[Show abstract][Hide abstract] ABSTRACT: Background During cardiopulmonary resuscitation (CPR) in patients with out-of-hospital cardiac arrest, the interruption of manual chest compressions for rescue breathing reduces blood flow and possibly survival. We assessed whether outcomes after continuous compressions with positive-pressure ventilation differed from those after compressions that were interrupted for ventilations at a ratio of 30 compressions to two ventilations. Methods This cluster-randomized trial with crossover included 114 emergency medical service (EMS) agencies. Adults with non-trauma-related cardiac arrest who were treated by EMS providers received continuous chest compressions (intervention group) or interrupted chest compressions (control group). The primary outcome was the rate of survival to hospital discharge. Secondary outcomes included the modified Rankin scale score (on a scale from 0 to 6, with a score of ≤3 indicating favorable neurologic function). CPR process was measured to assess compliance. Results Of 23,711 patients included in the primary analysis, 12,653 were assigned to the intervention group and 11,058 to the control group. A total of 1129 of 12,613 patients with available data (9.0%) in the intervention group and 1072 of 11,035 with available data (9.7%) in the control group survived until discharge (difference, -0.7 percentage points; 95% confidence interval [CI], -1.5 to 0.1; P=0.07); 7.0% of the patients in the intervention group and 7.7% of those in the control group survived with favorable neurologic function at discharge (difference, -0.6 percentage points; 95% CI, -1.4 to 0.1, P=0.09). Hospital-free survival was significantly shorter in the intervention group than in the control group (mean difference, -0.2 days; 95% CI, -0.3 to -0.1; P=0.004). Conclusions In patients with out-of-hospital cardiac arrest, continuous chest compressions during CPR performed by EMS providers did not result in significantly higher rates of survival or favorable neurologic function than did interrupted chest compressions. (Funded by the National Heart, Lung, and Blood Institute and others; ROC CCC ClinicalTrials.gov number, NCT01372748 .).
New England Journal of Medicine 11/2015; DOI:10.1056/NEJMoa1509139 · 55.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
The development of Advanced Life Support (ALS) Termination of Resuscitation (TOR) guidelines for Out-of-Hospital Cardiac Arrest (OHCA) seeks to improve the efficiency of scarce pre-hospital resources. However, as pre-hospital treatment for OHCA evolves and survival improves, these TOR guidelines must be reevaluated in the contemporary context of Emergency Medical Services (EMS) providing access to advanced resuscitation care.
Retrospective review of all adult (>18 years old), non-traumatic, OHCA patients (defined as patients with absence of pulse who received either CPR and/or defibrillation) treated by EMS in Richmond, Virginia, from January 1, 2009 to December 31, 2010. In addition to standard ALS, intra-arrest cold saline, mechanical CPR, and transportation to a comprehensive post-resuscitation center (CPRC) was provided. Patient treatment and outcomes were recorded via prehospital patient care reports and data were evaluated against previously established criteria for termination of resuscitation in an ALS EMS system. According to the aforementioned previously described criteria for TOR, patients meeting a single criterion for transport are recommended to be transported emergently to a comprehensive post-resuscitation care facility. Conversely, patients failing to meet any of the TOR criteria can be presumed to be expired without exception. Survival at 180 days was presumed when death could not be verified from publically reportable sources.
Of the 322 OHCA patients enrolled, the majority were male (59%), unwitnessed (52%), received no bystander CPR (67%), and presented in a non- shockable initial rhythm (79%), with an average age of 62.5 years. Overall survival was 17%, 14%,12%, and 11% at 7, 14, 30, and 180 days, respectively. Of the 75 patients for which TOR guidelines recommended termination, none survived yielding both 100% specificity (95% CI 100- 92.8%) and positive predictive value (95% CI 100-94.1%). However, TOR guidelines recommended transport of 208 of the 283 patients who died within 30 days, resulting in a sensitivity of 26.5% (95% CI 34.5-23.4%).
The TOR guidelines continue to have a reliable positive predictive value for death even in the setting of advanced EMS resuscitation methods and access to a CPRC. However, as the potential for survival from OHCA improves, the efficiency gained from their use is impacted greatly.
[Show abstract][Hide abstract] ABSTRACT: Background
The rate and effect of coronary interventions and induced hypothermia after out-of-hospital cardiac arrest (OHCA) are unknown. We measured the association of early (≤24 hours after arrival) coronary angiography, reperfusion, and induced hypothermia with favorable outcome after OHCA.
We performed a secondary analysis of a multicenter clinical trial (NCT00394706) conducted between 2007 and 2009 in 10 North American regions. Subjects were adults (≥ 18 years) hospitalized after OHCA with pulses sustained ≥ 60 minutes. We measured the association of early coronary catheterization, percutaneous coronary intervention, fibrinolysis, and induced hypothermia with survival to hospital discharge with favorable functional status (modified Rankin Score ≤ 3).
