The combined use of mechanical CPR and a carry sheet to maintain quality resuscitation in out-of-hospital cardiac arrest patients during extrication and transport

BackgroundQuality of manual cardiopulmonary resuscitation (CPR) during extrication and transport of out-of-hospital cardiac arrest victims is known to be poor. Performing manual CPR during ambulance transport poses significant risk to the attending emergency medical services crew. We sought to use pre-hospital video recording to objectively analyse the impact of introducing mechanical CPR with an extrication sheet (Autopulse, Zoll) to an advanced, second-tier cardiac arrest response team.MethodsThe study was conducted prospectively using defibrillator downloads and analysis of pre-hospital video recording to measure the quality of CPR during extrication from scene and ambulance transport of the OHCA patient. Adult patients with non-traumatic OHCA were included. The interruption to manual CPR to during extrication and to deploy the mechanical CPR device was analysed.ResultsIn the manual CPR group, 53 OHCA cases were analysed for quality of CPR during extrication. The median time that chest compression was interrupted to allow the patient to be carried from scene to the ambulance was 270 s (IQR 201–387 s). 119 mechanical CPR cases were analysed. The median time interruption from last manual compression to first Autopulse compression was 39 s (IQR 29–47 s). The range from last manual compression to first Autopulse compression was 14–118 s.ConclusionMechanical CPR used in combination with an extrication sheet can be effectively used to improve the quality of resuscitation during extrication and ambulance transport of the refractory OHCA patient. The time interval to deploy the mechanical CPR device can be shortened with regular simulation training.     

Computed tomography findings of complications resulting from cardiopulmonary resuscitation

IntroductionThis retrospective study was conducted to evaluate injuries related to cardiopulmonary resuscitation (CPR) and their associated factors using postmortem computed tomography (PMCT) and whole body CT after successful resuscitation.MethodsThe inclusion criteria were adult, non-traumatic, out-of-hospital cardiac arrest patients who were transported to our emergency room between April 1, 2008 and March 31, 2013. Following CPR, PMCT was performed in patients who died without return of spontaneous circulation (ROSC). Similarly, CT scans were performed in patients who were successfully resuscitated within 72 h after ROSC. The injuries associated with CPR were analysed retrospectively on CT images.ResultsDuring the study period, 309 patients who suffered out-of hospital cardiac arrest were transported to our emergency room and received CPR; 223 were enrolled in the study.The CT images showed that 156 patients (70.0%) had rib fractures, and 18 patients (8.1%) had sternal fractures. Rib fractures were associated with older age (78.0 years vs. 66.0 years, p < 0.01), longer duration of CPR (41 min vs. 33 min, p < 0.01), and lower rate of ROSC (26.3% vs. 55.3%, p < 0.01). All sternal fractures occurred with rib fractures and were associated with a greater number of rib fractures, higher age, and a lower rate of ROSC than rib fractures only cases. Bilateral pneumothorax was observed in two patients with rib fractures.ConclusionsPMCT is useful for evaluating complications related to chest compression. Further investigations with PMCT are needed to reduce complications and improve the quality of CPR.     

Do manual chest compressions provide substantial ventilation during prehospital cardiopulmonary resuscitation?

IntroductionChest compressions have been suggested to provide passive ventilation during cardiopulmonary resuscitation. Measurements of this passive ventilatory mechanism have only been performed upon arrival of out-of-hospital cardiac arrest patients in the emergency department. Lung and thoracic characteristics rapidly change following cardiac arrest, possibly limiting the effectiveness of this mechanism after prolonged resuscitation efforts. Goal of this study was to quantify passive inspiratory tidal volumes generated by manual chest compression during prehospital cardiopulmonary resuscitation.Materials and methodsA flowsensor was used during adult out-of-hospital cardiac arrest cases attended by a prehospital medical team. Adult, endotracheally intubated, non-traumatic cardiac arrest patients were eligible for inclusion. Immediately following intubation, the sensor was connected to the endotracheal tube. The passive inspiratory tidal volumes generated by the first thirty manual chest compressions performed following intubation (without simultaneous manual ventilation) were calculated.Results10 patients (5 female) were included, median age was 64 years (IQR 56, 77 years). The median compression frequency was 111 compression per minute (IQR 107, 116 compressions per minute). The median compression depth was 5.6 cm (IQR 5.4 cm, 6.1 cm). The median inspiratory tidal volume generated by manual chest compressions was 20 mL (IQR 13, 28 mL).ConclusionUsing a flowsensor, passive inspiratory tidal volumes generated by manual chest compressions during prehospital cardiopulmonary resuscitation, were quantified. Chest compressions alone appear unable to provide adequate alveolar ventilation during prehospital treatment of cardiac arrest.     

