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The number of critically ill patients that present to emergency departments across the world continues to rise. In fact, the proportion of critically ill patients in emergency departments is now higher than pre-COVID-19 pandemic levels. [1] The emergency physician (EP) is typically the first physician to evaluate and resuscitate the critically ill patient. Given the continued shortage of intensive care unit (ICU) beds, persistent staff shortages, and overall inefficient hospital throughput, EPs are often tasked with providing intensive care to these patients long beyond the initial resuscitation phase. Prolonged boarding of critically ill patients in the ED is associated with increased ICU and hospital length of stay, increased adverse events, ED staff burnout, decreased patient and family satisfaction, and, most importantly, increased mortality. [2–5]. As such, it is imperative for the EP to be knowledgeable about recent literature in resuscitation and critical care medicine, so that critically ill ED patients can continue to receive the best, most up-to-date evidence-based care. This review summarizes important articles published in 2023 that pertain to the resuscitation and management of select critically ill ED patients. Topics included in this article include cardiac arrest, post-cardiac arrest care, septic shock, rapid sequence intubation, severe pneumonia, transfusions, trauma, and critical procedures. [ABSTRACT FROM AUTHOR]

To assess the initial success rate and its correlated factors on cardiopulmonary resuscitation (CPR) in emergency prehospital cardiac arrest patients. The clinical information of 429 patients with cardiac arrest who underwent prehospital CPR in the fourth hospital of Hebei Medical University from Jan 2020 to Apr 2022 were evaluated. The patients were divided into the successful group (ROSC, n = 25) and the unsuccessful group (non-ROSC, n = 404) according to whether the autonomous circulation (ROSC) was resumed. The univariate analysis was performed to evaluate the differences in age, the start time of CPR, the application of electric defibrillation, and other related data between the two groups. The multivariate analysis evaluated protective factors affecting CPR's success in prehospital cardiac arrest patients. Patients with cardiogenic causes had the highest success rate of cardiopulmonary resuscitation. The causes of traffic accidents and drowning account for a low proportion. Furthermore, the median CPR length was 25.0 min, alternating from 1.5 to 64 mi. The univariate analysis revealed that age, the start time of CPR, application of electric defibrillation, and adrenaline dosage were correlated with CPR attempts (p < 0.05). Multivariate logistic regression analysis showed that the age of patients with prehospital CA, the location of prehospital CA, etiology, bystander CPR, CPR start time, defibrillation start time, tracheal intubation time, type of rhythm before resuscitation, adrenaline dosage <5 mg, and adrenaline administration time were all the influencing factors of prehospital CPR success (p < 0.01). The factors affecting CPR's success rate in prehospital CA patients are complicated. Establishing a few procedures to diminish the incidence of these risk factors is crucial. [ABSTRACT FROM AUTHOR]

BACKGROUND: Coronary artery disease remains the largest contributor to cardiac arrests worldwide; yet, long-term outcomes are often driven by neurological status after resuscitation. We examined the association between pre–percutaneous coronary intervention (PCI) level of consciousness (LOC) and outcomes among patients with cardiac arrest who underwent PCI. METHODS: The study cohort included patients undergoing PCI after cardiac arrest between April 2018 and March 2022 at 48 hospitals in the state of Michigan. Pre-PCI LOC was categorized as mentally alert, partially responsive, unresponsive, and unable to assess. In-hospital outcomes included mortality, bleeding, and acute kidney injury. RESULTS: Among 3021 patients who underwent PCI after cardiac arrest, 1394 (49%) were mentally alert, 132 (5%) were partially responsive, 698 (24%) were unresponsive, and 631 (22%) were unable to assess. The mentally alert cohort had lower mortality (4.59%) compared with the partially responsive (17.42%), unresponsive (50.14%), and unable to assess cohorts (38.03%; P<0.001). After adjusting for baseline differences, compared with mentally alert patients, the odds of mortality were markedly elevated in patients who were partially responsive (adjusted odds ratio, 4.63 [95% CI, 2.67–8.04]; P<0.001), unable to assess (adjusted odds ratio, 13.95 [95% CI, 9.97–19.51]; P<0.001), and unresponsive (adjusted odds ratio, 24.36 [17.34–34.23]; P<0.001). After adjustment, patients with impaired LOC also had higher risks of acute kidney injury and bleeding compared with mentally alert patients. CONCLUSIONS: Pre-PCI LOC is a strong predictor of in-hospital outcomes after PCI among cardiac arrest patients. A patient’s pre-PCI LOC should be considered an important factor when weighing treatment options, designing clinical trials, and counseling patients and their families regarding prognosis after PCI. [ABSTRACT FROM AUTHOR]

