The epidemiology of respiratory arrests in a teaching hospital

Aims

We aimed to characterise antecedent causes and outcomes of respiratory arrests occurring within a metropolitan tertiary teaching hospital in Melbourne, Australia.

Methods

We conducted a retrospective audit of respiratory arrests within our hospital over a 6-year period. Data were collected regarding patient characteristics, preceding clinical state, presumed causes and outcomes of arrests. We also compared outcomes of respiratory arrests to that of cardiac arrests occurring over the same period.

Results

We identified 82 respiratory arrests, occurring at a rate of 0.57/1000 inpatient admissions. Pre-existing respiratory, neurologic and cardiac disease was common, as was multi-morbidity. Preceding clinical instability was evident in 39% of arrests, most commonly elevated respiratory rate or progressive hypoxia. Pulmonary oedema was the most common cause of respiratory arrest followed by aspiration, neurologic events, medication side-effects, and tracheostomy-tube complications. In-hospital mortality for respiratory arrests was 25.1%, compared with 74.9% for cardiac arrests (p < 0.001) over the same time period.

Conclusions

Although rare, respiratory arrests are associated with significantly lower in-hospital mortality than cardiac arrests. Further studies are needed to better predict respiratory arrests and identify interventions to reduce incidence and improve outcomes.     

The impact of telemetry on survival of in-hospital cardiac arrests in non-critical care patients

Objective

Since the introduction of telemetry over a half century ago, it has expanded to various units and wards within health care institutions outside of the traditional critical care setting. Little is known on whether routine telemetry use is beneficial in this patient population. The aim of this study was to determine the impact of telemetry monitoring on survival of in-hospital cardiac arrests in patients admitted to non-critical care units.

Methods

A retrospective study of cardiac arrests in patients admitted to non-critical care units within the Winnipeg Regional Health Authority from 2002 to 2006 inclusive was performed. Baseline demographic, cardiac arrest, and outcome data were collected.

Results

Of the total 668 patients, the mean age was 70 ± 14 years with 404 (61%) males. Patients presenting with asystole or pulseless electrical activity (PEA) demonstrated an increased mortality as compared to those presenting with ventricular tachycardia (VT) or ventricular fibrillation (VF). Overall, 268 of 668 patients (40%) survived their initial arrest, 66 (10%) survived to hospital discharge and 49 (7%) survived transfer to another facility. Patients on telemetry vs. no telemetry had higher survival rates immediately following cardiac arrest (66% vs. 34%, OR = 3.67, p = 0.02), as well as higher survival to hospital discharge (30% vs. 6%, OR = 7.17, p = 0.01). Finally, patients with cardiac arrest during the night and early morning benefited proportionally the greatest from telemetry use.

Conclusion

Regardless of whether cardiac arrest was witnessed or unwitnessed, telemetry use was an independent and strong predictor of survival to hospital discharge.     

An eight year audit before and after the introduction of modified early warning score (MEWS) charts, of patients admitted to a tertiary referral intensive care unit after CPR

Aims

To determine whether cardiac arrest calls, the proportion of adult patients admitted to intensive care after CPR and their associated mortalities were reduced, in a four year period after the introduction of a 24/7 Critical Care Outreach Service and MEWS (Modified Early Warning System) Charts.

Methods

A retrospective analysis of prospectively collected data during two four-year periods, (2002-05 and 2006-09) in a UK University Teaching Hospital Comparisons were via χ² test. A p value of ≤0.05 was regarded as being significant.

Results

In the second audit period, compared to the first one, the number of cardiac arrest calls relative to adult hospital admissions decreased significantly (0.2% vs. 0.4%; p < 0.0001), the proportion of patients admitted to intensive care having undergone in-hospital CPR fell significantly (2% vs. 3%; p = 0.004) as did the in-hospital mortality of these patients (42% vs. 52%; p = 0.05).

