Extracorporeal life support associated with hypothermia and normoxemia in refractory cardiac arrest

Aim

We describe a 1-year experience with extracorporeal cardiopulmonary resuscitation (ECPR) for in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA) associated with intra-arrest hypothermia and normoxemia.

Methods

Since January 1st 2012, ECPR has been applied in our hospital to all patients less than 65 years of age and without major co-morbidities who develop refractory cardiac arrest (CA) with bystander CPR. Over a 1-year period of observation, we recorded 28-day survival with intact neurological outcome and the rate of organ donation.

Results

During the observational period, 24 patients were treated with ECPR, with a median age of 48 years. Ten patients had IHCA. Acute coronary syndrome and/or major arrhythmias were the main cause of arrest. Intra-arrest cooling was used in 17 patients; temperature on ECMO initiation in these patients was 32.9 °C [32–34]. The time from collapse to ECPR was 58 min [45–70] and was shorter in survivors than in non-survivors (41 min [39–58] vs. 60 min [55–77], p = 0.059). Non-survivors were more likely to have coagulopathy and received more blood transfusions. Six patients (25%) survived with good neurological outcome at day 28. Four patients with irreversible brain damage had organ function suitable for donation.

Conclusion

ECPR provided satisfactory survival rates with good neurologic recovery in refractory CA for both IHCA and OHCA. ECMO may help rapidly stabilise systemic haemodynamic status and restore organ function.     

C-reactive protein levels after cardiac arrest in patients treated with therapeutic hypothermia

Aim

Prognostication of outcome after cardiac arrest (CA) is challenging. We assessed the prognostic value of daily blood levels of C-reactive protein (CRP), a cheap and widely available inflammatory biomarker, after CA.

Methods

We reviewed the data of all patients admitted to our intensive care unit (ICU) after CA between January 2009 and December 2011 and who survived for at least 24 h. We collected demographic data, CA characteristics (initial rhythm; location of arrest; time to return of spontaneous circulation [ROSC]), occurrence of infection, ICU survival and neurological outcome at three months (good = cerebral performance category [CPC] 1–2; poor = CPC 3–5). CRP levels were measured daily from admission to day 3.

Results

A total of 130 patients were admitted after successful resuscitation from CA and survived more than 24 h; 76 patients (58%) developed an infection and overall mortality was 56%. CRP levels increased from admission to day 3. CRP levels were higher in in-hospital than in out-of-hospital CA, especially on admission and day 1 (44.1 vs. 2.1 mg L⁻¹ and 74.5 vs. 29.5 mg L⁻¹, respectively; p < 0.001), and in patients with non-shockable than in those with shockable rhythms. In a logistic regression model, high CRP levels on admission were independently associated with poor neurological outcome at 3 months.

Conclusion

CRP levels increase in the days following successful resuscitation of CA. Higher CRP levels in patients with in-hospital CA, non-shockable rhythms and infection, suggest a greater inflammatory response in these patients. High CRP levels on admission may identify patients at high-risk of poor outcome and could be a target for future therapies.     

Impact of the number of on-scene emergency life-saving technicians and outcomes from out-of-hospital cardiac arrest in Osaka City

Backgrounds

In Japan, ambulance staffing for cardiac arrest responses consists of a 3-person unit with at least one emergency life-saving technician (ELST). Recently, the number of ELSTs on ambulances has increased since it is believed that this improves the quality of on-scene care leading to better outcomes from out-of-hospital cardiac arrest (OHCA). The objective of this study was to evaluate the association between the number of on-scene ELSTs and OHCA outcome.

Methods

This was a prospective cohort study of all bystander-witnessed OHCA patients aged ≥18 years in Osaka City from January 2005 to December 2007 using on an Utstein-style database. The primary outcome measure was one-month survival with favorable neurological outcome defined as a cerebral performance category ≤2. Multivariable logistic regression model were used to assess the contribution of the number of on-scene ELSTs to the outcome after adjusting for confounders.