From 16,875 OHCA subjects, 3,981 (23.6%) arrived at 151 hospitals with sustained pulses. 1,317 (33.1%) survived to hospital discharge, with 1,006 (25.3%) favorable outcomes. Rates of early coronary catheterization (19.2%), coronary reperfusion (17.7%) or induced hypothermia (39.3%) varied between hospitals, and were higher in hospitals treating more subjects per year. Odds of survival and favorable outcome increased with hospital volume (per 5 subjects/year OR 1.06; 95%CI: 1.04-1.08 and OR 1.06; 95%CI: 1.04, 1.08, respectively). Survival and favorable outcome were independently associated with early coronary angiography (OR 1.69; 95%CI 1.06-2.70 and OR 1.87; 95%CI 1.15-3.04), coronary reperfusion (OR 1.94; 95%CI 1.34-2.82 and OR 2.14; 95%CI 1.46-3.14), and induced hypothermia (OR 1.36; 95%CI 1.01-1.83 and OR 1.42; 95%CI 1.04-1.94).
: Early coronary intervention and induced hypothermia are associated with favorable outcome and are more frequent in hospitals that treat higher numbers of OHCA subjects per year.
[Show abstract][Hide abstract] ABSTRACT: Rate of lactate change is associated with in-hospital mortality in post-cardiac arrest patients. This association has not been validated in a prospective multicenter study. The objective of the current study was to determine the association between percent lactate change and outcomes in post-cardiac arrest patients.
Four-center prospective observational study conducted from June 2011 to March 2012.
The National Post-Arrest Research Consortium is a clinical research network conducting research in post-cardiac arrest care. The network consists of four urban tertiary care teaching hospitals.
Inclusion criteria consisted of adult out-of-hospital non-traumatic cardiac arrest patients who were comatose after return of spontaneous circulation.
The primary outcome was survival to hospital discharge, and secondary outcome was good neurologic outcome. We compared the absolute lactate levels and the differences in the percent lactate change over 24 hours between survivors and nonsurvivors and between subjects with good and bad neurologic outcomes. One hundred patients were analyzed. The median age was 63 years (interquartile range, 50-75) and 40% were female. Ninety-seven percent received therapeutic hypothermia, and overall survival was 46%. Survivors and patients with good neurologic outcome had lower lactate levels at 0, 12, and 24 hours (p < 0.01). In adjusted models, percent lactate decrease at 12 hours was greater in survivors (odds ratio, 2.2; 95% CI, 1.1-6.2) and in those with good neurologic outcome (odds ratio, 2.2; 95% CI, 1.1-4.4).
Lower lactate levels at 0, 12, and 24 hours and greater percent decrease in lactate over the first 12 hours post cardiac arrest are associated with survival and good neurologic outcome.
Critical care medicine 04/2014; 42(8). DOI:10.1097/CCM.0000000000000332 · 6.31 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: On the basis of the current state of knowledge of PEA, in conjunction with its increased prevalence compared with tachyarrhythmic cardiac arrests, its historically poor outcome, and emerging suggestions that opportunities for better outcomes may be feasible, the working group made a series of recommendations that constitute a road map for future research. The workshop participants produced a working definition of the PEA syndrome and, on the basis of the literature, support the differentiation of primary and secondary forms of PEA. It was recognized that many different experimental and clinical
conditions may lead to the PEA syndrome. However, it is not clear whether there is a final common pathway at the cellular level for each of these conditions. Traditional experimental models of the PEA syndrome differ substantially from conditions in the majority of clinical cases. The Oregon SUDS, the Cardiac Arrest Registry to Enhance Survival, the Resuscitation Outcomes Consortium, and surveillance data on medication use before arrest suggest that there may be important patient “host factors” associated with PEA as the initial documented cardiac arrest rhythm. These observations are intriguing, but it is not clear whether these associations signal a causal relationship that may provide insight into the pathophysiological mechanisms underlying PEA. Several relatively simple and inexpensive modalities, potentially useful for further PEA classification, are readily available. Echocardiographic and end-tidal carbon dioxide observations provide real-time insight into the potential causes and prognosis of PEA, but little is known about the hemodynamics during clinical resuscitation. Therefore, methods to estimate the inotropic status and systemic vascular resistance during resuscitation would be potentially useful. The working group makes the following recommendations: 1. Develop a taxonomic classification of the known experimental and clinical conditions associated with PEA. 2. Conduct future experimental and clinical studies and report them using this taxonomic classification. 3. Identify new experimental models that better mimic the clinical conditions leading to the syndrome of PEA to elucidate the intracellular pathways that result in the syndrome of PEA. Development and refinement of such models should be a high priority, contributing to the design of pilot studies in humans. 4. Capture and analyze accurate additional data elements in existing and future cardiac arrest surveillance, notably prior illnesses and current medications, to further elucidate the relationship between patient host factors and the initial documented cardiac arrest rhythm. 5. Collect genetic, proteomic, and biomarker data on both experimental models and clinical subjects that may lead to a better understanding of the pathophysiology of PEA. 6. Obtain real-time hemodynamic information during
resuscitation, particularly when PEA occurs, to guide pharmacological management. Perform noninvasive
technologies such as bioimpedance and bioreactance in experimental cardiac arrest and PEA models to determine whether they can track hemodynamics accurately enough during low-flow states to be of potential use clinically. For those with promising results, consider conducting clinical studies of hemodynamically guided pharmacological intervention (eg, vasoconstrictor/vasodilator/inotropic therapy) during PEA. 7. Consider the merits of pilot testing of PEA-specific interventions in humans on the basis of promising experimental data such as synchronized mechanical chest compression and vasodilator therapy. 8. Conduct experimental and pilot clinical studies focusing on earlier application of therapeutic hypothermia,
particularly when initiated during ongoing resuscitation.