Conclusion

The four years following the introduction of a 24/7 Critical Care Outreach Service and MEWS Charts were associated with significant reductions in the incidence of cardiac arrest calls, the proportion of patients admitted to intensive care having undergone in-hospital CPR and their in-hospital mortality.     

Comparison of Medical Priority Dispatch (MPD) and Criteria Based Dispatch (CBD) relating to cardiac arrest calls

Background

Prompt emergency medical service (EMS) system activation with rapid delivery of pre-hospital treatment is essential for patients suffering out-of-hospital cardiac arrest (OHCA). The two most commonly used dispatch tools are Medical Priority Dispatch (MPD) and Criteria Based Dispatch (CBD). We compared cardiac arrest call processing using these two dispatch tools in two different dispatch centres.

Methods

Observational study of adult EMS confirmed (non-EMS witnessed) OHCA calls during one year in Richmond, USA (MPD) and Oslo, Norway (CBD). Patients receiving CPR prior to call, interrupted calls or calls where the caller did not have access to the patients were excluded from analysis. Dispatch logs, ambulance records and digitalized dispatcher and caller voice recordings were compared.

Results

The MPDS-site processed 182 cardiac arrest calls and the CBD-site 232, of which 100 and 140 calls met the inclusion criteria, respectively. The recognition of cardiac arrest was not different in the MPD and CBD systems; 82% vs. 77% (p = 0.42), and pre-EMS arrival CPR instructions were offered to 81% vs. 74% (p = 0.22) of callers, respectively. Time to ambulance dispatch was median (95% confidence interval) 15 (13, 17) vs. 33 (29, 36) seconds (p < 0.001) and time to chest compression delivery; 4.3 (3.7, 4.9) vs. 3.7 (3.0, 4.1) min for the MPD and CBD systems, respectively (p = 0.05).

Conclusion

Pre-arrival CPR instructions were offered faster and more frequently in the CBD system, but in both systems chest compressions were delayed 3–4 min. Earlier recognition of cardiac arrest and improved CPR instructions may facilitate earlier lay rescuer CPR.     

Dispatcher assessments for agonal breathing improve detection of cardiac arrest

Aim of study

To determine if a new protocol can increase the detection of agonal respirations by emergency medical dispatchers and thus the presence of cardiac arrest.

Methods

This is a prospective before and after study performed in a large metropolitan city. Cases were identified by review of all cardiac arrests called into a central medical control office. Data were collected through review of tapes and documentation obtained from routine quality assurance audits of these cardiac arrests at the dispatch office as well as reports written by paramedics at the scene of each case. Data were collected for 8 months prior to and 4 months after the implementation of a new dispatcher protocol designed to identify the presence of agonal breathing which included counting the respiratory rate, holding the phone next to the patient, and identifiers used to describe this type of breathing.

Results

During the 8 months prior to implementation of the new protocol, no patient had agonal respirations detected compared with 22 patients detected in the 4 months after implementation. The percentage of patients who did not have EMD criteria for cardiac arrest, but actually were in cardiac arrest decreased from 28.0% (168/599) to 18.8% (68/362; p = 0.0012). Survival to ED admission was similar between the two groups. Bystanders started CPR significantly more frequently after the new protocol was instituted (60.9% before vs. 71.5% afterward, p = 0.006).

Conclusion

Introduction of a new 9-1-1 dispatcher assessment protocol to assess for the presence of agonal respirations can significantly increase the detection cardiac arrest over the telephone.     

Body temperature changes are associated with outcomes following in-hospital cardiac arrest and return of spontaneous circulation

Introduction

Spontaneous changes in body temperature after return of circulation (ROSC) from cardiac arrest are common, but the association of these changes with outcomes in hospitalized patients who survive to 24 h post-ROSC is not known. We tested the hypothesis that adults who experience temperature lability in the first 24 h have worse outcomes compared with those who maintain normothermia.