Results

Of the 2408 bystander-witnessed OHCA patients, one ELST group was present in 639 (26.5%), two ELST were present in 1357 (56.4%), and three ELST group in 412 (17.1%). The three ELST group had a significantly higher rate of one-month survival with favorable neurological outcome compared with the one ELST group (8.0% versus 4.5%, adjusted OR 2.26, 95% CI 1.27–4.04), while the two ELST group did not (5.4% versus 4.5%, adjusted OR 1.34, 95% CI 0.82–2.19).

Conclusions

Compared with the one on-scene ELST group, the three on-scene ELST group was associated with the improved one-month survival with favorable neurological outcome from OHCA in Osaka City.     

Association of serum lactate and survival outcomes in patients undergoing therapeutic hypothermia after cardiac arrest

Introduction

Recent studies have suggested that serum lactate may serve as a marker to predict mortality after resuscitation from cardiac arrest (CA). The relationship between serum lactate and CA outcomes requires further characterization, especially among patients treated with therapeutic hypothermia (TH) and aggressive post-arrest care.

Methods

A retrospective analysis of patients resuscitated from non-traumatic CA at three urban U.S. hospitals was performed using an established internet-based post-arrest registry. Adult (≥18 years) patients resuscitated from CA and receiving TH treatment were included. Logistic regression analysis was used to adjust for potential confounders to survival outcomes. Survival to discharge served as the primary endpoint.

Results

A total of 199 post-CA patients treated with TH between 5/2005 and 11/2011 were included in this analysis. The mean age was 56.9 ± 16.5 years, 85/199 (42.7%) patients were female, and survival to discharge was attained in 84/199 (42.2%). While lower initial post-CA serum lactate levels were not associated with increased survival to discharge, subsequent lactate measurements were significantly associated with outcomes (24-h serum lactate levels in survivors vs. non-survivors, 2.7 ± 0.5 vs. 4.2 ± 0.4 mmol/L, p < 0.01). Multivariable logistic regression confirmed this relationship with survival to discharge (p < 0.01).

Conclusion

Lower serum lactate levels at 12 h and 24 h, but not initially following cardiac arrest, are associated with survival to hospital discharge after resuscitation from CA and TH treatment. Prospective investigation of serum lactate as a potential prognostic tool in CA is needed.     

Reduced in-hospital survival rates of out-of-hospital cardiac arrest victims with obstructive pulmonary disease

Aim

Out-of-hospital cardiac arrest (OHCA) due to sustained ventricular tachycardia/fibrillation (VT/VF) is common and often lethal. Patient's co-morbidities may determine survival after OHCA, and be instrumental in post-resuscitation care, but are poorly studied. We aimed to study whether patients with obstructive pulmonary disease (OPD) have a lower survival rate after OHCA than non-OPD patients.

Methods

We performed a community-based cohort study of 1172 patients with non-traumatic OHCA with ECG-documented VT/VF between 2005 and 2008. We compared survival to Emergency Room (ER), to hospital admission, to hospital discharge, and at 30 days after OHCA, of OPD-patients and non-OPD patients, using logistic regression analysis. We also compared 30-day survival of patients who were admitted to hospital, using multivariate logistic regression analysis.

Results

OPD patients (n = 178) and non-OPD patients (n = 994) had comparable survival to ER (75% vs. 78%, OR 0.9 [95% CI: 0.6–1.3]) and to hospital admission (56% vs. 57%, OR 1.0 [0.7–1.4]). However, survival to hospital discharge was significantly lower among OPD patients (21% vs. 33%, OR 0.6 [0.4–0.9]). Multivariate regression analysis among patients who were admitted to hospital (OPD: n = 100, no OPD: n = 561) revealed that OPD was an independent determinant of reduced 30-day survival rate (39% vs. 59%, adjusted OR 0.6 [0.4–1.0, p = 0.035]).

Conclusion

OPD-patients had lower survival rates after OHCA than non-OPD patients. Survival to ER and to hospital admission was not different between both groups. However, among OHCA victims who survived to hospital admission, OPD was an independent determinant of reduced 30-day survival rate.     