[Show abstract][Hide abstract] ABSTRACT: Aim
Neuromuscular blockade may improve outcomes in patients with acute respiratory distress syndrome. In post-cardiac arrest patients receiving therapeutic hypothermia, neuromuscular blockade is often used to prevent shivering. Our objective was to determine whether neuromuscular blockade is associated with improved outcomes after out-of-hospital cardiac arrest.
A post hoc analysis of a prospective observational study of comatose adult (>18 years) out-of-hospital cardiac arrest at 4 tertiary cardiac arrest centers. The primary exposure of interest was neuromuscular blockade for 24 h following return of spontaneous circulation and primary outcomes were in-hospital survival and functional status at hospital discharge. Secondary outcomes were evolution of oxygenation (PaO2:FiO2), and change in lactate. We tested the primary outcomes of in-hospital survival and neurologically intact survival with multivariable logistic regression. Secondary outcomes were tested with multivariable linear mixed-models.
A total of 111 patients were analyzed. In patients with 24 h of sustained neuromuscular blockade, the crude survival rate was 14/18 (78%) compared to 38/93 (41%) in patients without sustained neuromuscular blockade (p = 0.004). After multivariable adjustment, neuromuscular blockade was associated with survival (adjusted OR: 7.23, 95% CI: 1.56–33.38). There was a trend toward improved functional outcome with neuromuscular blockade (50% versus 28%; p = 0.07). Sustained neuromuscular blockade was associated with improved lactate clearance (adjusted p = 0.01).
We found that early neuromuscular blockade for a 24-h period is associated with an increased probability of survival. Secondarily, we found that early, sustained neuromuscular blockade is associated with improved lactate clearance.
[Show abstract][Hide abstract] ABSTRACT: Both commercial aviation and resuscitation are complex activities in which team members must respond to unexpected emergencies in a consistent, high quality manner. Lives are at stake in both activities and the two disciplines have similar leadership structures, standard setting processes, training methods, and operational tools. Commercial aviation crews operate with remarkable consistency and safety, while resuscitation team performance and outcomes are highly variable. This commentary provides the perspective of two physician-pilots showing how commercial aviation training, operations, & safety principles can be adapted to resuscitation team training and performance.
[Show abstract][Hide abstract] ABSTRACT: An estimated 600,000 Americans are victims of sudden, unexpected, out-of-hospital cardiac arrest (OHCA) each year.(1) Emergency Medical Services (EMS) providers attempt resuscitation in 360,000 of these "EMS-treated" individuals. EMS crews declare another 240,000 victims dead on arrival because the cardiac arrest was un-witnessed and the victim's body shows physical signs that death has not just occurred. Approximately 9.5% of EMS-treated cardiac arrest victims survived to hospital discharge. However, if one includes the 240,000 victims in whom EMS doesn't even attempt resuscitation, the likelihood of surviving an out-of-hospital cardiac arrest in the United States is only 5.7%. Stated differently, only 1 in every 18 OHCA victims in the United States will survive to hospital discharge.
