Graham Nichol

University of Washington | UW · Division of Emergency Medicine

Background: About 80 percent of patients with out-of-hospital cardiac arrest (OHCA) present with a non-shockable initial rhythm (asystole or pulseless electrical activity (PEA)), which is associated with lower survival. Advanced airway management and oxygen delivery are important OHCA interventions, but their impact based on different presenting rh...

Background: While early vasopressor administration (epinephrine, vasopressin) and early advanced airway management (laryngeal tube [LT], endotracheal intubation [ETI]) have been associated with improved outcomes after out-of-hospital cardiac arrest (OHCA), their optimal sequence during resuscitation remains unclear. Aims: To determine the associati...

Background: While prehospital advanced airway devices are commonly used in out-of-hospital cardiac arrest (OHCA), whether gas exchange differs between devices is unknown. Objective: To characterize arterial blood gas (ABG) differences between patients receiving laryngeal tube (LT) or endotracheal intubation (ETI) in the Pragmatic Airway Resuscitati...

Background: The impact of ultrafast hypothermia, i.e. delivered intra-arrest or immediately after return of spontaneous circulation (ROSC), on functional neurologic outcome after out-of-hospital cardiac arrest (OHCA) is unclear. In two prior trials, prehospital transnasal evaporative intra-arrest cooling was safe, feasible and reduced time to targe...

The members of the International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force have written a comprehensive summary of trials of the effectiveness of induced hypothermia (IH) or targeted temperature management (TTM) in comatose patients after cardiac arrest (CA). However, in-depth analysis of these studies is incomplet...

Objective We sought to evaluate the utility and validity of ICU-free days and ventilator-free days as candidate outcomes for OHCA trials. Methods We conducted a secondary analysis of the Pragmatic Airway Resuscitation Trial. We determined ICU-free (days alive and out of ICU during the first 30 days) and ventilator-free days (days alive and without...

Background We sought to describe ventilation rates during out-of-hospital cardiac arrest (OHCA) resuscitation and their associations with airway management strategy and outcomes. Methods We analyzed continuous end-tidal carbon dioxide capnography data from adult OHCA enrolled in the Pragmatic Airway Resuscitation Trial (PART). Using automated sign...

Objective: Compared with traditional out-of-hospital cardiac arrest (OHCA) trial outcomes such as hospital survival, alternative outcomes such as intensive care unit-free (IFD) and ventilator-free days (VFD) have potential advantages including requiring smaller sample sizes to detect significant differences. Few studies have evaluated these outcome...

Study objective: While often prioritized in the resuscitation of patients with out-of-hospital cardiac arrest, the optimal timing of advanced airway insertion is unknown. We evaluated the association between the timing of advanced airway (laryngeal tube and endotracheal intubation) insertion attempt and survival to hospital discharge in adult out-...

Importance Emergency research is challenging to do well as it involves time sensitive interventions in unstable patients. There is limited time to obtain informed consent from the patient or their legally authorized representative (LAR). Such research is permitted under exception from informed consent (EFIC) if specific criteria are met, including...

Background: Analyses of data recorded by monitor-defibrillators that measure CPR depth with different methods show significant relationships between the process and outcome of CPR. Our objective was to evaluate whether chest compression depth was significantly associated with outcome based on accelerometer-recordings obtained with monitor-defibril...

Background A large, randomized trial showed no significant difference in survival to discharge between cardiopulmonary resuscitation (CPR) strategies of 30 compressions with pause for 2 ventilations per cycle (30:2) and continuous chest compression with asynchronous ventilations (CCC). Data from the same trial suggested that adherence to the intend...

In Reply Mr Sang and Dr Xu discuss potential explanations for the lack of benefit seen in our study with the use of sodium nitrite during resuscitation after out-of-hospital cardiac arrest.¹ They cite 2 potential reasons for this lack of benefit: a delay in nitrite administration compared with animal studies and a potential benefit of sodium nitrit...

Importance Therapeutic delivery of sodium nitrite during resuscitation improved survival in animal models of cardiac arrest, but efficacy has not been evaluated in clinical trials in humans. Objective To determine whether parenteral administration of sodium nitrite given by paramedics during resuscitation for out-of-hospital cardiac arrest improve...

Objective While emphasized in clinical practice, the association between advanced airway insertion first-pass success (FPS) and patient outcomes is incompletely understood. We sought to determine the association of airway insertion FPS with adult out-of-hospital cardiac arrest (OHCA) outcomes in the Pragmatic Airway Resuscitation Trial (PART). Met...