Dispatcher instruction of chest compression-only CPR increases actual provision of bystander CPR

BackgroundA preceding randomized controlled trial demonstrated that chest compression-only cardiopulmonary resuscitation (CPR) instruction by dispatcher was more effective to increase bystander CPR than conventional CPR instruction. However, the actual condition of implementation of each type of dispatcher instruction (chest compression-only CPR [CCCPR] or conventional CPR with rescue breathing) and provision of bystander CPR in real prehospital settings has not been sufficiently investigated.MethodsThis registry prospectively enrolled patients aged =>18 years suffering an out-of-hospital cardiac arrest (OHCA) of non-traumatic causes before emergency-medical-service (EMS) arrival, who were considered as target subjects of dispatcher instruction, resuscitated by EMS personnel, and transported to medical institutions in Osaka, Japan from January 2005 through December 2012. The primary outcome measure was provision of CPR by a bystander. Multiple logistic regression analysis was used to assess factors that were potentially associated with provision of bystander CPR.ResultsAmong 37,283 target subjects of dispatcher instruction, 5743 received CCCPR instruction and 13,926 received conventional CPR instruction. The proportion of CCCPR instruction increased from 5.7% in 2005 to 25.6% in 2012 (p for trend <0.001). The CCCPR instruction group received bystander CPR more frequently than conventional CPR instruction group (70.0% versus 62.1%, p < 0.001). In the multivariable analysis, CCCPR dispatcher instruction was significantly associated with provision of bystander CPR compared with conventional CPR instruction (adjusted odds ratio 1.44, 95% CI 1.34–1.55).ConclusionsCCCPR dispatcher instruction among adult OHCA patients significantly increased the actual provision of bystander CPR.     

Prehospital Echocardiography During Resuscitation Impacts Treatment in a Physician-Staffed Helicopter Emergency Medical Service: an Observational Study

Background: Patients in cardiac arrest must receive algorithm-based management such as basic life support and advanced (cardiac) life support. International guidelines dictate diagnosing and treating any factor that may have caused the arrest or may be complicating the resuscitation. Ultrasound may be of potential value in this process and can be used in a prehospital setting. The objective is to evaluate the use of prehospital ultrasound during traumatic and non-traumatic CPR and determine its impact on prehospital treatment decisions in a Dutch helicopter emergency medical service (HEMS). Methods: We conducted an observational study in cardiac arrest patients, of any cause, in whom the Nijmegen HEMS performed CPR with concurrent echocardiography. The participating physicians had to adhere to Advanced Life Support protocols as per standard operating procedure. Simultaneous with the interruptions of chest compressions to allow for heart rhythm analysis, ultrasound-trained HEMS physicians performed echocardiography according to study protocol. The HEMS nurse and physician recorded patient data and data on impacted (supported or altered) patient treatment decisions. Results: From February 2014 through November 2016, we included 56 patients who underwent 102 ultrasound examinations. Sixty-two (61%) ultrasound examinations impacted 78 treatment decisions in 49 patients (88%). The impacted treatment was related to termination of CPR in 32 (57%), fluid management (14%), drugs selection and doses (14%), and choice of destination hospital (5%). Causes of cardiac arrest included trauma (48%), cardiac (21%), medical (14%), asphyxia (9%), and other (7%). Conclusion: Prehospital echocardiography has an impact on patient treatment and may be a useful tool to support decision-making during CPR in a Dutch HEMS.     