Chest compression depth and survival in out-of-hospital cardiac arrest

Aim

Outcomes from out-of-hospital cardiac arrest (OHCA) may improve if rescuers perform chest compressions (CCs) deeper than the previous recommendation of 38–51 mm and consistent with the 2010 AHA Guideline recommendation of at least 51 mm. The aim of this study was to assess the relationship between CC depth and OHCA survival.

Methods

Prospective analysis of CC depth and outcomes in consecutive adult OHCA of presumed cardiac etiology from two EMS agencies participating in comprehensive CPR quality improvement initiatives. Analysis: Multivariable logistic regression to calculate adjusted odds ratios (aORs) for survival to hospital discharge and favorable functional outcome.

Results

Among 593 OHCAs, 136 patients (22.9%) achieved return of spontaneous circulation, 63 patients (10.6%) survived and 50 had favorable functional outcome (8.4%). Mean CC depth was 49.8 ± 11.0 mm and mean CC rate was 113.9 ± 18.1 CC min⁻¹. Mean depth was significantly deeper in survivors (53.6 mm, 95% CI: 50.5–56.7) than non-survivors (48.8 mm, 95% CI: 47.6–50.0). Each 5 mm increase in mean CC depth significantly increased the odds of survival and survival with favorable functional outcome: aORs were 1.29 (95% CI 1.00–1.65) and 1.30 (95% CI 1.00–1.70) respectively.

Conclusion

Deeper chest compressions were associated with improved survival and functional outcome following OHCA. Our results suggest that adhering to the 2010 AHA Guideline-recommended depth of at least 51 mm could improve outcomes for victims of OHCA.     

Increasing arterial oxygen partial pressure during cardiopulmonary resuscitation is associated with improved rates of hospital admission

Aim

As recent clinical data suggest a harmful effect of arterial hyperoxia on patients after resuscitation from cardiac arrest (CA), we aimed to investigate this association during cardiopulmonary resuscitation (CPR), the earliest and one of the most crucial phases of recirculation.

Methods

We analysed 1015 patients who from 2003 to 2010 underwent out-of-hospital CPR administered by emergency medical services serving 300,000 inhabitants. Inclusion criteria for further analysis were nontraumatic background of CA and patients >18 years of age. One hundred and forty-five arterial blood gas analyses including oxygen partial pressure (paO2) measurement were obtained during CPR.

Results

We observed a highly significant increase in hospital admission rates associated with increases in paO2 in steps of 100 mmHg (13.3 kPa).Subsequently, data were clustered according to previously described cutoffs (≤60 mmHg [8 kPa]], 61–300 mmHg [8.1–40 kPa], >300 mmHg [>40 kPa]). Baseline variables (age, sex, initial rhythm, rate of bystander CPR and collapse-to-CPR time) of the three compared groups did not differ significantly. Rates of hospital admission after CA were 18.8%, 50.6% and 83.3%, respectively. In a multivariate analysis, logistic regression revealed significant prognostic value for paO2 and the duration of CPR.

Conclusion

This study presents novel human data on the arterial paO2 during CPR in conjunction with the rate of hospital admission. We describe a significantly increased rate of hospital admission associated with increasing paO2. We found that the previously described potentially harmful effects of hyperoxia after return of spontaneous circulation were not reproduced for paO2 measured during CPR.Clinical trial registration: n/a.     

Hypothermia and associated outcomes in seriously injured trauma patients in a predominantly sub-tropical climate

Aim

This study aimed to determine factors linked to hypothermia (<35 °C) in Queensland trauma patients. The relationship of hypothermia with mortality, admission to intensive care and hospital length of stay was also explored.

Methods

A retrospective analysis of data from the Queensland Trauma Registry was undertaken, and included all patients admitted to hospital for ≥24 h during 2003 and 2004 with an injury severity score (ISS) > 15. Demographic, injury, environmental, care and clinical status factors were considered.