Background: Sodium-glucose cotransporter 2 inhibitors (SGLT2is) have beneficial pleiotropic effects, contributing to improved cardiovascular and renal outcomes for patients with and without diabetes. The impact of SGLT2is on arrhythmic burden remains largely unexplored through randomized trials. Methods: In this multicenter, double-blind, randomized, placebo-controlled trial, we investigated the effects of ertugliflozin on arrhythmic burden among patients with heart failure with an ejection fraction less than 50%. All patients had an implantable cardioverter-defibrillator (ICD) with or without a cardiac resynchronization therapy device (CRT-D) and were randomized (1:1) to receive either ertugliflozin 5 mg once daily or placebo. The primary end point was the number of incident sustained (>30 seconds) ventricular tachycardia or ventricular fibrillation events from baseline to week 52. Secondary end points included the total number of non-sustained ventricular tachycardias, appropriate ICD therapies, changes in N-terminal pro-brain-type natriuretic peptide (NTproBNP) levels, and the number of heart failure hospitalizations. Results: Randomization was prematurely terminated, after class IA guideline recommendations were published for SGLT2is in patients with heart failure regardless of the ejection fraction. The final analysis included 46 patients (11% of the originally planned sample size). The yearly rate of the primary end point was 3.5 (95% confidence interval [CI] 2.8 to 4.4) with ertugliflozin compared with 13.3 with placebo (95% CI 11.8 to 14.8; rate ratio 0.16, 95% CI 0.04 to 0.61; P<0.001). There were no apparent differences in appropriate ICD therapies, hospitalizations, NTproBNP levels, or predefined adverse and serious adverse events. Conclusions: Ertugliflozin reduced sustained ventricular tachycardia or ventricular fibrillation events in adults with heart failure and an ICD compared with placebo; however, our trial ended early and thus results should be interpreted with caution. (Funded by Investigator-initiated Studies Program of Merck Sharp & Dohme Corp and Pfizer; EudraCT number, 2020-002581-14; ClinicalTrials.gov number NCT04600921.) [ABSTRACT FROM AUTHOR]

Implantable cardioverter-defibrillators (ICDs) reduce sudden cardiac death (SCD) and improve survival in patients with a history of life-threatening arrhythmia or sudden cardiac arrest, and in select populations at high risk of SCD due to ventricular arrhythmias. However, patients with ICDs may receive inappropriate or unnecessary shocks, which have been associated with pro-arrhythmia, psychological sequelae, poor quality of life, and increased mortality. The benefits and risks of ICD therapy are therefore directly impacted on by physician operative and programming decisions. This article aims to provide a detailed review of transvenous ICD programming as guided by clinical trials. [ABSTRACT FROM AUTHOR]

Cardiac arrest is the most important cause of death worldwide. Often, those who survive have an increased mortality and disability risk that is mainly associated with the development of hypoxic- ischemic brain injury (HIBI). This review examines current methods and recent advancements in neuroprognostication after cardiac arrest, focusing on the multimodal approach recommended by current guidelines. Recent studies have shown that a multimodal approach for neuroprognostication has the highest specificity to determine unfavorable outcomes after cardiac arrest. New biomarkers, such as neurofilament light chain alongside advancements in machine learning models, have shown promising results in predicting outcomes. Although several prognostic scoring systems have been developed to predict neurological outcomes as early as hospital admission, their prognostic efficacy is still being determined due to several associated limitations. Although several strategies for improving neurological outcomes during and after cardiac arrest exist, HIBI remains the leading cause of disability among survivors. A multimodal approach, including at least two diagnostic modalities, is crucial for accurate prognostication. Emerging technologies, including machine learning models and biomarkers, offer potential improvements to existing prognostic strategies, emphasizing the need for consistent guideline adherence to optimize patient care. [ABSTRACT FROM AUTHOR]

Out‐of‐hospital cardiac arrest (OHCA) is a global public health problem, with survival rates remaining low at around 10% or less despite widespread cardiopulmonary resuscitation (CPR) training and availability of automated external defibrillators (AEDs). This is partly due to the challenges of knowing when and where a sudden OHCA occurs and where the nearest AED is located. In response, countries around the world have begun to use network technology‐based smartphone applications. These applications are activated by emergency medical service dispatchers and alert preregistered volunteer first responders (VFRs) to nearby OHCAs using Global Positioning System localization. Accumulating evidence, although mostly from observational studies, shows their effectiveness in increasing the rate of bystander CPR, defibrillation, and patient survival. Current guidelines recommend the use of these VFR alerting systems, and the results of ongoing randomized trials are awaited for further dissemination. This article also proposed the concept of a life‐saving mobile network (LMN), which uses opportunistic network and wireless sensor network technologies to create a dynamic mesh network of potential victims, rescuers, and defibrillators. The LMN works by detecting a fatal arrhythmia with a wearable sensor device, localizing the victim and the nearest AED with nearby smartphones, and notifying VFRs through peer‐to‐peer communication. While there are challenges and limitations to implementing the LMN in society, this innovative network technology would reduce the tragedy of sudden cardiac death from OHCA. [ABSTRACT FROM AUTHOR]