Objective: Paramedics often perform endotracheal intubation (ETI) in the management of out-of-hospital cardiac arrest (OHCA). While ETI assisted by use of the gum elastic Bougie has been associated with improved first-pass intubation success in the emergency department, its influence upon out-of-hospital cardiac arrest (OHCA) ETI is unknown. We com...

Objective Paramedics may perform endotracheal intubation (ETI) while treating patients with out-of-hospital cardiac arrest (OHCA). The gum elastic Bougie (Bougie) is an intubation adjunct that may optimize intubation success. There are few reports of Bougie-assisted intubation in OHCA nor its association with outcomes. We compared intubation succes...

Background Prior studies have reported racial disparities in survival from out-of-hospital cardiac arrest (OHCA). However, these studies did not evaluate the association of race with OHCA course of care and outcomes. The purpose of this study was to evaluate racial disparities in OHCA airway placement success and patient outcomes in the multicenter...

Objective We evaluated the effect of chest compression fraction (CCF) on survival to hospital discharge and return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA) patients with non-shockable rhythms. Methods This is a retrospective analysis (completed in 2016) of a prospective cohort study which included OHCA patients fr...

Brain and heart injury cause most out-of-hospital cardiac arrest deaths but limited pharmacotherapy exists to protect these tissues. Nitrite is a nitric oxide precursor that is protective in pre-clinical models of ischemic injury and safe in Phase I testing. Protection may occur by cGMP generation via the sGC pathway or through S-nitrosothiol and n...

Objectives: Tailoring hypothermia duration to ischemia duration may improve outcome from out-of-hospital cardiac arrest. We investigated the association between the hypothermia/ischemia ratio and functional outcome in a secondary analysis of data from the Resuscitation Outcomes Consortium Amiodarone, Lidocaine, or Placebo Study trial. Design: Co...

Background: Prior studies have reported racial disparities in survival from out-of-hospital cardiac arrest (OHCA). However, these studies did not evaluate how emergency medical services (EMS) provider assessment of race impacts OHCA interventions and survival. Our objective was to evaluate racial disparities in OHCA airway management and patient ou...

Introduction: The multicenter Pragmatic Airway Resuscitation Trial (PART) demonstrated better adult out-of-hospital cardiac arrest (OHCA) outcomes with initial laryngeal tube (LT) insertion than endotracheal intubation (ETI) airway management. While emphasized in clinical practice, the effect of advanced airway insertion first-pass success (FPS) up...

Context: Research in an emergency setting is challenging because the window of opportunity to treat may be short, and preclude time to obtain informed consent from the patient or their representative. Such research can be conducted under exception from informed consent (EFIC) if specific criteria are met. In the United States, this includes notific...

Objective: To systematically review the effectiveness and safety of intravascular temperature management (IVTM) versus surface cooling methods (SCM) for induced hypothermia (IH). Methods: Systematic review and meta-analysis. English-language PubMed, Embase and the Cochrane Database of Systematic Reviews were searched on May 27, 2019. The quality of...

Objectives: Trauma resuscitations are complex critical care events that present patient safety-related risk. Simulation-based leadership training is thought to improve trauma care; however, there is no robust evidence supporting the impact of leadership training on clinical performance. The objective of this study was to assess the clinical impact...

Study objective: Intubation and laryngeal tube insertion are common airway management strategies in out-of-hospital cardiac arrest. Bayesian analysis offers an alternate statistical approach to assess the results of a trial. We use Bayesian analysis to compare the effectiveness of initial laryngeal tube versus initial intubation strategies on outc...

Objective Clinical trial investigators often assemble internal study monitoring committees to measure individual or group adherence with trial performance benchmarks. We examined the processes and results of study monitoring in an international trial of out‐of‐hospital cardiac arrest. Methods We studied Study Monitoring Committee operations for th...

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Because the extent to which delays in initiating cardiopulmonary resuscitation (CPR) versus the time from CPR to defibrillation or epinephrine treatment affects survival remains unknown, it was hypothesized that all three independently de...

Introduction: Out-of-hospital cardiac arrest (OHCA) survival varies greatly between communities. The Utstein template was developed and promulgated to improve the comparability of OHCA outcome reports, but it has undergone limited empiric validation. We sought to assess how much of the variation in OHCA survival between emergency medical services...

Introduction: Epinephrine and advanced airway management are commonly used during treatment of out-of-hospital cardiac arrest (OHCA). Recent studies suggest that early but not late administration of epinephrine is associated with improved survival. The purpose of this study was to evaluate the effect of initial airway strategy on timing to the fir...