Results

A total of 2182 patients were included; 124 (5.7%) had hypothermia on admission to the definitive care hospital, while a further 156 (7.1%) developed hypothermia during hospitalisation. Factors associated with hypothermia on admission included winter, direct admission to a definitive care hospital, an ISS ≥ 40, a Glasgow Coma Scale of 3 or ventilated and sedated, and hypotension on admission. Hypothermia on admission to the definitive care hospital was an independent predictor of mortality (odds ratio [OR] = 4.05; 95% confidence interval [CI] 2.26–7.24) and hospital length of stay (incidence rate ratio [IRR] = 1.22; 95% CI 1.03–1.43). Hypothermia during definitive care hospitalisation was independently associated with mortality (OR = 2.52; 95% CI 1.52–4.17), intensive care admission (OR = 1.73; 95% CI 1.20–2.93) and hospital length of stay (IRR = 1.18; 95% CI 1.02–1.36).

Conclusions

Trauma patients in a predominantly sub-tropical climate are at risk of accidental and endogenous hypothermia, with associated higher mortality and care requirements. Prevention of hypothermia is important for all severely injured patients.     

Sublingual microcirculation is impaired in post-cardiac arrest patients

Aim

We hypothesized that microcirculatory dysfunction, similar to that seen in sepsis, occurs in post-cardiac arrest patients and that better microcirculatory flow will be associated with improved outcome. We also assessed the association between microcirculatory dysfunction and inflammatory markers in the post-cardiac arrest state.

Methods

We prospectively evaluated the sublingual microcirculation in post-cardiac arrest patients, severe sepsis/septic shock patients, and healthy control patients using Sidestream Darkfield microscopy. Microcirculatory flow was assessed using the microcirculation flow index (MFI) at 6 and 24 h in the cardiac arrest patients, and within 6 h of emergency department admission in the sepsis and control patients.

Results

We evaluated 30 post-cardiac arrest patients, 16 severe sepsis/septic shock patients, and 9 healthy control patients. Sublingual microcirculatory blood flow was significantly impaired in post-cardiac arrest patients at 6 h (MFI 2.6 [IQR: 2–2.9]) and 24 h (2.7 [IQR: 2.3–2.9]) compared to controls (3.0 [IQR: 2.9–3.0]; p < 0.01 and 0.02, respectively). After adjustment for initial APACHE II score, post-cardiac arrest patients had significantly lower MFI at 6-h compared to sepsis patients (p < 0.03). In the post-cardiac arrest group, patients with good neurologic outcome had better microcirculatory blood flow as compared to patients with poor neurologic outcome (2.9 [IQR: 2.4–3.0] vs. 2.6 [IQR: 1.9–2.8]; p < 0.03). There was a trend toward higher median MFI at 24 h in survivors vs. non-survivors (2.8 [IQR: 2.4–3.0] vs. 2.6 [IQR: 2.1–2.8] respectively; p < 0.09). We found a negative correlation between MFI-6 and vascular endothelial growth factor (VEGF) (r = −0.49, p = 0.038). However, after Bonferroni adjustment for multiple comparisons, this correlation was statistically non-significant.

Conclusion

Microcirculatory dysfunction occurs early in post-cardiac arrest patients. Better microcirculatory function at 24 h may be associated with good neurologic outcome.     

Emergency department factors associated with survival after sudden cardiac arrest

Background

Sudden cardiac arrest (SCA) is a leading cause of death in the US. Recent innovations in post-arrest care have been demonstrated to increase survival. However, little is known about the impact of emergency department (ED) and hospital characteristics on survival to hospital admission and ultimate outcome.

Objective

We sought to describe the incidence of SCA presenting to the ED and to identify ED and hospital characteristics associated with survival to hospital admission.

Methods

We identified patients with diagnoses of atraumatic cardiac arrest or ventricular fibrillation (ICD-9 427.5 or 427.41) in the 2007 Nationwide Emergency Department Sample (NEDS), a nationally representative estimate of all ED admissions in the United States. We defined SCA as cardiac arrest in the out-of-hospital or ED settings. We used the NEDS sample design to generate nationally representative estimates of the incidence of SCA that presents to EDs. We performed unadjusted and adjusted analyses to examine the relation between patient, ED, and hospital characteristics and outcome using logistic regression. Our primary outcome was survival to hospital admission. Survival to hospital discharge was a secondary outcome. Data are presented as odds ratios (OR) with 95% confidence intervals (CI).