Background: Ventricular tachycardia (VT) remains a risk in repaired Tetralogy of Fallot (rTOF); however, long‐term benefits of VT ablation have not been established. This study compares the outcomes of rTOF patients with and without VT ablation. Methods: We searched multiple databases examining the outcomes of rTOF patients who had undergone VT ablation compared to those without ablation. Primary outcomes were VT recurrence, sudden cardiac death (SCD), and all‐cause mortality. Subgroup analysis was conducted based on the type of ablation (catheter and surgical). Slow‐conducting anatomical isthmus (SCAI)‐based catheter ablation (CA) was also analyzed separately. The secondary outcome was the risk factors for the pre‐ablation history of VT. Results: Fifteen cohort studies with 1459 patients were included, 21.4% exhibited VTs. SCAI was found in 30.4% of the population, with 3.7% of non‐inducible VT. Factors significantly associated with VT before ablation included a history of ventriculostomy, QRS duration ≥180 ms, fragmented QRS, moderate to severe pulmonary regurgitation, high premature ventricular contractions burden, late gadolinium enhancement, and SCAI. Ablation was only beneficial in reducing VTs recurrence in SCAI‐based CA (risk ratio (RR) 0.11; 95% CI 0.03 to 0.33. p < 0.001; I2 = 0%) with no recurrence in patients with preventive ablation (mean follow‐up time 91.14 ± 77.81 months). The outcomes of VT ablation indicated a favorable trend concerning SCD and all‐cause mortality (RR 0.49 and 0.44, respectively); however, they were statistically insignificant. Conclusions: SCAI‐based CA has significant advantages in reducing VT recurrence in rTOF patients. Risk stratification plays a key role in determining the decision to perform ablation. [ABSTRACT FROM AUTHOR]

Background: Diagnosis of Brugada syndrome (BrS) may be established by exposing a Type 1 Brugada pattern using a sodium channel blocker. Data on the outcomes of different patient populations with drug‐induced Type 1 Brugada pattern are limited. The present study reports on the characteristics and outcome of subjects with ajmaline induced Type 1 Brugada pattern. Methods: A multicenter retrospective study including all consecutive cases of ajmaline‐induced Type 1 Brugada pattern from seven centers. Results: A total of 260 patients (69.9% males, mean age 43.4 ± 13.5) were included. Additional characteristics included history of syncope (n = 56, 21.5%), family history of BrS (n = 58, 22.3%) or sudden cardiac death (n = 47, 18.1%) and ventricular fibrillation (n = 3, 1.2%). Patients were divided into those meeting current diagnostic criteria for drug‐induced BrS (DIBrS) and compared to the drug‐induced Brugada pattern (DIBrECG). Females were significantly overrepresented in the DIBrS group (n = 50, 40% vs. n = 29, 21.5%, p =.001). A significantly higher prevalence of type 2/3 Brugada ECG at baseline was found in the DIBrECG group (n = 108, 80.8% vs. n = 75, 60% in the DIBrS, p =.026). During a median follow up of three (IQR 1.50–5.32) years, a single event of significant arrhythmia occurred in the DIBrS group. Conclusion: Less than half of subjects with ajmaline‐induced Brugada pattern met current criteria for BrS. These individuals had very low rate of adverse outcomes during a follow up of 3 years, irrespective of the indication for the test or eligibility for the BrS diagnosis. [ABSTRACT FROM AUTHOR]

Collapse after out-of-hospital cardiac arrest (OHCA) can cause severe traumatic brain injury (TBI). We aimed to investigate the clinical characteristics and treatment strategies for patients with OHCA and TBI. We analyzed a consecutive cohort of patients with intrinsic OHCA retrospectively treated between January 2011 and December 2021 at a single critical care center, and presented a case series of seven patients. Patients with collapse-related TBI were examined for the causes and situations of cardiac arrest, laboratory data, radiological images, targeted temperature management (TTM), coronary angiography (CAG), percutaneous coronary intervention (PCI), and extracorporeal cardiopulmonary resuscitation (ECPR). Of the 197 patients with intrinsic OHCA, 7 (3.6%) had TBI (age range: 49–70 years; 6 men). All seven patients presented with ventricular fibrillation in the initial electrocardiograms, with four refractory cases treated with ECPR. All patients underwent CAG under heparinization, and four underwent PCI with antiplatelet administration. Initial head computed tomography indicated an intracranial hemorrhage (ICH) in three patients. ICH appeared or was exacerbated in six patients after CAG with or without PCI, except in one who underwent delayed PCI. All patients displayed elevated plasma D-dimer levels, and four underwent neurosurgical procedures. Four patients survived (three with cerebral performance category [CPC] 2, one with CPC 3) and three died; two had hypoxic-ischemic brain injury and one had severe TBI. Delayed ICH occurred frequently. Individualized management is required based on the extent of brain and cardiac damage, including optimal TTM, PCI procedures, and antiplatelet medications. Early detection of ICH and emergency treatment are critical for multi-disciplinary collaboration. • Collapse after out-of-hospital cardiac arrest (OHCA) can cause severe traumatic brain injury (TBI). • All patients with OHCA and TBI presented with ventricular fibrillation, requiring emergency coronary angiography. • Percutaneous coronary intervention (PCI) or extracorporeal cardiopulmonary resuscitation (ECPR) was indicated. • Most intracranial hemorrhage (ICH) appeared or was exacerbated after PCI or ECPR. • Early detection of ICH and emergency treatment are critical for a multi-disciplinary collaboration. [ABSTRACT FROM AUTHOR]

