGD use in humans and the effects on carotid artery blood flow is warranted.

Regionalisation of out-of-hospital cardiac arrest care for patients without prehospital return of spontaneous circulation - Corrected Proof

2012-03-26

Abstract: Study objectives: The aim of this study was to evaluate the risk of prolonged transportation against the benefit of treatment in high-volume centres for out-of-hospital cardiac arrest (OHCA) patients without prehospital return of spontaneous circulation (ROSC).Methods: This study used a nationwide EMS-assessed OHCA database (2006–2008). Patients with cardiac aetiology were selected from the registry. A high-volume centre was defined as a hospital that received an average of more than 33 cases per year. OHCA patients without prehospital ROSC were divided into subgroups according to their destination (high-volume centre vs. low-volume centre) and transport interval. The rates of survival to discharge were compared among these groups using multivariate logistic regression analysis.Results: During the study period, 54,499 OHCA patients were assessed by EMS in Korea. Of these patients, prehospital resuscitation was attempted for 29,345 patients with presumed cardiac origin. After excluding cases with inappropriate time data, 27,662 cases were selected for further analysis. 15,885 (57.4%) patients were transported to low-volume centres while the rest were transported to high-volume centres. The rate of survival to discharge was 1.43% and 4.78%, respectively. A multivariate analysis indicated that even with a longer transport interval (TI)(TI 5–9min vs. TI 0–4min), the high-volume centres presented a better overall outcome.Conclusion: A higher rate of survival to discharge was demonstrated when OHCA patients without prehospital ROSC were transported to high-volume rather than low-volume centres. The rate was still significantly higher when the transportation time was longer compared with that of low-volume centres.

Effects of bone marrow mesenchymal stem cells in a rat model of myocardial infarction - Corrected Proof

Tong Wang, Shijie Sun, Zhi Wan, Max Harry Weil, Wanchun Tang — 2012-03-26

Abstract: Aim: Infusion of bone marrow mesenchymal stem cells (MSCs) improves myocardial function following myocardial infarction (MI). The mechanisms, however, remain controversial. This study was to investigate changes of MSCs in vivo after administration into myocardial infarcted rats. Our hypothesis was that MSCs might differentiate into contractile myocytes and improve myocardial function in vivo.Methods: MI was induced in 21 Sprague–Dawley rats by ligation of the left anterior descending artery. One week after ligation, 18 rats were randomized to receive MSCs labeled with PKH26 in a phosphate buffer solution (PBS) by direct injection into the infarcted myocardium. The remaining 3 rats received PBS alone as placebo. An additional 3 non-ligated rats served as a normal group to obtain normal myocytes.Results: Every week for 6 weeks, hearts from 3 rats injected with MSCs were harvested to observe single cardiomyocytes. Although each week numerous round MSCs were found in the hearts of animals treated with MSCs, beating cardiomyocyte-like cells labeled with PKH26 were observed at the sixth week. The contractility of cardiomyocyte-like cells was the same to that of the unlabeled contractile native cardiomyocytes at the sixth week and that of the normal group (10.71±1.59 vs. 11.09±3.42 vs. 11.21±2.16, p>0.05). The contractility of cardiomyocyte-like cells was greater than cells both from the first week (10.71±1.59 vs. 7.37±3.47, p<0.01) and the second week (10.71±1.59 vs. 8.08±3.11, p<0.05) which was associated with significantly increased ejection fraction.Conclusions: MSCs can differentiate into beating cardiomyocytes in a rat model of MI and improve myocardial function.

Life signs in “dead” patients - Corrected Proof

2012-03-26

Interruption of resuscitation has major ethical issues. We recently faced an ethical dilemma, while managing two patients with cardiac arrest. Patients were managed by an Emergency Physician in prehospital setting. No recuperation of cardiac activity occurred despite prolonged advanced life support. The continuation of resuscitation process appeared trivial.

In-hospital chest compressions—The patient on a bed - Corrected Proof

Anthony J. Handley — 2012-03-23

Basic life support (BLS) guidelines have, in the main, been designed to be easily taught to and remembered by lay members of the public as well as being suitable for healthcare professionals. To this end, simplification has been in the forefront of the minds of those responsible for previous and current guidelines. But has the need for simplification resulted in less-than-ideal CPR when performed by healthcare professionals?