Results

Of the 966 hospitals in the NEDS, 933 (96.6%) reported at least one SCA and were included in the analysis. We identified 38,593 cases of cardiac arrest representing an estimated 174,982 cases nationally. Overall ED SCA survival to hospital admission was 26.2% and survival to discharge was 15.7%. Greater survival to admission was seen in teaching hospitals (OR 1.3 95% CI 1.1–1.5, p = 0.001), hospitals with ≥20,000 annual ED visits (OR 1.3 95% CI 1.1–1.6, p = 0.003), and hospitals with percutaneous coronary intervention capability (OR 1.6 95% CI 1.4–1.8, p < 0.001). Higher SCA volume (>40 annually) was associated with lower survival overall (OR 0.7 95% 0.6–0.9, p = 0.010), but not when transferred patients were excluded from the analysis (OR 0.8 95% CI 0.6–1.1, p = 0.116).

Conclusions

An estimated 175,000 cases of SCA present to or occur in US EDs each year. Percutaneous coronary intervention capability, ED volume, and teaching status were associated with higher survival to hospital admission. Emergency departments with higher annual SCA volume had lower survival rates, possibly because they transfer fewer patients. An improved understanding of the contribution of ED care to survival following SCA may be useful in advancing our understanding of how best to organize a system of care to ensure optimal outcomes for patients with SCA.     

New treatment bundles improve survival in out-of-hospital cardiac arrest patients: A historical comparison

Introduction

Before the introduction of the new international cardiac arrest treatment guidelines in 2005, patients with out-of-hospital cardiac arrest (OHCA) of cardiac origin in Northern Italy had very poor prognosis. Since 2006, a new bundle of care comprising use of automated external defibrillators (AEDs) and therapeutic hypothermia (TH) was started, while extracorporeal CPR program (ECPR) for selected refractory CA and dispatcher-assisted cardio-pulmonary resuscitation (CPR) was started in January 2010.

Objectives

We hypothesized that a program of bundled care might improve outcome of OHCA patients.

Methods

We analyzed data collected in the OHCA registry of the MB area between September 2007 and August 2011 and compared this with data from 2000 to 2003.

Results

Between 2007 and 2011, 1128 OHCAs occurred in the MB area, 745 received CPR and 461 of these had a CA of presumed cardiac origin. Of these, 125 (27%) achieved sustained ROSC, 60 (13%) survived to 1 month, of whom 51 (11%) were discharged from hospital with a good neurological outcome (CPC ≤ 2), and 9 with a poor neurological outcome (CPC > 2).Compared with data from the 2000 to 2003 periods, survival increased from 5.6% to 13.01% (p < 0.0001). In the 2007–2011 group, low-flow time and bystander CPR were independent markers of survival.

Conclusions

OHCA survival has improved in our region. An increased bystander CPR rate associated with dispatcher-assisted CPR was the most significant cause of increased survival, but duration of CA remains critical for patient outcome.     

Prognostic value of electrographic postanoxic status epilepticus in comatose cardiac-arrest survivors in the therapeutic hypothermia era

Background

The independent prognostic significance of postanoxic status epilepticus (PSE) has not been evaluated prospectively since the introduction of therapeutic hypothermia. We studied 1-year functional outcomes and their determinants in comatose survivors of cardiac arrest (CA), with special attention to PSE.

Methods

106 comatose CA survivors admitted to the intensive care unit in 2005–2010 were included in a prospective observational study. The main outcome measure was a Cerebral Performance Category scale (CPC) of 1 or 2 (favorable outcome) 1 year after CA.