Mountainous areas pose a challenge for the out-of-hospital cardiac arrest (OHCA) chain of survival. Survival rates for OHCAs in mountainous areas may differ depending on the location. Increased survival has been observed compared to standard location when OHCA occurred on ski slopes. Limited data is available about OHCA in other mountainous areas. The objective was to compare the survival rates with a good neurological outcome of OHCAs occurring on ski slopes (On-S) and off the ski slopes (Off S) compared to other locations (OL). Analysis of prospectively collected data from the cardiac arrest registry of the Northern French Alps Emergency Network (RENAU) from 2015 to 2021. The RENAU corresponding to an Emergency Medicine Network between all Emergency Medical Services and hospitals of 3 counties (Isère, Savoie, Haute-Savoie). The primary outcome was survival at 30 days with a Cerebral Performance Category scale (CPC) of 1 or 2 (1: Good Cerebral Performance, 2: Moderate Cerebral Disability). A total of 9589 OHCAs were included: 213 in the On-S group, 141 in the Off-S group, and 9235 in the OL group. Cardiac etiology was more common in On-S conditions (On-S: 68.9% vs Off S: 51.1% vs OL: 66.7%, p < 0.001), while Off-S cardiac arrests were more often due to traumatic circumstances (Off S: 39.7% vs On-S: 21.7% vs OL: 7.7%, p < 0.001). Automated external defibrillator (AED) use before rescuers' arrival was lower in the Off-S group than in the other two groups (On-S: 15.2% vs OL: 4.5% vs Off S: 3.7%; p < 0.002). The first AED shock was longer in the Off-S group (median time in minutes: Off S: 22.0 (9.5–35.5) vs On-S: 10.0 (3.0–19.5) vs OL: 16.0 (11.0–27.0), p = 0.03). In multivariate analysis, on-slope OHCA remained a positive factor for 30-day survival with a CPC score of 1 or 2 with a 1.96 adjusted odds ratio (95% confidence interval (CI), 1.02–3.75, p = 0.04), whereas off-slope OHCA had an 0.88 adjusted odds ratio (95% CI, 0.28–2.72, p = 0.82). OHCAs in ski-slopes conditions were associated with an improvement in neurological outcomes at 30 days, whereas off-slopes OHCAs were not. Ski-slopes rescue patrols are efficient in improving outcomes. [ABSTRACT FROM AUTHOR]

Hypertrophic cardiomyopathy is a genetic heart condition occurring in up to 1 in 200 patients in the United States, many of whom are young and otherwise healthy. This condition puts those affected at increased risk for adverse cardiac outcomes, including sudden cardiac arrest and death, with particular concern for this to occur during exercise and other forms of exertion. Recent studies aimed at evaluating the risk of exercise in hypertrophic cardiomyopathy patients have suggested thatmoderate and even vigorous exercise may be safe for certain patients. Clinical guidelines are changing to reflect this recent information and to encourage a shared decision-making approach, which can allow more hypertrophic cardiomyopathy patients to participate in health-promoting exercise activities. [ABSTRACT FROM AUTHOR]

Moral distress can impact nurses and the care team significantly. A profession dedicated to the principles of caring and compassion is often subjected to patients receiving futile treatment. With the proliferation of extreme life-prolonging measures come the difficulties in the withdrawal of those medical modalities. If a prognosis is poor and care is perceived as curative rather than palliative, providers may often feel conflicted and distressed by their interventions. The American Association of Colleges of Nursing has expressed growing concern about an increase in the use of inappropriate life-support treatments related to futile care. The compelling case of a severely beaten 69-year-old homeless manwho had cardiac-arrested and was resuscitated after an unknown amount of down-time, provides the contextual framework for this report. Ethical conflicts can become very challenging, which inevitably increases the suffering of the patient and their caregivers. Research findings suggest that health care organizations can benefit from enacting processes that make ethical considerations an early and routine part of everyday clinical practice. A proactive approach to ethical conflicts may improve patient care outcomes and decrease moral distress. [ABSTRACT FROM AUTHOR]