Background We aimed to determine the change in treatment strategies and times to treatment over the first 5 years of the Mission: Lifeline program. Methods and Results We assessed pre‐ and in‐hospital care and outcomes from 2008 to 2012 for patients with ST ‐segment–elevation myocardial infarction at US hospitals, using data from the National Card...

Background: Exception from infor med consent (EFIC) is allowed using federal regulations 21 CFR 50.24 and facilitates research on patients with critical conditions such as cardiac arrest. Little is known regarding the differences in the application of EFIC requirements such as community consultation (CC), public disclosure (PD) and patient notific...

Introduction: Out-of-hospital cardiac arrest (OHCA) remains a significant source of morbidity and mortality in the United States. In addition to cardiopulmonary resuscitation (CPR) and defibrillation, epinephrine and advanced airway management are often used in treatment. Recent studies suggest early administration of epinephrine is associated with...

Background Targeted temperature management (TTM) for out-of-hospital cardiac arrest is associated with improved functional survival and is a class I recommendation in resuscitation guidelines. However, patterns of utilization of TTM and adherence to recommended TTM guidelines in contemporary practice are unknown. Methods and Results In a multicent...

Introduction: Hemodynamic-guided cardiopulmonary resuscitation (HGCPR) achieves better outcomes than standard resuscitation. Currently, HGCPR requires an invasive procedure, infeasible during resuscitation. Non-invasive measures of blood flow could provide useful hemodynamic guidance to rescuers. Objective: We describe initial efforts to develop...

Importance Emergency medical services (EMS) commonly perform endotracheal intubation (ETI) or insertion of supraglottic airways, such as the laryngeal tube (LT), on patients with out-of-hospital cardiac arrest (OHCA). The optimal method for OHCA advanced airway management is unknown. Objective To compare the effectiveness of a strategy of initial...

Background: The Resuscitation Outcomes Consortium (ROC)epidemiological registry (Epistry) provides opportunities to assess trends in out-of-hospital cardiac arrest treatment and outcomes. Methods: Patient, event, system, treatment, and outcome data from adult (>18 years) out-of-hospital cardiac arrest (OHCA) from 10 geographically diverse North...

It is hypothesized that intravenous (IV) sodium nitrite given during resuscitation of out-of-hospital cardiac arrest (OHCA) will improve survival. We performed a phase 1 open-label study of IV sodium nitrite given during resuscitation of 120 patents with OHCA from ventricular fibrillation or nonventricular fibrillation initial rhythms by Seattle Fi...

Background: Large variations exist in the care processes and outcomes for patients who experience in-hospital cardiac arrest (IHCA). We examined if Get With The Guidelines-Resuscitation (GWTG-R) participation duration was associated with improved care processes. Methods and results: We calculated an overall process composite performance score fo...

Cardiac arrest effectiveness trials have traditionally reported outcomes that focus on survival. A lack of consistency in outcome reporting between trials limits the opportunities to pool results for meta-analysis. The COSCA initiative (Core Outcome Set for Cardiac Arrest), a partnership between patients, their partners, clinicians, research scient...

Cardiac arrest effectiveness trials have traditionally reported outcomes that focus on survival. A lack of consistency in outcome reporting between trials limits the opportunities to pool results for meta-analysis. The COSCA initiative (Core Outcome Set for Cardiac Arrest), a partnership between patients, their partners, clinicians, research scient...

Background: Prior observational studies suggest no additional benefit from advanced life support (ALS) when compared with providing basic life support (BLS) for patients with out-of-hospital cardiac arrest (OHCA). We compared the association of ALS care with OHCA outcomes using prospective clinical data from the Resuscitation Outcomes Consortium (...

Introduction: The aim of this study was to investigate regional variation in the characteristics, incidence and outcomes of out-of-hospital cardiac arrest (OHCA) in Australia and New Zealand. Methods: This was a population-based cohort study of OHCA using data from the Aus-ROC Australian and New Zealand OHCA Epistry over the period of 01 January...

The American Heart Association previously recommended implementation of cardiac resuscitation systems of care that consist of interconnected community, emergency medical services, and hospital efforts to measure and improve the process of care and outcome for patients with cardiac arrest. In addition, the American Heart Association proposed a natio...

Background - Survival following out-of-hospital cardiac arrest (OHCA) with shockable rhythms can be improved with early defibrillation. Although shockable OHCA accounts for only ≈25% of overall arrests, ≈60% of public OHCAs are shockable, offering the possibility of restoring thousands of individuals to full recovery with early defibrillation by b...