Results

CA occurred out-of-hospital in 89 (84%) patients and was witnessed from onset in 94 (89%). Median times were 6 min (IQR, 0–11) from CA to first-responder arrival and 23 min (14–40) from collapse to return of spontaneous circulation. PSE was diagnosed in 33 (31%) patients at a median of 39 h (4–49) after CA. PSE was refractory in 24 (22%) cases and malignant in 19 (20%). After 1 year, 31 (29.3%) patients had favorable outcomes including 2 (6.44%) with PSE. Factors independently associated with poor outcome (CPC ≥ 3) were PSE (odds ratio [OR], 14.28; 95% confidence interval [95% CI], 2.77–50.0; P = 0.001), time to restoration of spontaneous circulation (OR, 1.04/min; 95% CI, 1–1.07; P = 0.035), and LOD score on day 1 (OR, 1.28/point; 95% CI, 1.08–1.54; P = 0.003).

Conclusion

PSE strongly and independently predicts a poor outcome in comatose CA survivors receiving therapeutic hypothermia, but some patients with PSE survive with good functional outcomes. PSE alone is not sufficient to predict failure to awaken after CA in the era of therapeutic hypothermia.     

Arterial carbon dioxide tension and outcome in patients admitted to the intensive care unit after cardiac arrest

Background

Arterial carbon dioxide tension (PaCO₂) affects neuronal function and cerebral blood flow. However, its association with outcome in patients admitted to intensive care unit (ICU) after cardiac arrest (CA) has not been evaluated.

Methods and results

Observational cohort study using data from the Australian New Zealand (ANZ) Intensive Care Society Adult-Patient-Database (ANZICS-APD). Outcomes analyses were adjusted for illness severity, co-morbidities, hypothermia, treatment limitations, age, year of admission, glucose, source of admission, PaO₂ and propensity score.We studied 16,542 consecutive patients admitted to 125 ANZ ICUs after CA between 2000 and 2011. Using the APD-PaCO₂ (obtained within 24 h of ICU admission), 3010 (18.2%) were classified into the hypo- (PaCO₂ < 35 mmHg), 6705 (40.5%) into the normo- (35–45 mmHg) and 6827 (41.3%) into the hypercapnia (>45 mmHg) group. The hypocapnia group, compared with the normocapnia group, had a trend toward higher in-hospital mortality (OR 1.12 [95% CI 1.00–1.24, p = 0.04]), lower rate of discharge home (OR 0.81 [0.70–0.94, p < 0.01]) and higher likelihood of fulfilling composite adverse outcome of death and no discharge home (OR 1.23 [1.10–1.37, p < 0.001]). In contrast, the hypercapnia group had similar in-hospital mortality (OR 1.06 [0.97–1.15, p = 0.19]) but higher rate of discharge home among survivors (OR 1.16 [1.03–1.32, p = 0.01]) and similar likelihood of fulfilling the composite outcome (OR 0.97 [0.89–1.06, p = 0.52]). Cox-proportional hazards modelling supported these findings.

Conclusions

Hypo- and hypercapnia are common after ICU admission post-CA. Compared with normocapnia, hypocapnia was independently associated with worse clinical outcomes and hypercapnia a greater likelihood of discharge home among survivors.     

Esophageal temperature after out-of-hospital cardiac arrest: An observational study

Introduction

Out-of-hospital cardiac arrest (OHCA) is a significant cause of death and severe neurological disability. The only post-return of spontaneous circulation (ROSC) therapy shown to increase survival is mild therapeutic hypothermia (MTH). The relationship between esophageal temperature post OHCA and outcome is still poorly defined.

Methods

Prospective observational study of all OHCA patients admitted to a single centre for a 14-month period (1/08/2008 to 31/09/2009). Esophageal temperature was measured in the Emergency Department and Intensive Care Unit (ICU). Selected patients had pre-hospital temperature monitoring. Time taken to reach target temperature after ROSC was recorded, together with time to admission to the Emergency Department and ICU.