Outcomes of patients resuscitated from cardiac arrest in the setting of drug overdose

ObjectivesTo compare the attributes and clinical outcomes of patients with cardiac arrest in the setting of drug overdose (OD) to patients with cardiac arrest from non-drug related etiologies.MethodsWe utilized a US inpatient cardiac arrest registry used to study targeted temperature management (TTM) to identify patients with cardiac arrest in the setting of drug overdose between 2005 and 2013. Data regarding the cardiac arrest, resuscitation interventions, use of post-arrest TTM, urine drug screen, survival, and neurologic outcome were examined. These results were compared to patients suffering cardiac arrest from other causes during the same time period using Wilcoxon rank-sum tests for continuous variables and chi-square tests on categorical variables.ResultsApproximately 2.5% (64/2584) of cardiac arrests occurred in the setting of drug overdose. Patients in the OD cohort were younger, more likely to be male, and more likely to have an out-of-hospital cardiac arrest that was unwitnessed with no bystander CPR and from a non-shockable rhythm. However, the patients in the OD cohort had similar rates of survival and good neurologic outcomes (Cerebral Performance Category 1–2) compared to non-OD patients. A fraction of initially resuscitated patients in each group (8% in OD cohort vs. 15% in non-OD cohort, p = ns) did not receive post-arrest TTM due to prompt awakening following resuscitation.ConclusionsPatients resuscitated from cardiac arrest in the setting of drug OD have neurologic and survival outcomes comparable to non-OD patients despite lower rates of bystander CPR, shockable rhythms, and witnessed arrest.     

Left Ventricular Compressions Improve Hemodynamics in a Swine Model of Out-of-Hospital Cardiac Arrest

Introduction: We hypothesized that chest compressions located directly over the left ventricle (LV) would improve hemodynamics, including coronary perfusion pressure (CPP), and return of spontaneous circulation (ROSC) in a swine model of cardiac arrest. Methods: Transthoracic echocardiography (echo) was used to mark the location of the aortic root and the center of the left ventricle on animals (n = 26) which were randomized to receive chest compressions in one of the two locations. After a period of ten minutes of ventricular fibrillation, basic life support (BLS) with mechanical cardiopulmonary resuscitation (CPR) was initiated and performed for ten minutes followed by advanced cardiac life support (ACLS) for an additional ten minutes. During BLS the area of maximal compression was verified using transesophageal echo. CPP and other hemodynamic variables were averaged every two minutes. Results: Mean CPP was not significantly higher in the LV group during all time intervals of resuscitation; mean CPP was significantly higher in the LV group during the 12–14 minute interval of BLS and during minutes 22–30 of ACLS (p < 0.05). Aortic systolic and diastolic pressures, right atrial systolic pressures, and end-tidal CO2 (ETCO2) were higher in the LV group during all time intervals of resuscitation (p < 0.05). Nine of the left ventricle group (69%) achieved ROSC and survived to 60 minutes compared to zero of the aortic root group (p < 0.001). Conclusions: In our swine model of cardiac arrest, chest compressions over the left ventricle improved hemodynamics and resulted in a greater proportion of animals with ROSC and survival to 60 minutes.     

The effect of transport on quality of cardiopulmonary resuscitation in out-of-hospital cardiac arrest

IntroductionMost manikin and clinical studies have found decreased quality of CPR during transport to hospital. We wanted to study quality of CPR before and during transport for out-of-hospital cardiac arrest patients and also whether quality of CPR before initiation of transport was different from the quality in patients only receiving CPR on scene.Materials and methodsQuality of CPR was prospectively registered with a modified defibrillator for consecutive cases of out-of-hospital cardiac arrest in three ambulance services during 2002–2005. Ventilations were registered via changes in transthoracic impedance and chest compressions were measured with an extra chest compression pad placed on the patients’ sternum. Paired t-tests were used to analyse quality of CPR before vs. during transport with ongoing CPR. Unpaired t-tests were used to compare CPR quality prior to transport to CPR quality in patients with CPR terminated on site.ResultsQuality of CPR did not deteriorate during transport, but as previously reported overall quality of CPR was substandard. Quality of CPR performed on site was significantly better when transport was not initiated with ongoing CPR compared to episodes with initiation of transport during CPR: fraction of time without chest compressions was 0.45 and 0.53 (p < 0.001), compression depth 37 mm and 34 mm (p = 0.04), and number of chest compressions per minute 61 and 56 (p = 0.01), respectively.ConclusionCPR quality was sub-standard both before and during transport. Early decision to transport might have negatively affected CPR quality from the early stages of resuscitation.     