The number of critically ill patients that present to emergency departments across the world has risen steadily for nearly two decades. Despite a decrease in initial emergency department (ED) volumes early in the COVID-19 pandemic, the proportion of critically ill patients is now higher than pre-pandemic levels [1]. The emergency physician (EP) is often the first physician to evaluate and resuscitate a critically ill patient. In addition, EPs are frequently tasked with providing critical care long beyond the initial resuscitation. Prolonged boarding of critically ill patients in the ED is associated with increased duration of mechanical ventilation, increased intensive care unit (ICU) length of stay, increased hospital length of stay, increased medication-related adverse events, and increased in-hospital, 30-day, and 90-day mortality [2–4]. Given the continued increase in critically ill patients along with the increases in boarding critically ill patients in the ED, it is imperative for the EP to be knowledgeable about recent literature in resuscitation and critical care medicine, so that critically ill patients continue to receive evidence-based care. This review summarizes important articles published in 2022 that pertain to the resuscitation and management of select critically ill ED patients. These articles have been selected based on the authors review of key critical care, resuscitation, emergency medicine, and medicine journals and their opinion of the importance of study findings as it pertains to the care of the critically ill ED patient. Topics covered in this article include cardiac arrest, post-cardiac arrest care, rapid sequence intubation, mechanical ventilation, fluid resuscitation, and sepsis. [ABSTRACT FROM AUTHOR]

Epinephrine is recommended without an apparent ceiling dosage during cardiac arrest. However, excessive alpha- and beta-adrenergic stimulation may contribute to unnecessarily high aortic afterload, promote post-arrest myocardial dysfunction, and result in cerebral microvascular insufficiency in patients receiving extracorporeal cardiopulmonary resuscitation (ECPR). This was a retrospective cohort study of adults (≥ 18 years) who received ECPR at large academic ECMO center from 2018 to 2022. Patients were grouped based on the amount of epinephrine given during cardiac arrest into low (≤ 3 mg) and high (> 3 mg) groups. The primary endpoint was neurologic outcome at hospital discharge, defined by cerebral performance category (CPC). Multivariable logistic regression was used to assess the relationship between cumulative epinephrine dosage during arrest and neurologic outcome. Among 51 included ECPR cases, the median age of patients was 60 years, and 55% were male. The mean cumulative epinephrine dose administered during arrest was 6.2 mg but ranged from 0 to 24 mg. There were 18 patients in the low-dose (≤ 3 mg) and 25 patients in the high-dose (> 3 mg) epinephrine groups. Favorable neurologic outcome at discharge was significantly greater in the low-dose (55%) compared to the high-dose (24%) group (p = 0.025). After adjusting for age, those who received higher doses of epinephrine during the arrest were more likely to have unfavorable neurologic outcomes at hospital discharge (odds ratio 4.6, 95% CI 1.3, 18.0, p = 0.017). After adjusting for age, cumulative epinephrine doses above 3 mg during cardiac arrest may be associated with unfavorable neurologic outcomes after ECPR and require further investigation. [ABSTRACT FROM AUTHOR]

There is an absence of literature regarding the risks of catastrophic medical outcomes (CMOs) such as stroke, cardiac arrest, and pulmonary embolism in microvascular free tissue transfer. This study aims to determine the CMO and mortality rates, as well as risk factors, associated with microvascular reconstruction of the head and neck, extremity, and breast. This study uses data from the American College of Surgeons National Surgical Quality Improvement Program. Cases of microvascular free tissue transfer from 2012 to 2021 were analyzed to assess the 30-day rates of CMOs, including death, as well as associated risk factors. Of the 22,839 included patients, 785 (3.44%) experienced 1043 CMOs, including 99 (0.43%) deaths. Pulmonary complications of prolonged respiratory failure and pulmonary embolism were the most common. Independent risk factors included age, male sex, underweight status, longer operation times, American Society of Anesthesiologists (ASA) class of III or above, wound classification other than clean, and underlying conditions such as diabetes, hypertension, chronic obstructive pulmonary disorder, dyspnea, metastatic cancer, and ventilator dependence. CMOs were associated with an average 10-day delay in hospital discharge. Multivariate regression analysis revealed that head and neck reconstructions were associated with increased risk of CMO (OR 4.96; p < 0.0001). This is the largest study to examine CMOs following microvascular free tissue transfer. Compared to previous literature spanning the period between 2006 and 2011, we observed a decreased rate of CMOs but a slight increase in 30-day mortality. Our data provide updated and comprehensive criteria for risk stratification and patient counseling. The modifiable risk factors reported in our study should be considered in elective, non-urgent cases of microvascular reconstruction. [ABSTRACT FROM AUTHOR]