Background: International guidelines recommend administration of 1 mg of intravenous epinephrine every 3 to 5 minutes during cardiac arrest. The optimal dose of epinephrine is not known. We evaluated the association of reduced frequency and dose of epinephrine with survival after out-of-hospital cardiac arrest (OHCA). Methods: Included were pati...

Introduction: The ventricular fibrillation (VF) electrocardiogram (ECG) waveform is known to deteriorate over time if untreated, recover with CPR, and to predict defibrillation success. VF ECG measures could inform CPR quality feedback algorithms based on patient physiologic response. Objectives: Investigate the effects of chest compression paramet...

Background: Patients resuscitated from cardiac arrest have brain and cardiac injury. Recent animal studies suggest that the administration of sodium nitrite after resuscitation from 12minutes of asystole limits acute cardiac dysfunction and improves survival and neurologic outcomes. It has been hypothesized that low doses of IV sodium nitrite give...

Cardiac arrest is the cessation of cardiac activity associated with unresponsiveness, no normal breathing, and no signs of circulation.¹ Most out-of-hospital cardiac arrest (OHCA) occurs in residential settings, and arrest in a private location is associated with a worse outcome than that in a public location.² For decades, outcomes after OHCA did...

Cardiac arrest is defined as the termination of cardiac activity associated with loss of consciousness, of spontaneous breathing, and of circulation. Sudden cardiac arrest and sudden cardiac death (SCD) are terms often used interchangeably. Most patients with out-of-hospital cardiac arrest have shown coronary artery disease or symptoms during the h...

Importance We examined whether resuscitation care and outcomes vary by the racial composition of the neighborhood where out-of-hospital cardiac arrests (OHCAs) occur. Objective To evaluate the association between bystander treatments (cardiopulmonary resuscitation and automatic external defibrillation) and timing of emergency medical services pers...

Aim of the study: Current guidelines recommend targeted temperature management to improve neurological outcome after cardiac arrest. Evidence regarding an ideal sedative/analgesic regimen including skeletal muscle paralysis is limited. Methods: Patients were randomized to either a continuous administration of rocuronium (continuous-NMB-group) or...

Background Some patients with out-of-hospital cardiac arrest (OHCA) assessed by emergency medical services (EMS) do not receive attempts at resuscitation on the basis of perceived futility. Aims 1) To measure variability in the initiation of resuscitation attempts in EMS-assessed OHCA patients across EMS agencies, 2) to evaluate the association be...

Dr. Nichol has received funding from ZOLL Medical Corporation (Chelmsford, Massachusetts); and serves as a consultant to ZOLL Circulation (San Jose, California). Dr. Hira has received honoraria from Abiomed; and serves as a consultant for Abbott Vascular.

Over the last 15 years, treatment of comatose post-cardiac arrest patients has evolved to include therapeutic strategies such as urgent coronary angiography with percutaneous coronary intervention (PCI), targeted temperature management (TTM)—requiring mechanical ventilation and sedation—and more sophisticated and cautious prognostication. In 2015,...

Introduction Lay use of automated external defibrillators (AEDs) before the arrival of emergency medical services (EMS) providers on scene increases survival after out-of-hospital cardiac arrest (OHCA). AEDs have been placed in public locations may be not ready for use when needed. We describe a protocol for AED surveillance that tracks these devic...

Introduction: This pilot study used a simulation-based platform to evaluate the effect of an automated mechanical chest compression device on team communication and patient management. Methods: Four-member emergency department interprofessional teams were randomly assigned to perform manual chest compressions (control, n = 6) or automated chest...

Background: Whether viability imaging can impact long-term patient outcomes is uncertain. The PARR-2 study (Positron Emission Tomography and Recovery Following Revascularization) showed a nonsignificant trend toward improved outcomes at 1 year using an F-18-fluorodeoxyglucose positron emission tomography (PET)-assisted strategy in patients with su...

Background: Efficient trials of interventions for patients with out-of-hospital cardiac arrest (OHCA) should have adequate but not excess power to detect a difference in outcomes. The minimum clinically important difference (MCID) is the threshold value in outcomes observed in a trial at which providers should choose to adopt a treatment. There ha...

Introduction: Emerging infectious diseases often create concern and fear among the public. Ebola virus disease (EVD) and enterovirus (EV-68) are uncommon viral illnesses compared to influenza. The objective of this study was to determine risk for these viral diseases and then determine how public perception of influenza severity and risk of infecti...

Background: Treatment of out-of-hospital cardiac arrest (OHCA) requires prompt intervention. Better outcomes are associated with briefer time from dispatch of emergency medical services (EMS) providers to arrival on scene, application of a defibrillator or insertion of an advanced airway. We assessed whether time from receipt of a call by a teleco...