Materials and methods

A prospective observational study from a multicenter registry of cardiac arrests (National Registry of Cardiopulmonary Resuscitation) from 355 US and Canadian hospitals. 14,729 adults with return of circulation from a pulseless cardiac arrest. We excluded those who died or were discharged before 24 h post-event, those made Do-Not-Resuscitate (DNR) within 24 h of event, those that had a preceding trauma, and those with multiple cardiac arrests. Finally, we included only subjects that had both a lowest (T_min) and highest (T_max) body temperature value recorded during the first 24-h after ROSC, resulting in a study sample of 3426 patients.

Results

After adjustment for potential covariates, there was a lower odds of survival in those having an episode of hypothermia (adjusted odds ratio [OR], 0.62; 95% confidence interval [CI], 0.48–0.80), those having an episode of hyperthermia (OR, 0.67; 95% CI, 0.48–0.80), and those having an episode of both (OR, 0.59; 95% CI, 0.39–0.91). Among those who survived to discharge, there was also a lower odds of favorable neurologic performance in those who had an episode of hyperthermia (OR, 0.71; 95% CI, 0.51–0.98).

Conclusions

Episodes of temperature lability following in-hospital resuscitation from cardiac arrest are associated with lower odds of surviving to discharge. Hyperthermia is also associated with fewer patients leaving the hospital with favorable neurologic performance. Further studies should identify whether therapeutic control over changes in body temperature after in-hospital cardiac arrest improves outcomes.     

Resuscitation characteristics and outcomes in suspected drug overdose-related out-of-hospital cardiac arrest

Introduction

We sought to compare characteristics of emergency medical services-treated out-of-hospital cardiac arrests resulting from suspected drug overdose with non-overdose cases and test the relationship between suspected overdose and survival to hospital discharge.

Methods

Data from emergency medical services-treated, non-traumatic out-of-hospital cardiac arrests from 2006 to 2008 and late 2009 to 2011 were obtained from four EMS agencies in the Pittsburgh, Pennsylvania metropolitan area. Case definition for suspected drug overdose was naloxone administration, indication on the patient care report and/or indication by a review of hospital records. Resuscitation parameters included chest compression fraction, rate, and depth and the administration of resuscitation drugs. Demographic and outcome variables compared by suspected overdose status included age, sex, and survival to hospital discharge.

Results

From 2342 treated out-of-hospital cardiac arrests, 180 were suspected overdose cases (7.7%) and were compared to 2162 non-overdose cases. Suspected overdose cases were significantly younger (45 vs. 65, p < 0.001), less likely to be witnessed by a bystander (29% vs. 41%, p < 0.005), and had a higher rate of survival to hospital discharge (19% vs. 12%, p = 0.014) than non-overdoses. Suspected overdose cases had a higher overall chest compression fraction (0.69 vs. 0.67, p = 0.018) and higher probability of adrenaline, sodium bicarbonate, and atropine administration (p < 0.001). Suspected overdose status was predictive of survival to hospital discharge when controlling for other variables (p < 0.001).

Conclusion

Patients with suspected overdose-related out-of-hospital cardiac arrest were younger, received different resuscitative care, and survived more often than non-overdose cases.     

Emergency department initiation of cardiopulmonary bypass: a case report and review of the literature

Background

Out-of-hospital cardiac arrest carries a dismal prognosis. Percutaneous extracorporeal membrane oxygenation (ECMO) has been used with success for in-hospital arrests, and some literature suggests improvement in long-term survival for out-of-hospital arrests as well.

Objectives

This case highlights the use of ECMO in the emergency department.

Case Report

We report a case in which emergency physician-initiated ECMO was used as a bridge to definitive care in an out-of- hospital cardiac arrest in the United States.

Conclusions

ECMO is a novel adjunct for patients in cardiac arrest in whom the usual advanced life support techniques have failed.     

An assessment of the triage performance of the efferent arm of the rapid response system

Objectives

To measure the triage performance of the efferent arm of a rapid response system (RRS) by assessing the 24 h outcome of patients triaged to remain on the ward after rapid response team (RRT) review.