Mechanical active compression–decompression cardiopulmonary resuscitation (ACD-CPR) versus manual CPR according to pressure of end tidal carbon dioxide (PETCO2) during CPR in out-of-hospital cardiac arrest (OHCA)

AimIn animal and human studies, measuring the pressure of end tidal carbon dioxide (P_ETCO₂) has been shown to be a practical non-invasive method that correlates well with the pulmonary blood flow and cardiac output (CO) generated during cardiopulmonary resuscitation (CPR). This study aims to compare mechanical active compression–decompression (ACD) CPR with standard CPR according to P_ETCO₂ among patients with out-of-hospital cardiac arrest (OHCA), during CPR and with standardised ventilation.MethodsThis prospective, on a cluster level, pseudo-randomised pilot trial took place in the Municipality of Göteborg. During a 2-year period, all patients aged >18 years suffering an out-of-hospital cardiac arrest (OHCA) of presumed cardiac etiology were enrolled. The present analysis included only tracheally intubated patients in whom P_ETCO₂ was measured for 15 min or until the detection of a pulse-giving rhythm.ResultsIn all, 126 patients participated in the evaluation, 64 patients in the mechanical chest compression group and 62 patients in the control group. The group receiving mechanical ACD-CPR obtained the significantly highest P_ETCO₂ values according to the average (p = 0.04), initial (p = 0.01) and minimum (p = 0.01) values. We found no significant difference according to the maximum value between groups.ConclusionIn this hypothesis generating study mechanical ACD-CPR compared with manual CPR generated the highest initial, minimum and average value of P_ETCO₂. Whether these data can be repeated and furthermore be associated with an improved outcome after OHCA need to be confirmed in a large prospective randomised trial.     

Zone 3 REBOA does not provide hemodynamic benefits during nontraumatic cardiac arrest

BackgroundResuscitative endovascular balloon occlusion of the aorta (REBOA) may be a novel intervention to improve cardiopulmonary resuscitation (CPR) quality during cardiac arrest. Zone 1 supraceliac aortic occlusion improves coronary and cerebral blood flow. It is unknown if Zone 3 occlusion distal to the renal arteries offers a similar physiologic benefit while maintaining blood flow to organs above the point of occlusion.MethodsFifteen swine were anesthetized, instrumented, and placed into ventricular fibrillation. Mechanical CPR was immediately initiated. After 5 min of CPR, Zone 1 REBOA, Zone 3 REBOA, or no intervention (control) was initiated. Hemodynamic variables were continuously recorded for 30 min.ResultsThere were no significant differences between groups before REBOA deployment. Once REBOA was deployed, Zone 1 animals had statistically greater diastolic blood pressure compared to control (median [IQR]: 19.9 mmHg [9.5–20.5] vs 3.9 mmHg [2.4–4.8], p = .006). There were no differences in diastolic blood pressure between Zone 1 and Zone 3 (8.6 mmHg [5.1–13.1], p = .10) or between Zone 3 and control (p = .10). There were no significant differences in systolic blood pressure, cerebral blood flow, or time to return of spontaneous circulation (ROSC) between groups.ConclusionIn our swine model of cardiac arrest, Zone 1 REBOA improved diastolic blood pressure when compared to control. Zone 3 does not offer a hemodynamic benefit when compared to no occlusion. Unlike prior studies, immediate use of REBOA after arrest did not result in an increase in ROSC rate, suggesting REBOA may be more beneficial in patients with prolonged no-flow time.Institutional protocol numberFDG20180024A     

The dynamic pattern of end-tidal carbon dioxide during cardiopulmonary resuscitation: difference between asphyxial cardiac arrest and ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest

Introduction  

Partial pressure of end-tidal carbon dioxide (PetCO2) during cardiopulmonary resuscitation (CPR) correlates with cardiac output and consequently has a prognostic value in CPR. In our previous study we confirmed that initial PetCO2 value was significantly higher in asphyxial arrest than in ventricular fibrillation/pulseless ventricular tachycardia (VF/VT) cardiac arrest. In this study we sought to evaluate the pattern of PetCO2 changes in cardiac arrest caused by VF/VT and asphyxial cardiac arrest in patients who were resuscitated according to new 2005 guidelines.     