Introduction: Out-of-hospital cardiac arrest (OHCA) is a global health problem with low survival. Regional variation in survival has heightened interest in combining cardiac arrest registries to understand and improve OHCA outcomes. While individual OHCA registries exist in Australian and New Zealand ambulance services, until recently these regist...

Background Antiarrhythmic drugs are used commonly in out-of-hospital cardiac arrest for shock-refractory ventricular fibrillation or pulseless ventricular tachycardia, but without proven survival benefit. Methods In this randomized, double-blind trial, we compared parenteral amiodarone, lidocaine, and saline placebo, along with standard care, in a...

Introduction Out-of-hospital cardiac arrest (OHCA) is a global health problem with low survival. Regional variation in survival has heightened interest in combining cardiac arrest registries to understand and improve OHCA outcomes. While individual OHCA registries exist in Australian and New Zealand ambulance services, until recently these registri...

Importance Survival rates after in-hospital cardiac arrest (IHCA) vary significantly among US centers; whether this variation is owing to differences in IHCA care quality is unknown. Objective To evaluate hospital-level variation to determine whether hospital process composite performance measures of IHCA care quality are associated with patient...

Aims We sought to review cellular changes that occur with reperfusion to try to understand whether ischemia-reperfusion injury (RI) is a potentially modifiable therapeutic target for cardioprotection or neuroprotection in patients undergoing cardiopulmonary resuscitation. Data sources Articles written in English and published in PubMed. Results R...

Airway management is an important component of resuscitation from out-of-hospital cardiac arrest (OHCA). The optimal approach to advanced airway management is unknown. The Pragmatic Airway Resuscitation Trial (PART) will compare the effectiveness of endotracheal intubation (ETI) and Laryngeal Tube (LT) insertion upon 72-hour survival in adult OHCA....

Each year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together the most up-to-date statistics related to heart disease, stroke, and other cardiovascular and metabolic diseases and presents them in its Heart Disease...

Barriers to informed consent are ubiquitous in the conduct of emergency care research across a wide range of conditions and clinical contexts. They are largely unavoidable; can be related to time constraints, physical symptoms, emotional stress, and cognitive impairment; and affect patients and surrogates. US regulations permit an exception from in...

Background: Communication and teamwork failures correlate with diagnostic errors and deviations from ACLS protocols during cardiac arrest (CA) resuscitation. High task workloads stress teams’ capacity and negatively impact team effectiveness. The LUCAS ® Chest Compression System (Physio-Control, Redmond, WA) is an automated chest compression device...

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 tha...

Background: The frequency of lethal overdose due to prescription and non-prescription drugs is increasing in North America. The aim of this study was to estimate overall and regional variation in incidence and outcomes of out-of-hospital cardiac arrest due to overdose across North America. Methods: We conducted a retrospective cohort study using...

Utstein-style guidelines contribute to improved public health internationally by providing a structured framework with which to compare emergency medical services systems. Advances in resuscitation science, new insights into important predictors of outcome from out-of-hospital cardiac arrest, and lessons learned from methodological research prompte...

High quality chest compressions are the cornerstone of effective cardiopulmonary resuscitation (CPR). There is no available method of real time noninvasive hemodynamic measurement and feedback to inform rescuers of the efficacy of compressions. Ultrasound-based measures of blood flow may provide immediate, noninvasive hemodynamic information. Our o...

Until recently, most communities reported that outcomes after out-of-hospital cardiac arrest (OHCA) had not improved for more than 30 years.¹ This contrasts markedly with the significant and important reductions in mortality associated with care of other acute cardiovascular conditions such as ST-elevation myocardial infarction.² In recognition of...

Background: Survival varies among those resuscitated from out-of-hospital cardiac arrest (OHCA). Evidence-based performance measures have been used to describe hospital quality of care in conditions such as acute coronary syndrome and major trauma. It remains unclear if adherence to performance measures is associated with better outcome in patient...

Regionalization may improve critical care delivery, yet stakeholders cite concerns about its feasibility. We sought to determine the operational effects of prehospital regionalization of nontrauma, nonarrest critical illness. King County, Washington. Discrete event simulation study. All 2006 hospital discharge data, linked to all adult, eligible pa...

Importance Assessment of morbidity is an important component of evaluating interventions for patients with out-of-hospital cardiac arrest (OHCA). Objective We evaluated among survivors of OHCA cognition, functional status, health-related quality of life and depression as functions of patient and emergency medical services (EMS) factors. Design Pros...