Methods

We performed a retrospective observational study of all consecutive RRS activations between August 2005 and December 2011 in a university-affiliated hospital. Calls involving patients with documented limitations of medical therapy (LOMT) orders were excluded. We determined patients who were triaged to stay on the ward at the end of their first (index) call and analyzed their vital status and location 24 h later. Finally, we reviewed medical charts of patients triaged to remain on the ward and had a cardiac arrest and/or died within 24 h of RRT review.

Results

We studied 8304 RRT calls. We excluded 1794 calls involving patients with LOMT, 2165 that were repeat calls, 20 where data was missing, 650 where patients were immediately transferred to a high dependency (HDU) or an intensive care unit (ICU) and 92 where calls were rapidly upgraded to cardiac arrest calls. Thus, we identified 3583 index calls at the end of which patients were triaged to remain on the ward. Within 24 h, 454 (12.7%) of those had a repeat RRT activation and 378 were transferred to HDU/ICU. 12 (0.3%) suffered a cardiac arrest on the ward. Altogether, 14 (0.4%) patients died within 24 h of the index RRT activation. Of those 6 had LOMT applied after the call, 4 had been admitted to ICU in a further call and 6 (0.2%) patients had unexpected cardiac arrest on the ward.

Conclusions

The rate of unexpected cardiac arrest in the 24 h following RRT activation is very low for patients triaged to stay on the ward. Major triage errors by the RRT appear uncommon.     

Systematic downloading and analysis of data from automated external defibrillators used in out-of-hospital cardiac arrest

Background

Valuable information can be retrieved from automated external defibrillators (AEDs) used in victims of out-of-hospital cardiac arrest (OHCA). We describe our experience with systematic downloading of data from deployed AEDs. The primary aim was to compare the proportion of shockable rhythm from AEDs used by laypersons with the corresponding proportion recorded by the Emergency Medical Services (EMS) on arrival.

Methods

In a 20-month study, we collected data on OHCAs in the Capital Region of Denmark where an AED was deployed prior to arrival of EMS. The AEDs were brought to the emergency medical dispatch centre for data downloading and rhythm analysis. Patient data were retrieved from the medical records from the admitting hospital, whereas data on EMS rhythm analyses were obtained from the Danish Cardiac Arrest Register between 2001 and 2010.

Results

A total of 121 AEDs were deployed, of which 91 cases were OHCAs with presumed cardiac origin. The prevalence of initial shockable rhythm was 55.0% (95% CI [44.7–64.8%]). This was significantly greater than the proportion recorded by the EMS (27.6%, 95% CI [27.0–28.3%], p < 0.0001). Shockable arrests were significantly more likely to be witnessed (92% vs. 34%, p < 0.0001) and the bystander CPR rate was higher (98% vs. 85%, p = 0.04). More patients with initial shockable rhythm achieved return of spontaneous circulation upon hospital arrival (88% vs. 7%, p < 0.0001) and had higher 30-day survival rate (72% vs. 5%, p < 0.0001).

Conclusion

AEDs used by laypersons revealed a higher proportion of shockable rhythms compared to the EMS rhythm analyses.     

A standardized Code Blue Team eliminates variable survival from in-hospital cardiac arrest

Background

Recent studies suggest that time of day affects survival from in-hospital cardiac arrest. Lower survival rates are observed during nights and on weekends, except in areas with consistent physician care, such as the Emergency Department. Since 1997, our hospital has utilized a standard, hospital-wide “Code Blue Team” (CBT) to respond to cardiac arrests at any time. This team is always led by an emergency physician, and includes specially trained nurses.

Objective

To assess if time of day or week affects survival from in-hospital cardiac arrest when a trained, consistent, emergency physician-led CBT is implemented.