From clinical judgment to odds: A history of prognostication in anoxic-ischemic coma - Corrected Proof

Eelco F.M. Wijdicks — 2012-03-23

Abstract: Persistent coma from a major anoxic-ischemic injury to the brain may indicate there is less chance for full recovery. The tools of prognostication to assess comatose survivors of cardiopulmonary resuscitation have developed over several decades. Physicians would initially base their judgment on experience and data on outcome in these patients in the early years were merely on awakening not on disability.In the late 1970s, a large multicenter prospective study was performed on outcome in nontraumatic coma. The impetus for this study was the result of Plum and Jennet's collaboration. In 1981 – for the first time – complex statistics were used to improve the accuracy of prognosis and became known as the “Levy algorithms.” These early seminal studies shaped the prediction models and implied that clinical information alone could assist physicians in making a prediction. Later, probabilistic methods became more commonplace.

Early adrenaline administration does not improve circulatory recovery during resuscitation from severe asphyxia in newborn piglets - Corrected Proof

Rikard Linner, Olof Werner, Valeria Perez-de-Sa, Doris Cunha-Goncalves — 2012-03-22

Abstract: Aim of the study: To investigate the effects of early intravenous adrenaline administration on circulatory recovery, cerebral reoxygenation, and plasma catecholamine concentrations, after severe asphyxia-induced bradycardia and hypotension.Methods: One-day-old piglets were left in apnoea until heart rate and mean arterial pressure were less than 50min−1 and 25mmHg, respectively. They randomly received adrenaline, 10μgkg−1 (n=16) or placebo (n=15) and were resuscitated with air ventilation and, when needed, closed-chest cardiac massage (CCCM). Eight not asphyxiated animals served as time controls.Results: CCCM was required in 13 piglets given adrenaline and in 13 given placebo. Time to return of spontaneous circulation was: 72 (66–85)s vs. 77 (64–178)s [median (quartile range)] (p=0.35). Time until cerebral regional oxygen saturation (CrSO2) had increased to 30% was 86 (79–152)s vs. 126 (88–309)s (p=0.30). The two groups did not differ significantly in CrSO2, heart rate, arterial pressure, right common carotid artery blood flow, or number of survivors: 13 vs. 11 animals. Plasma concentration of adrenaline, 2.5min after resuming ventilation, was 498 (268–868)nmoll−1 vs. 114 (80–306)nmoll−1 (p=0.01). Corresponding noradrenaline concentrations were 1799 (1058–4182)nmoll−1 vs. 1385 (696–3118)nmoll−1 (ns). In the time controls, the concentrations were 0.4 (0.2–0.6)nmoll−1 of adrenaline and 1.8 (1.3–2.4)nmoll−1 of noradrenaline.Conclusion: The high endogenous catecholamine levels, especially those of noradrenaline, may explain why early administered adrenaline did not significantly improve resuscitation outcome.

Female sex is not associated with improved rates of ROSC or short term survival following prolonged porcine ventricular fibrillation - Corrected Proof

Joshua C. Reynolds, Jon C. Rittenberger, James J. Menegazzi — 2012-03-22

Abstract: Objectives: There may be a survival benefit in female patients experiencing cardiac arrest, which could affect the interpretation of in vivo animal studies. We hypothesized that sex predicts return of spontaneous circulation (ROSC) and short-term survival (SURV) in porcine studies of prolonged ventricular fibrillation (VF).Methods: Retrospective analysis of eight comparable experiments performed in our lab using mixed-breed domestic swine of either sex. All experiments included prolonged untreated VF, CPR, defibrillation, and drugs. We defined ROSC as systolic blood pressure ≥80mmHg for ≥1min. Short-term survival was defined 20 or 60min, depending on protocol. Categorical variables were compared with chi-square test and Fisher's exact test. Continuous variables were compared with two-sample t-test and one-way ANOVA. Multiple logistic regression determined predictors of ROSC and SURV, utilizing cluster analysis by experimental protocol. Candidate variables were sex, weight, anesthesia duration, VF duration, and CPR ratio.Results: Of 263 swine analyzed (53.2% male), 58.6% of males and 68.3% of females had ROSC (p=0.10), whereas 50.0% of males and 61.0% of females experienced SURV (p=0.07).Results: Of 263 swine analyzed (53.2% male), 58.6% of males and 68.3% of females had ROSC (p=0.10), whereas 50.0% of males and 61.0% of females experienced SURV (p=0.07). Neither sex nor any identified candidate variable predicted ROSC or SURV. Both models had acceptable fit with Hosmer–Lemeshow values of 0.35 and 0.31, respectively.Conclusions: Sex predicts neither ROSC nor SURV in a swine model of prolonged VF.