Outcome of out-of-hospital cardiac arrest over a period of 15 years in comparison to the RACA score in a physician staffed urban emergency medical service in Germany

BackgroundPatient outcome after out of hospital cardiac arrest (OHCA) depends on the cardiopulmonary resuscitation (CPR) performance and might also be influenced by organisation of the emergency medical service (EMS) and implementation of guidelines.AimTo assess the rate of return of spontaneous circulation (ROSC) after cardiac arrest to the predicted rate by the ROSC after cardiac arrest (RACA) score over a 15-year period reflecting three different implemented ALS-guidelines in a physician-staffed EMS.MethodsAll adult patients with non-traumatic OHCA in the EMS of Bonn from 1996 to 2011 were included. Utstein data from three 5-years time periods (1996–2001, 2001–2006, 2006–2011) representing different ALS-guideline implementations were collected. Group comparisons were made in terms of incidence, epidemiology and short-term outcome of CPR with emphasis on changes over time and factors of importance. In each group observed ROSC rate were compared to the predicted ROSC rates (the RACA score).ResultsCPR by the ALS unit was attempted in a total of 1989 patients (735, 666, and 588 patients in the first, second and third period, respectively). Average crude incidence of CPR per 100,000 person-years decreased over time (61.3; 55.5; 49.0/100,000/years) while patients treated were significantly older (65.5 ± 16.5; 67.9 ± 15; 68.9 ± 15.7 (p < 0.001)). Observed ROSC rates were higher than predicted by the RACA score in all time periods, however, admittance to ICU decreased significantly from 50% in the first five-year period to 38% last five-year period (p < 0.001). From first to third period the proportion of arrests with first observed rhythm of VT/VF arrests did not change (29% vs. 27%, p = 0.323) nor there were changes in bystander CPR rates (17% vs. 17%, p = 0.520).ConclusionsIn a 15-years period and in the setting of a physician-staffed EMS the ROSC rates remain higher than predicted by the RACA score but the admittance to the ICU after OHCA declined significantly. This finding was accompanied by a decrease in CPR incidence and an increase in age of patients.     

Continuous Quality Improvement Efforts Increase Survival with Favorable Neurologic Outcome after Out-of-hospital Cardiac Arrest

Objective: To assess system-wide implementation of specific therapies focused on perfusion during cardiopulmonary resuscitation (CPR) and cerebral recovery after Return of Spontaneous Circulation (ROSC). Methods: Before and after retrospective analysis of an out-of-hospital cardiac arrest database. Implementation trial in the urban/suburban community of Alameda County, California, USA, population 1.6 million, from November 2009–December 2012. Adult patients with non-traumatic out-of-hospital cardiac arrest (OHCA) who received CPR and/or defibrillation. The impedance threshold device was used throughout this study and there was an increased use of mechanical CPR (mCPR) and in-hospital therapeutic hypothermia (HTH). Results: Rates of ROSC, survival to hospital discharge and Cerebral Performance Category (CPC) scores were compared using univariate and multivariable analyses. A total of 2,926 adult non-traumatic patients with OHCA received CPR during the study period. From 2009–2011 to 2012, there was an increase in ROSC from 29.0% to 34.4% (p = 0.003) and a non-significant increase in hospital discharge from 10.2% to 12.0% (p = 0.16). There was a 76% relative increase in survival with favorable neurologic function between the two periods, as determined by CPC ≤ 2, from 4.5% to 7.9% (unadjusted OR = 1.80; CI = 1.31, 2.48; p < 0.001). After adjusting for witnessed arrest, bystander CPR, initial rhythm (VT/VF vs. others), placement of an advanced airway, EMS response time, drugs administered, and age, the OR was 1.61 (1.10, 2.36; p = 0.015). Using a stepwise multivariable logistic regression model, the independent predictors of CPC ≤ 2 were 2012 (vs. 2009–2011; p = 0.022), witnessed arrest (p < 0.001), initial rhythm VT/VF (p < 0.001), and advanced airway (inverse association p < 0.001). Additional analyses of the three prescribed therapies, separately and in combination, demonstrated that for those patients admitted to the hospital, mCPR with HTH had the biggest impact on survival to hospital discharge with CPC ≤ 2. Conclusions: Specific therapies within a system of care (mCPR, HTH), developed to enhance circulation during CPR and cerebral recovery after ROSC, significantly improved survival by 74% with favorable neurologic function following OHCA.     