Cardiac arrest is a major public health issue, in which emergency medical services (EMS) initiating or continuing resuscitation in about 50% to 60% of cases. The aim of this study was to determine whether blood lactate levels and their course during cardiopulmonary resuscitation are prognostic indicators of the return of spontaneous cardiac activity (ROSC) in non-traumatic out-of-hospital cardiac arrest (OHCA). This was a prospective, interventional, multi-center study between 2017 and 2020. Patients above the age of 18 years (>50 years for women) who had non-traumatic OHCA and did not achieve ROSC before the arrival of the EMS, and for whom the medical team decided to initiate or continue cardiopulmonary resuscitation have been included. The primary endpoint was the return of spontaneous cardiac activity during out-of-hospital cardiopulmonary resuscitation, and secondary endpoint was survival at day 28. The lactate was initially measured simultaneously on a venous and capillary sample and then in capillary samples throughout the CPR, using POC device. A total 60 patients were included. Median age was 71 [IQR: 62–84] and 21.3% were female. Among them, 25% underwent ROSC in out-of-hospital setting, and 13,3% were alive at D-28. The median venous lactate value in all patients at T0 (time at which the EMS set up the peripheral venous line) was 6.2 mmol/L [IQR: 4.6–8.1], with no difference between patients with or without ROSC: 6.4 mmol/L [IQR:4.7–7.9] for patients with ROSC and 6.2 mmol/L [IQR: 4.7–8] for patients without ROSC (p = 0.87). The variables independently associated with ROSC were initial EtCo2 value (aOR = 1.12; 95% CI 1.01–1.25); the initial shockable rhythm (aOR = 10.2; 95% CI 1.18–88.2); and the pre-ROSC adrenaline dose (aOR = 0.54; 95% CI 0.35–0.82). In this prospective multi-center study, there was no independent association between lactate values during cardiopulmonary resuscitation and ROSC in non-traumatic OHCA. However, the post-ROSC pre-hospital kinetics of lactate (i.e., during the first 30 min) seem to be associated with survival. [ABSTRACT FROM AUTHOR]

The survivors of cardiac arrest experienced vary extent of hypoxic ischemic brain injury causing mortality and long-term neurologic disability. However, there is still a need to develop robust and reliable prognostic models that can accurately predict these outcomes. To establish reliable models for predicting 90-day neurological function and mortality in adult ICU patients recovering from cardiac arrest. We enrolled patients who had recovered from cardiac arrest at Binhaiwan Central Hospital of Dongguan, from January 2018 to July 2021. The study's primary outcome was 90-day neurological function, assessed and divided into two categories using the Cerebral Performance Category (CPC) scale: either good (CPC 1–2) or poor (CPC 3–5). The secondary outcome was 90-day mortality. We analyzed the relationships between risk factors and outcomes individually. A total of four models were developed: two multivariable logistic regression models (models 1 and 2) for predicting neurological function, and two Cox regression models (models 3 and 4) for predicting mortality. Models 2 and 4 included new neurological biomarkers as predictor variables, while models 1 and 3 excluded. We evaluated calibration, discrimination, clinical utility, and relative performance to establish superiority between the models. Model 1 incorporates variables such as gender, site of cardiopulmonary resuscitation (CPR), total CPR time, and acute physiology and chronic health evaluation II (APACHE II) score, while model 2 includes gender, site of CPR, APACHE II score, and serum level of ubiquitin carboxy-terminal hydrolase L1 (UCH-L1). Model 2 outperforms model 1, showcasing a superior area under the receiver operating characteristic curve (AUC) of 0.97 compared to 0.83. Additionally, model 2 exhibits improved accuracy, sensitivity, and specificity. The decision curve analysis confirms the net benefit of model 2. Similarly, models 3 and 4 are designed to predict 90-day mortality. Model 3 incorporates the variables such as site of CPR, total CPR time, and APACHE II score, while model 4 includes APACHE II score, total CPR time, and serum level of UCH-L1. Model 4 outperforms model 3, showcasing an AUC of 0.926 and a C-index of 0.830. The clinical decision curve analysis also confirms the net benefit of model 4. By integrating new neurological biomarkers, we have successfully developed enhanced models that can predict 90-day neurological function and mortality outcomes more accurately. [ABSTRACT FROM AUTHOR]

High-risk pulmonary embolism (PE) is a complex, life-threatening condition, and emergency clinicians must be ready to resuscitate and rapidly pursue primary reperfusion therapy. The first-line reperfusion therapy for patients with high-risk PE is systemic thrombolytics (ST). Despite consensus guidelines, only a fraction of eligible patients receive ST for high-risk PE. This review provides emergency clinicians with a comprehensive overview of the current evidence regarding the management of high-risk PE with an emphasis on ST and other reperfusion therapies to address the gap between practice and guideline recommendations. High-risk PE is defined as PE that causes hemodynamic instability. The high mortality rate and dynamic pathophysiology of high-risk PE make it challenging to manage. Initial stabilization of the decompensating patient includes vasopressor administration and supplemental oxygen or high-flow nasal cannula. Primary reperfusion therapy should be pursued for those with high-risk PE, and consensus guidelines recommend the use of ST for high-risk PE based on studies demonstrating benefit. Other options for reperfusion include surgical embolectomy and catheter directed interventions. Emergency clinicians must possess an understanding of high-risk PE including the clinical assessment, pathophysiology, management of hemodynamic instability and respiratory failure, and primary reperfusion therapies. [ABSTRACT FROM AUTHOR]