[Show abstract][Hide abstract] ABSTRACT: The prevalence of troponin elevations in patients with cardiac arrest (CA) using newer generation troponin assays when the ninety-ninth percentile is used has not been well described. We studied patients admitted with CA without ST elevation myocardial infarction (MI). Treatment included a multidisciplinary protocol that included routine use of hypothermia for appropriate patients. Serial assessment of cardiac biomarkers, including troponin I was obtained over the initial 24 to 36 hours. Patients were classified into 1 of 5 groups on the basis of multiples of the ninety-ninth percentile (upper reference limit [URL]), using the peak troponin I value: <1×, 1 to 3×, 3 to 5×, 5 to 10×, and >10×. Serial changes between the initial and second troponin I values were also assessed. A total of 165 patients with CA (mean age 58 ± 16, 67% men) were included. Troponin I was detectable in all but 2 patients (99%); all others had peak troponin I values that were greater than or equal to the URL. Most patients had peak troponin I values >10× URL, including patients with ventricular fibrillation or ventricular tachycardia (85%), asystole (50%), and pulseless electrical activity (59%). Serial changes in troponin I were present in almost all patients: ≥20% change in 162 (98%), ≥30% change in 159 (96%), and an absolute increase of ≥0.02 ng/ml in 85% of patients. In conclusion, almost all patients with CA who survived to admission had detectable troponin I, most of whom met biomarker guideline criteria for MI. Given the high mortality of these patients, these data have important implications for MI mortality reporting at CA treatment centers.
The American journal of cardiology 06/2013; 112(7). DOI:10.1016/j.amjcard.2013.05.024 · 3.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Out-of-hospital cardiac arrest claims the lives of approximately 382,800 adult Americans each year. The majority of these victims have underlying structural heart disease, usually in the form of coronary atherosclerosis. Out-of-hospital cardiac arrest occurring in public places is usually caused by a chance arrhythmic event that is triggered by an interaction between structural heart abnormalities and transient, functional electrophysiological disturbances. In such cases, the single most important determinant of survival is the time interval from initiation of the cardiac arrest until defibrillation. Waveform capnography, regionalized post-resuscitation care with therapeutic hypothermia, bundled goal-directed therapy, and frequent EEG (preferably continuous) recording are now important American Heart Association CPR Guideline recommendations.
[Show abstract][Hide abstract] ABSTRACT: Objectives:
Identify the occurrence rate of post-arrest psychological distress; evaluate methodological approaches; suggest future research priorities; address clinical implications.
The electronic databases PubMed/MEDLINE and PsychInfo/APA PsycNET were utilized to search for terms including 'Cardiac Arrest', 'Therapeutic Hypothermia' and 'Depression', 'Anxiety', 'Quality of Life', 'Posttraumatic Stress Disorder (PTSD)', 'Psychological Outcomes', 'Hospital Anxiety and Depression Scale (HADS)', and 'Beck Depression Inventory (BDI)'.
High rates of psychological distress have been reported after OHCA. Specifically, incidence rates of depression have ranged from 14% to 45%; anxiety rates have ranged from 13% to 61%; PTSD rates reportedly range from 19% to 27%. Variability between studies is likely attributable to methodological variations relating to measures used, time since arrest, and research setting.
Given the occurrence rate of psychological distress after OHCA, psychological screening and early intervention seems indicated in the cardiac arrest population. Further studies are needed to better establish occurrence rates in both inpatient and outpatient settings, determine appropriate measures and normative cut off scores, and decide on the most appropriate method of intervention.
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES: To determine the rate of appropriate documentation of endotracheal tube (ET) position confirmation in the American Heart Association's Get With the Guidelines-Resuscitation (GWTG-R) and to determine whether outcomes of patients who experience in-hospital cardiac arrest differ in relation to documentation rate. DESIGN: Analysis of data from the GWTG-R, a prospective observational registry of in-hospital cardiac arrest and resuscitation. SETTING: Database containing clinical information from the 507 hospitals participating in the GWTG-R. PATIENTS: Adults resuscitated after in-hospital cardiac arrest. MEASUREMENTS: The rate of appropriate documentation of ET position confirmation, defined as the use of capnography or an esophageal detector device (EDD); relationship between appropriate documentation of ET position confirmation and return of spontaneous circulation (ROSC) or survival to hospital discharge. Proportions with 95% CI are reported for prevalence data. Binary logistic regression was used to determine the relationship between appropriate documentation of ET position confirmation and outcome (ROSC, survival to hospital discharge). Adjusted and unadjusted odds ratios are reported. MAIN RESULTS: Of the 176,054 patients entered into the GWTG-R database, 75,777 had an ET placed. For 13,263 (17.5%) of these patients, ET position confirmation was not documented in the chart. Auscultation alone was documented in 19,480 (25.7%) cases. Confirmation of ET position by capnography or EDD was documented in 43,034 (56.8%) cases. ROSC occurred in 39,063 (51.6%), and 13,474 (17.8%) survived to discharge. Patients whose ET position was confirmed by capnography or EDD were more likely to have ROSC (adjusted OR 1.229 [1.179, 1.282]) and to survive to hospital discharge (adjusted OR 1.093 [1.033, 1.157]). CONCLUSION: Documentation of ET position confirmation in patients who experience cardiac arrest is suboptimal. Appropriate documentation of ET position confirmation in the GWTG-R is associated with greater likelihood of ROSC and survival to hospital discharge.