CPR Induced Consciousness During Out-of-Hospital Cardiac Arrest: A Case Report on an Emerging Phenomenon

Background: High quality cardiopulmonary resuscitation (CPR) has produced a relatively new phenomenon of consciousness in patients with vital signs absent. Further research is necessary to produce a viable treatment strategy during and post resuscitation. Objective: To provide a case study done by paramedics in the field illustrating the need for sedation in a patient whose presentation was consistent with CPR induced consciousness. Resuscitative challenges are provided as well as potential future treatment options to minimize harm to both patients and prehospital providers. Case Report: A 52-year-old male presented as a witnessed out-of-hospital cardiac arrest (OHCA). During CPR the patient began to exhibit signs of life including severe agitation and thrashing of his limbs while CPR was ongoing for ventricular fibrillation prior to defibrillation. Resuscitation became considerably more complicated due to the violent and counterintuitive motions done by the patient during their own resuscitation. Despite the atypical presentation of cardiac arrest the patient was successfully resuscitated employing high quality CPR, standard advanced life support (ALS) care as well as two double sequential external defibrillation shocks. The patient underwent emergency percutaneous coronary intervention (PCI) for a 100% occlusion of his left anterior descending artery (LAD). The patient returned home 3 days later fully recovered with a Cerebral Performance Score of 1. Conclusion: CPR induced consciousness is emerging as a new phenomenon challenging providers of high quality CPR during cardiac arrest resuscitation. Our case report describes the manifestations of CPR induced consciousness as well as the resuscitative challenges which occur during resuscitation. Further research is required to determine the true frequency of this condition as well as treatment algorithms that would allow for appropriate and safe management for both the patient and EMS providers.     

Early mechanical cardiopulmonary resuscitation can improve outcomes in patients with non-traumatic cardiac arrest in the emergency department

ObjectiveTo compare the outcomes of patients with non-traumatic cardiac arrest (CA) who received early versus late mechanical cardiopulmonary resuscitation (CPR) with the Lund University Cardiac Assist System (LUCAS) device in the emergency department (ED).MethodsThis was a retrospective observational study in the ED of a single medical center performed from May 2018 to December 2019; 68 patients with CA were eligible. We grouped the patients according to the time to initiating LUCAS use after CA into an early group (≤4 minutes) and late group (>4 minutes).ResultsThe rate of return of spontaneous circulation (ROSC) was higher in the early group vs the late group (69.2% vs 52.4%, respectively). The 4-hour survival rate was significantly higher in the early group vs the late group (83.3% vs 45.5%, respectively), and CPR duration was significantly shorter in the early group (23.3 ± 12.5 vs 31.1 ± 14.8 minutes, respectively).ConclusionEarly mechanical CPR can improve the success of achieving ROSC and the 4-hour survival rate in patients with non-traumatic CA in the ED, considering that more benefits were observed in patients who received early vs late LUCAS device therapy.     

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.     

Exploratory Observational Study of Extracorporeal Cardiopulmonary Resuscitation for Nonshockable Out-Of-Hospital Cardiac Arrest Occurring After an Emergency Medical Services Arrival: SOS-KANTO 2012 Study Report

BackgroundThe outcomes of patients with nonshockable out-of-hospital cardiac arrest (OHCA) are poor, but may be improved by extracorporeal cardiopulmonary resuscitation (E-CPR).ObjectiveTo examine the effects of veno-arterial extracorporeal membranous oxygenation (ECMO) as E-CPR in patients with nonshockable OHCA after emergency medical services (EMS) arrival for whom satisfactory cardiopulmonary resuscitation (CPR) was immediately performed.MethodsAmong 16,452 patients enrolled in the SOS-KANTO 2012 study, we examined data on 531 patients aged ≥ 18 years who performed activities of daily living (ADL) well or had moderate disability before the onset of cardiac arrest (CA) and those with normal spontaneous respiration or pulse palpation upon EMS arrival. CPR was performed immediately after CA onset, and advanced life support was provided upon hospital arrival for these patients. We divided patients into ECMO and non-ECMO groups. We retrospectively analyzed background factors and clinical outcomes.ResultsE-CPR was performed on 38 (7.2%) patients. In the univariate analysis, the mean age of the ECMO group was lower, ADL function before onset was more favorable, mean body weight was higher, and the mean interval from onset until hospital arrival was shorter than those in the non-ECMO group. One-to 3-month survival or favorable cerebral function outcome rates were higher in the ECMO group than in the non-ECMO group. In the multivariate analysis, ECMO use and the interval from onset until hospital arrival were independent prognostic factors for favorable cerebral functional outcomes at 1 and 3 months.ConclusionE-CPR may be associated with favorable outcomes in carefully selected patients with nonshockable OHCA.     