Results from a needs assessment conducted by nursing professional development practitioners across several clinics in the Midwest showed current educational methods to prepare for medical emergencies were insufficient. A champion model was used to complete in situ medical emergency response simulations. This proved to be an effective method for staff preparation when resources were limited and identified opportunities for practice improvement. [ABSTRACT FROM AUTHOR]

There are limited data on how patients with cardiogenic shock (CS) die. The Critical Care Cardiology Trials Network is a research network of cardiac intensive care units coordinated by the Thrombolysis In Myocardial Infarction (TIMI) Study Group (Boston, MA). Using standardized definitions, site investigators classified direct modes of in-hospital death for CS admissions (October 2021 to September 2022). Mutually exclusive categories included 4 modes of cardiovascular death and 4 modes of noncardiovascular death. Subgroups defined by CS type, preceding cardiac arrest (CA), use of temporary mechanical circulatory support (tMCS), and transition to comfort measures were evaluated. Among 1068 CS cases, 337 (31.6%) died during the index hospitalization. Overall, the mode of death was cardiovascular in 82.2%. Persistent CS was the dominant specific mode of death (66.5%), followed by arrhythmia (12.8%), anoxic brain injury (6.2%), and respiratory failure (4.5%). Patients with preceding CA were more likely to die from anoxic brain injury (17.1% vs 0.9%; P <.001) or arrhythmia (21.6% vs 8.4%; P <.001). Patients managed with tMCS were more likely to die from persistent shock (P <.01), both cardiogenic (73.5% vs 62.0%) and noncardiogenic (6.1% vs 2.9%). Most deaths in CS are related to direct cardiovascular causes, particularly persistent CS. However, there is important heterogeneity across subgroups defined by preceding CA and the use of tMCS. [ABSTRACT FROM AUTHOR]

This review aimed to investigate the effect of crew ratios of on-scene advanced life support (ALS)-trained personnel on patients with out-of-hospital cardiac arrest (OHCA). We systematically searched PubMed, Ovid EMBASE, and the Cochrane Central Register of Controlled Trials databases from the inception date until September 30, 2022, for eligible studies. Two reviewers independently screened the studies for relevance, extracted data, and quality. We compared the effect of the ratio of on-scene ALS-trained personnel >50 % to those with a ratio ≤50 % among prehospital personnel on the clinical outcomes of OHCA patients. The primary outcome was survival-to-discharge and secondary outcomes were any return of spontaneous circulation (ROSC), sustained ROSC (≥2 h), and favourable neurological outcome at discharge (cerebral performance category scores: 1 or 2). Pooled odds ratios (ORs) were calculated, and the certainty of evidence was assessed. From 10,864 references, we identified four non-randomised studies, including 16,475 patients. Two studies were performed in Japan and two in Taiwan. There were significant differences in survival-to-discharge (OR: 1.24, 95 % confidence interval [CI]: 1.07–1.44, I2: 7 %), any ROSC (OR:1.22, 95 % CI: 1.04–1.43, I2: 74 %) and sustained ROSC (OR: 1.39, 95 % CI: 1.16–1.65, I2: 40 %), but insignificant differences in favourable neurological outcome at discharge. The overall certainty of evidence was rated as very low for all outcomes. Prehospital ALS care with a ratio of on-scene ALS-trained personnel >50 % could improve OHCA patient outcomes than crew ratios ≤50 %. Further studies are required to reach a robust conclusion. [ABSTRACT FROM AUTHOR]

A 69-year-old woman was admitted after a cardiac arrest. She developed status epilepticus and was later found to have variable morphologies of a "spiked helmet sign" (SHS) on ECGs in the setting of prolonged QT interval, raising the question of whether this sign is a manifestation of QT prolongation. [ABSTRACT FROM AUTHOR]