Potential negative effects of epinephrine on carotid blood flow and ETCO2 during active compression–decompression CPR utilizing an impedance threshold device - Corrected Proof

2012-03-22

Abstract: Objectives: This study examines the effects of IV epinephrine administration on carotid blood flow (CBF) and end tidal CO2 (ETCO2) production in a swine model of active compression–decompression CPR with an impedance threshold device (ACD-CPR+ITD).Methods: Six female swine (32±1kg) were anesthetized, intubated and ventilated. Intracranial, thoracic aorta and right atrial pressures were measured via indwelling catheters. CBF was recorded. ETCO2, SpO2 and EKG were monitored. V-fib was induced and went untreated for 6min. Three minutes each of standard CPR (STD), STD-CPR+impedance threshold device (ITD) and active compression–decompression (ACD)-CPR+ITD were performed. At minute 9 of the resuscitation, 40μg/kg of IV Epinephrine was administered and ACD-CPR+ITD was continued for 1min. Statistical analysis was performed with a paired t-test. p values of <0.05 were considered statistically significant and all values are reported in mmHg unless otherwise noted.Results: Aortic pressure, cerebral and coronary perfusion pressures increased from STD

Vasopressors in cardiac arrest: A systematic review - Corrected Proof

Todd M. Larabee, Kirsten Y. Liu, Jenny A. Campbell, Charles M. Little — 2012-03-19

Abstract: Objectives: To review the literature addressing whether the use of vasopressors improves outcomes in patients who suffer cardiac arrest.Methods: Databases were searched using the terms: “(adrenaline or noradrenaline or vasopressor) and (heart arrest or cardiac arrest) and therapy”. Inclusion criteria were human studies, controlled trials, meta-analysis or case series. Exclusion criteria were articles with no abstract, abstract-only citations without accompanying article, non-English abstracts, vasopressor studies without human clinical trials, case reports, reviews, and articles addressing traumatic arrest.Results: 1603 papers were identified of which 53 articles were included for review. The literature addressed 5 main therapeutic questions. (1) Outcomes comparing any vasopressor to placebo. (2) Outcomes comparing vasopressin (alone or in combination with epinephrine) to epinephrine. (3) Outcomes comparing high dose epinephrine to standard dose epinephrine. (4) Outcomes comparing any alternative vasopressor to epinephrine. (5) Outcomes examining vasopressor use in pediatric cardiac arrest.Conclusion: There are few studies that compare vasopressors to placebo in resuscitation from cardiac arrest. Epinephrine is associated with improvement in short term survival outcomes as compared to placebo, but no long-term survival benefit has been demonstrated. Vasopressin is equivalent for use as an initial vasopressor when compared to epinephrine during resuscitation from cardiac arrest. There is a short-term, but no long-term, survival benefit when using high dose vs. standard dose epinephrine during resuscitation from cardiac arrest. There are no alternative vasopressors that provide a long-term survival benefit when compared to epinephrine. There is limited data on the use of vasopressors in the pediatric population.

Video-based CPR training – the importance of quality assurance - Corrected Proof

Naheed Akhtar, Richard A. Field, Robin P. Davies, Gavin D. Perkins — 2012-03-19

Clinical practice guidelines advise that all clinical staff should receive annual refresher training in cardiopulmonary resuscitation (CPR) skills. However, sub-optimal standards of resuscitation performance exist amongst healthcare professionals. The traditional approach of instructor-led basic life support (BLS) training may not be the most effective method for delivering resuscitation training calling for alternative mediums. Self-instruction videos which teach basic CPR have proven effective in training healthcare professionals and for supporting training in Automated External Defibrillator (AED) use. The International Liaison Committee on Resuscitation (ILCOR) concluded that well designed self-instruction programmes with minimal or no instructor coaching can be effective alternative approach to instructor-led courses for laypeople and healthcare providers learning BLS and AED skills. It is, therefore, of great importance to evaluate and compare performance outcomes using both traditional and alternative training methods.