Relationship between Time-to-ROSC and Survival in Out-of-hospital Cardiac Arrest ECPR Candidates: When is the Best Time to Consider Transport to Hospital?

Objective: Extracorporeal cardiopulmonary resuscitation (ECPR) may improve outcomes for refractory out-of-hospital cardiac arrest (OHCA). Transport of intra-arrest patients to hospital however, may decrease CPR quality, potentially reducing survival for those who would have achieved return-of-spontaneous-circulation (ROSC) with further on-scene resuscitation. We examined time-to-ROSC and patient outcomes for the optimal time to consider transport. Methods: From a prospective registry of consecutive adult non-traumatic OHCA's, we identified a hypothetical ECPR-eligible cohort of EMS-treated patients with age ≤ 65, witnessed arrest, and bystander CPR or EMS arrival < 10 minutes. We assessed the relationship between time-to-ROSC and survival, and constructed a ROC curve to illustrate the ability of a pulseless state to predict non-survival with conventional resuscitation. Results: Of 6,571 EMS-treated cases, 1,206 were included with 27% surviving. Increasing time–to–ROSC (per minute) was negatively associated with survival (adjusted OR 0.91; 95%CI 0.89–0.93%). The yield of survivors per minute of resuscitation increased from commencement and started to decline in the 8th minute. Fifty percent and 90% of survivors had achieved ROSC by 8.0 and 24 min, respectively, at which times the probability of survival for those with initial shockable rhythms was 31% and 10%, and for non-shockable rhythms was 5.2% and 1.6%. The ROC curve illustrated that the 16th minute of resuscitation maximized sensitivity and specificity (AUC = 0.87, 95% CI 0.85–0.89). Conclusion: Transport for ECPR should be considered between 8 to 24 minutes of professional on-scene resuscitation, with 16 minutes balancing the risks and benefits of early and later transport. Earlier transport within this window may be preferred if high quality CPR can be maintained during transport and for those with initial non-shockable rhythms.     

The effects of sodium bicarbonate during prolonged cardiopulmonary resuscitation

BackgroundThis study was performed to determine the effects of sodium bicarbonate injection during prolonged cardiopulmonary resuscitation (for > 15 minutes).MethodsThe retrospective cohort study consisted of adult patients who presented to the emergency department (ED) with the diagnosis of cardiac arrest in 2009. Data were retrieved from the institutional database.ResultsA total of 92 patients were enrolled in the study. Patients were divided into 2 groups based on whether they were treated (group1, n = 30) or not treated (group 2, n = 62) with sodium bicarbonate. There were no significant differences in demographic characteristics between groups. The median time interval between the administration of CPR and sodium bicarbonate injection was 36.0 minutes (IQR: 30.5-41.8 minutes). The median amount of bicarbonate injection was 100.2 mEq (IQR: 66.8-104.4). Patients who received a sodium bicarbonate injection during prolonged CPR had a higher percentage of return of spontaneous circulation, but not statistical significant (ROSC, 40.0% vs. 32.3%; P = .465). Sustained ROSC was achieved by 2 (6.7%) patients in the sodium bicarbonate treatment group, with no survival to discharge. No significant differences in vital signs after ROSC were detected between the 2 groups (heart rate, P = .124; systolic blood pressure, P = .094). Sodium bicarbonate injection during prolonged CPR was not associated with ROSC after adjust for variables by regression analysis (Table 3; P = .615; odds ratio, 1.270; 95% confidence interval: 0.501-3.219)ConclusionsThe administration of sodium bicarbonate during prolonged CPR did not significantly improve the rate of ROSC in out-of-hospital cardiac arrest.     

Survival in cancer patients after out-of-hospital cardiac arrest

Background  

The survival of cancer patients who undergo cardiopulmonary resuscitation (CPR) after in-hospital cardiac arrest is poor. The survival of cancer patients who undergo CPR after out-of-hospital cardiac arrest is unknown. We sought to determine survival rates in such patients and to identify phrases in patient charts that might have prompted end-of-life discussions.