Results

164 OHCA patients were included in the study. 105 (64.0%) were pronounced dead in the Emergency Department. 59 (36.0%) were admitted to ICU for cooling; 40 (24.4%) died in ICU and 19 (11.6%) survived to hospital discharge. Patients who achieved ROSC and had esophageal temperature measured pre-hospital (n = 29) had a mean pre-hospital temperature of 33.9 °C (95% CI 33.2-34.5). All patients arriving in the ED post OHCA had a relatively low esophageal temperature (34.3 °C, 95% CI 34.1-34.6). Patients surviving to hospital discharge were warmer on admission to ICU than patients who died in hospital (35.7 °C vs 34.3 °C, p < 0.05). Patients surviving to hospital discharge also took longer to reach T_targ than non-survivors (2 h 48 min vs 1 h 32 min, p < 0.05).

Conclusions

Following OHCA all patients have esophageal temperatures below normal in the pre-hospital phase and on arrival in the Emergency Department. Patients who achieve ROSC following OHCA and survive to hospital discharge are warmer on arrival in ICU and take longer to reach target MTH temperatures compared to patients who die in hospital. The mechanisms of action underlying esophageal temperature and survival from OHCA remain unclear and further research is warranted to clarify this relationship.     

The Outcomes of Emergency Pharmacist Participation during Acute Myocardial Infarction

Background

Current guidelines recommend door-to-balloon times of 90 min or less for patients presenting to the emergency department (ED) with ST-segment elevation myocardial infarction (STEMI).

Objectives

To determine if a clinical pharmacist for the ED (EPh) is associated with decreased door/diagnosis-to-cardiac catheterization laboratory (CCL) time and decreased door-to-balloon time.

Methods

A retrospective observational cohort study of ED patients with STEMI requiring urgent cardiac catheterization was conducted. Blinded data collection included timing of ED and CCL arrival, diagnostic electrocardiogram (ECG), and balloon angioplasty. For cases diagnosed after ED arrival, diagnosis time was substituted for door time. Diagnosis was the time ST elevations were evident on serial ECG. EPh present and not-present groups were compared. During the study period there were two EPhs and presence was determined by their scheduled time in the ED. Univariate and multivariate analyses was used to detect differences.

Results

Multivariate analysis of 120 patients, controlled for CCL staff presence and arrival by pre-hospital services, determined that EPh presence is associated with a mean 13.1-min (95% confidence interval [CI] 6.5–21.9) and 11.5-min (95% CI 3.9–21.5) decrease in door/diagnosis-to-CCL and door-to-balloon times, respectively. Patients were more likely to achieve a door/diagnosis-to-CCL time ≤ 30 min (odds ratio [OR] 3.1, 95% CI 1.3–7.8) and ≤ 45 min (OR 2.9, 95% CI–1.0, 8.5) and a door-to-balloon time ≤ 90 min (OR 1.9, 95% CI 0.7–5.5) more likely when the EPh was present.

Conclusions

EPh presence during STEMI presentation to the ED is independently associated with a decrease in door/diagnosis-to-CCL and door-to-balloon times.     

Incidence and factors associated with cardiac arrest complicating emergency airway management

Objective

Cardiac arrest (CA) is a rare but recognized complication of emergency airway management. Our aim was to measure the incidence of peri-intubation CA during emergency intubation and identify factors associated with this complication.

Methods

Retrospective cohort study of emergency endotracheal intubations performed in a large, urban emergency department over a one-year period. Patients were included if they were >18 years old and not in CA prior to intubation. Multiple logistic regression modeling was used to define factors independently associated with CA.

Results

A total 542 patients underwent emergency intubation during the study period and 410 met inclusion criteria for this study. CA occurred in 17/410 (4.2%) at a median of 6 min post-intubation. Nearly two-thirds of CA events occurred within 10 min of drug induction; early peri-intubation CA rate 2.4% (95% CI: 1.3–4.5%). Pulseless electrical activity was the initial rhythm in the majority of cases. More than half of CA events were successfully resuscitated but CA was associated with increased odds of hospital death (OR 14.8; 95% CI: 4.2–52). Pre-intubation hemodynamic and oximetry variables were associated with CA. CA was more common in patients experiencing pre intubation hypotension (12% vs 3%; p < 0.002). Pre RSI shock index (SI) and weight were independently associated with CA.