Methods

This is an analysis of prospectively collected data on initial survival rates (return of spontaneous circulation >20 min) of all cardiac arrests that were managed by the CBT from 2000 to 2008. Cardiac arrests were also subcategorized based on initial cardiac rhythm. Survival rates were compared according to time of day or week.

Results

A total of 1692 cardiac arrests were included. There was no significant difference in the overall rate of initial survival between day/evening vs. night hours (odds ratio [OR] 1.04, 95% confidence interval [CI] 0.83–1.29), or between weekday vs. weekend hours (OR 1.10, 95% CI 0.85–1.38). This held true for all cardiac rhythms.

Conclusion

At our institution, there is no significant difference in survival from cardiac arrest when a standardized “Code Blue Team” is utilized, regardless of the time of day or week.     

Use of rapid sequence intubation predicts improved survival among patients intubated after out-of-hospital cardiac arrest

Objective

Some observational studies indicate that endotracheal intubation is associated with a worse outcome compared to bag-mask ventilation after out-of-hospital cardiac arrest in emergency medical services (EMS) systems without rapid sequence intubation (RSI). We evaluated the role of RSI in airway management following cardiac arrest.

Methods

We conducted a cohort study of all non-traumatic arrest patients treated by a metropolitan EMS system from 2007 to 2011. Advanced airway management information was obtained from a prospective airway registry and linked to a cardiac arrest registry. We used multivariate logistic regression to estimate the association between attempted intubation status and survival to hospital discharge.

Results

Of 3133 patients, 82% underwent attempted intubation without RSI, 15% underwent attempted RSI, and 3% experienced no intubation attempt. Survival to hospital discharge differed by attempted intubation status: 11% (n = 291/2576) for intubation without RSI, 48% (n = 226/471) for RSI, and 71% (n = 61/86) for “no intubation.” Compared to the intubation without RSI group, the adjusted odds ratios of survival were 5.6 (95% CI 4.3, 7.2) for the RSI group and 15 (95% CI 9, 27) for the “no intubation” group.

Conclusion

In this population-based cohort of out-of-hospital cardiac arrest, RSI was used in 15% of patients and associated with a better prognosis than intubation attempted without paralytics. Because this subset with a favorable prognosis may not be readily intubated in systems without paralytics, these findings could help to explain the adverse relationship between intubation and survival observed in prior studies.     

Effect of mattress and bed frame deflection on real chest compression depth measured with two CPR sensors

Aim

Implementation of chest compression (CC) feedback devices with a single force and deflection sensor (FDS) may improve the quality of CPR. However, CC depth may be overestimated if the patient is on a compliant surface. We have measured the true CC depth during in-hospital CPR using two FDSs on different bed and mattress types.

Methods

This prospective observational study was conducted at Tampere University Hospital between August 2011 and September 2012. During in-hospital CPR one FDS was placed between the rescuer's hand and the patient's chest, with the second attached to the backboard between the patient's back and the mattress. The real CC depth was calculated as the difference between the total depth from upper FDS to lower FDS.

Results

Ten cardiac arrests on three different bed and mattress types yielded 10,868 CCs for data analyses. The mean (SD) mattress/bed frame effect was 12.8 (4) mm on a standard hospital bed with a gel mattress, 12.4 (4) mm on an emergency room stretcher with a thin gel mattress and 14.1 (3) mm on an ICU bed with an emptied air mattress. The proportion of CCs with an adequate depth (≥50 mm) decreased on all mattress types after compensating for the mattress/bed frame effect from 94 to 64%, 98 to 76% and 91 to 17%, in standard hospital bed, emergency room stretcher and ICU bed, respectively (p < 0.001).

Conclusion

The use of FDS without real-time correction for deflection may result in CC depth not reaching the recommended depth of 50 mm.     

Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device

Background

A recent out-of-hospital cardiac arrest (OHCA) clinical trial showed improved survival to hospital discharge (HD) with favorable neurologic function for patients with cardiac arrest of cardiac origin treated with active compression decompression cardiopulmonary resuscitation (CPR) plus an impedance threshold device (ACD + ICD) versus standard (S) CPR. The current analysis examined whether treatment with ACD + ITD is more effective than standard (S-CPR) for all cardiac arrests of non-traumatic origin, regardless of the etiology.

Methods

This is a secondary analysis of data from a randomized, prospective, multicenter, intention-to-treat, OHCA clinical trial. Adults with presumed non-traumatic cardiac arrest were enrolled and followed for one year post arrest. The primary endpoint was survival to hospital discharge (HD) with favorable neurologic function (Modified Rankin Scale score ≤ 3).

Results

Between October 2005 and July 2009, 2738 patients were enrolled (S-CPR = 1335; ACD + ITD = 1403). Survival to HD with favorable neurologic function was greater with ACD + ITD compared with S-CPR: 7.9% versus 5.7%, (OR 1.42, 95% CI 1.04, 1.95, p = 0.027). One-year survival was also greater: 7.9% versus 5.7%, (OR 1.43, 95% CI 1.04, 1.96, p = 0.026). Nearly all survivors in both groups had returned to their baseline neurological function by one year. Major adverse event rates were similar between groups.

Conclusions

Treatment of out-of-hospital non-traumatic cardiac arrest patients with ACD + ITD resulted in a significant increase in survival to hospital discharge with favorable neurological function when compared with S-CPR. A significant increase survival rates was observed up to one year after arrest in subjects treated with ACD + ITD, regardless of the etiology of the cardiac arrest.     

Effects of a mandatory basic life support training programme on the no-flow fraction during in-hospital cardiac resuscitation: An observational study

Aim of the study

Many hospitals have basic life support (BLS) training programmes, but the effects on the quality of chest compressions are unclear. This study aimed to evaluate the no-flow fraction (NFF) during BLS provided by standard care nursing teams over a five-year observation period during which annual participation in the BLS training was mandatory.

Methods

All healthcare professionals working at Dresden University Hospital were instructed in BLS and automated external defibrillator (AED) use according to the current European Resuscitation Council guidelines on an annual basis. After each cardiac arrest occurring on a standard care ward, AED data were analyzed. The time without chest compressions during the period without spontaneous circulation (i.e., the no-flow fraction) was calculated using thoracic impedance data.

Results

For each year of the study period (2008–2012), a total of 1454, 1466, 1487, 1432, and 1388 health care professionals, respectively, participated in the training. The median no-flow fraction decreased significantly from 0.55 [0.42; 0.57] (median [25‰; 75‰]) in 2008 to 0.3 [0.28; 0.35] in 2012. Following revision of the BLS curriculum after publication of the 2010 guidelines, cardiac arrest was associated with a higher proportion of patients achieving ROSC (72% vs. 48%, P = 0.025) but not a higher survival rate to hospital discharge (35% vs. 19%, P = 0.073).

Conclusion

The NFF during in-hospital cardiac resuscitation decreased after establishment of a mandatory annual BLS training for healthcare professionals. Following publication of the 2010 guidelines, more patients achieved ROSC after in-hospital cardiac arrest.     

Extracorporeal life support as rescue strategy for out-of-hospital and emergency department cardiac arrest

Background

Extracorporeal life support (ECLS) has been utilized as a rescue strategy for patients with cardiac arrest unresponsive to conventional cardiopulmonary resuscitation.

Objective

We sought to describe our institution's experience with implementation of ECLS for out-of-hospital and emergency department (ED) cardiac arrests. Our primary outcome was survival to hospital discharge.

Methods

Consecutive patients placed on ECLS in the ED or within one hour of admission after out-of-hospital or ED cardiac arrest were enrolled at two urban academic medical centers in the United States from July 2007–April 2014.