Conclusions

In this series, 1 in 25 emergency intubations was associated with the complication of CA. Peri-intubation CA is associated with increased mortality. Pre-intubation patient characteristics are associated with this complication.     

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.     

Stent thrombosis: An increased adverse event after angioplasty following resuscitated cardiac arrest

Background

The leading cause of sudden cardiac death is myocardial ischemia. As for uncomplicated acute myocardial infarction (AMI), international guidelines plead for early coronary angiography with, in case of culprit lesion, angioplasty and stent implantation. However after cardiac arrest (CA), shock, hypothermia and changes in antiplatelet pharmacokinetic may promote stent thrombosis (ST). Incidence of ST in this situation has never been studied.

Objective

The aim of this study was to investigate incidence and determinants of ST after ischemic CA successfully revascularized.

Methods

We analyzed 208 consecutive patients admitted in our institution for AMI and who underwent PCI with stent implantation. Among these patients, 55 presented a resuscitated CA and were compared to 153 without CA (control group). All patients in the CA group received hypothermia (33 °C for 24 h) following resuscitation and PCI.

Results

There was no difference between the 2 groups for age, gender, cardiovascular risk factors, coronary lesions and type of stent. In the CA group, patients were less frequently pre-treated with heparin (50.9% vs 98.7%, p < 0.001) and aspirin (52.7% vs 99%, p < 0.001). In the CA group, we observed a significantly higher incidence of confirmed acute or subacute ST than in the control group: 10.9% vs 2.0% (p = 0.01). None of CA patients had received a dual antiplatelets therapy (0% vs 99%). LVEF at admission was lower in the CA group (40.3% vs 48%; p < 0.001), and shock was more frequent (83.6% vs 8.5%; p < 0.001). Survival at 28 days was 50.1% in CA group vs 98.0% (p < 0.001). In multivariate analysis, CA before stenting appears to be an independent risk factor for confirmed ST (OR = 12.9; 95%CI 1.3–124.6; p = 0.027).

Conclusion

In CA patients treated with cooling, stenting for AMI is associated with a high risk of ST. Shock, insufficient antithrombotic treatment, pharmacokinetic changes related to hypothermia may contribute to this higher risk. A strategy aiming to reduce this complication may probably improve prognosis of patients who underwent coronary sudden death.     

Resuscitation of patients suffering from sudden cardiac arrests in nursing homes is not futile

Background

Survival after out-of-hospital cardiac arrest (OHCA) has increased in recent years, and new data are therefore needed to avoid unsubstantiated statements when debating futility of resuscitation attempts following OHCA in nursing home (NH)-residents. We aimed to investigate the outcome and prognosis after OHCA in NH.

Methods

Consecutive Emergency Medical Service (EMS) attended OHCA-patients in Copenhagen during 2007–2011 were included. Utstein-criteria for pre-hospital data and review of individual patient charts for in-hospital post-resuscitation care were collected.

Results

A total of 2541 consecutive OHCA-patients were recorded, 245 (10%) of who were current NH-residents. NH-patients were older, more frequently female, had more witnessed arrests, fewer shockable primary rhythm and assumed cardiac aetiology, but shorter time to the return of spontaneous circulation (ROSC) compared to OHCA in non-nursing homes (non-NH). Overall 30-day survival rate was 9% in NH and 18% in non-NH, p < 0.001. Of the 245 NH-arrests 79 (32%) patients were admitted to hospital compared to 937 (41%) from non-NH (p < 0.001). Thirty-day survival rate in patients admitted to hospital were 27% for NH- and 42% for non-NH-patients, p < 0.001. OHCA in NH was, however, not associated with a significantly worse prognosis (HR = 0.88 (0.64–1.21), p = 0.4) after adjustment for known prognostic factors including co-morbidity.

Conclusions

Nursing home residents resuscitated from OHCA and admitted to hospital have similar survival rates as non-NH-patients when adjusting for known prognostic factors and pre-existing co-morbidity. A policy of not attempting resuscitation in nursing homes at all may therefore not be justified.