Results

During the study period, 26 patients were included. Average age was 40 ± 15 years, 54% were male, and 42% were white. Initial cardiac rhythms were ventricular fibrillation or pulseless ventricular tachycardia in 42%. The average time from initial cardiac arrest to initiation of ECLS was 77 ± 51 min (range 12–180 min). ECLS cannulation was unsuccessful in two patients. Eighteen (69%) had complications related to ECLS, most commonly bleeding and ischemic events. Four patients (15%) survived to discharge, three of whom were neurologically intact at 6 months.

Conclusion

ECLS shows promise as a rescue strategy for refractory out-of-hospital or ED cardiac arrest but is not without challenges. Further investigations are necessary to refine the technique, patient selection, and ancillary therapeutics.     

Evaluation of telephone-cardiopulmonary resuscitation advice for paediatric cardiac arrest

Introduction

Telephone-cardiopulmonary resuscitation (CPR) advice aims to increase the quality and quantity of bystander CPR, one of the few interventions shown to improve outcome in cardiac arrest. We evaluated a current paediatric telephone protocol (AMPDS v11.1) to assess the effectiveness of verbal CPR instructions in paediatric cardiac arrest.

Methods

Consecutive emergency calls classified by the AMPDS as cardiac arrests in children <8 years old, over an 11 month period, were compared with their corresponding patient report forms (PRFs) to confirm the diagnosis. Audio recordings and PRFs were then evaluated to assess whether bystander CPR was given, and when it was, the time taken to perform CPR interventions, before paramedic arrival.

Results

Of the 42 calls reviewed, 19 (45.2%) were confirmed as cardiac arrest. CPR was already underway in two cases (10.5%). Of the remaining callers, 11 (64.7%) agreed to attempt T-CPR, resulting in an overall bystander-CPR rate of 68.4%. The median time to open the airway was 126 s (62-236 s, n = 11), deliver the first ventilation was 180 s (135-360 s, n  = 11), and perform the first chest compression was 280 s (164-420 s, n  = 9).

Conclusion

Although current telephone-CPR instructions improve the numbers of children in whom bystander CPR is attempted, effectiveness is likely to be limited by the significant delays in actually delivering basic life support.     

Outcomes of patients with trauma and intraoperative cardiac arrest

Background

Although the occurrence of intraoperative cardiac arrest is rare, it is a severe adverse event with a high mortality rate. Trauma patients have additional causes for intraoperative arrest, and we hypothesised that the survival of trauma patients who experienced intraoperative cardiac arrest would be worse than nontrauma patients who experienced intraoperative cardiac arrest.

Objectives

The aim of the present study was to compare the outcomes of trauma and nontrauma patients after intraoperative cardiac arrest.

Methods

In a tertiary university hospital and trauma centre, the intraoperative cardiac arrest cases were evaluated from January 2007 to December 2009, excluding patients submitted to cardiac surgery. Data were prospectively collected using the Utstein-style. Outcomes among the patients with trauma were compared to the patients without trauma.

Results

We collected data from 81 consecutive intraoperative cardiac arrest cases: 32 with trauma and 49 without trauma. Patients in the trauma group were younger than the patients in the nontrauma group (44 ± 23 vs. 63 ± 17, p < 0.001). Hypovolaemia (63% vs. 35%, p = 0.022) and metabolic/hydroelectrolytic disturbances (41% vs. 2%, p < 0.001) were more likely to cause the cardiac arrest in the trauma group. The first documented arrest rhythm did not differ between the groups, and pulseless electrical activity was the most prevalent rhythm (66% vs. 53%, p = 0.698). The return of spontaneous circulation (47% vs. 63%, p = 0.146) and survival to discharge with favourable neurological outcome (16% vs. 14%, p = 0.869) did not differ between the two groups.

Conclusions

The outcomes did not differ between patients with trauma and nontrauma intraoperative cardiac arrest.     

Continuous neuromuscular blockade is associated with decreased mortality in post-cardiac arrest patients

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.

Methods

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.

Results

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).

Conclusions

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.