Hiatal hernia (HH) is a common disease in the general population. It is often asymptomatic, but if it does present clinical manifestations, these are usually gastrointestinal. Gastroesophageal reflux is the main symptom that accompanies it. Depending on the severity of the hernia, it is classified into several subtypes from I–IV. Especially, IV type (giant HH) can lead to various cardiopulmonary symptoms with several degrees of severity. It is necessary to keep this possibility in mind among the various differential diagnoses that may occur in this clinical setting. The current paper aims to review the literature on classic and novel information on the HH – cardiovascular system relationship. Epidemiological data, physiological aspects of the heart compressed by HH, cardiovascular symptoms, electrocardiographic changes, echocardiographic alterations and clinical implications are discussed. Normally, the stomach and the heart are not in direct contact because they are in different cavities, the thorax and the abdomen, respectively. When part of the stomach moves toward the chest through the diaphragm, we say there is a hiatal hernia (HH). Most of the time the HH symptoms are mild and clearly digestive. In severe cases, surgical repair of the HH is required. Even in these circumstances, digestive symptoms continue to be the most frequent. However, some patients present cardiovascular symptoms and few or no digestive symptoms. This easily creates diagnostic confusion, which leads to incorrect treatments and unnecessary expenses. In extreme cases, as seen in giant HH, the degree of cardiovascular involvement is very serious. There are documented cases that have suffered cardiac arrest, arrhythmias of different types and symptoms like classic acute myocardial infarction. It is required that clinical doctors and surgeons are aware that this complication exists. Only with this in mind can a timely diagnosis be achieved. Some emergency measures have been saving, gastric decompression with a tube being the most important. The main mechanism that explains the serious cardiovascular consequences of giant HH is cardiac compression. The dissemination of this knowledge can help save lives. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Mortality and morbidity rates are very high in patients admitted to the Intensive Care Unit (ICU) after cardiac arrest. In this study, we aimed to determine the mortality rates, risk factors, and predictive factors for mortality in post-cardiac arrest patients admitted to the ICU. PATIENTS AND METHODS: Following approval from the Ethics Committee, we conducted a retrospective review of patient files for individuals over the age of 18 who received treatment for cardiac arrest in the ICU from January 2017 to June 2020. Demographic data of the patients, comorbidities, arrest location, etiology of arrest, duration of hospitalization, CPR duration, APACHE 2 scores, pH and HCO3 measurements in initial blood gases, lactate levels (1st, 6th, 12th, 24th hour), change in lactate levels (24-1), rate of lactate change, procalcitonin (PRC) levels (1st and 24th hour), change in PRC levels (24-1), rate of PRC change, and blood glucose levels were recorded. The patients were divided into two groups (survivors and non-survivors groups). RESULTS: 151 patients were included in the study. pH and HCO3 levels were lower in the non-survivors group than in the survivors group. Initial PRC levels were similar in both groups, but the 24th-hour PRC levels were higher, and the changes in PRC levels in the first 24 hours were greater in the non-survivors group. The lactate changes in the first 24 hours were higher in the non-survivors group. The receiver operating characteristic (ROC) curve showed that the HCO3 levels, 1st-, 6th-, 12th-, and 24th-hour lactate levels, and changes in lactate levels had predictability for mortality. In logistic regression analysis, we found that high 24th-hour lactate levels and changes in lactate levels were independent risk factors for mortality. CONCLUSIONS: Considering PRC and lactate levels, along with clinical examination and laboratory findings, may improve the accuracy of determining the prognosis of patients experiencing cardiac arrest. [ABSTRACT FROM AUTHOR]

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To indicate predictors of witnessed hypothermic cardiac arrest. We conducted a retrospective analysis of 182 patients with severe accidental hypothermia (i.e., with core body temperature of ≤28 °C) who presented with preserved spontaneous circulation at first contact with medical services. We divided the study population into two groups: patients who suffered hypothermic cardiac arrest (HCA) at any time between encounter with medical service and restoration of normothermia, and those who did not sustain HCA. The analyzed outcome was the occurrence of cardiac arrest prior to achieving normothermia. Hemodynamic and biochemical parameters were analyzed with regard to their association with the outcome. Fifty-two (29%) patients suffered HCA. In a univariable analysis, four variables were significantly associated with the outcome, namely heart rate (p < 0.001), systolic blood pressure (p = 0.03), ventricular arrhythmia (p = 0.001), and arterial oxygen partial pressure (p = 0.002). In the multivariable logistic regression the best model predicting HCA included heart rate, PaO 2 , and Base Excess (AUROC = 0.78). In prehospital settings, when blood gas analysis is not available, other multivariable model including heart rate and occurrence of ventricular arrhythmia (AUROC = 0.74) can be used. In this study population, threshold values of heart rate of 43/min, temperature-corrected PaO 2 of 72 mmHg, and uncorrected PaO 2 of 109 mmHg, presented satisfactory sensitivity and specificity for HCA prediction. In patients with severe accidental hypothermia, the occurrence of HCA is associated with a lower heart rate, hypoxemia, ventricular arrhythmia, lower BE, and lower blood pressure. These parameters can be helpful in the early selection of high-risk patients and their allocation to extracorporeal rewarming facilities. [ABSTRACT FROM AUTHOR]

Out-of-hospital cardiac arrest (OHCA) victims in rural communities have worse outcomes despite higher rates of bystander cardiopulmonary resuscitation (CPR) than urban communities. In this retrospective cohort study we attempt to evaluate selected aspects of the continuum of care, including post-arrest care, for rural OHCA victims, and we investigated factors that could contribute to rural areas having higher rates of bystander CPR. We analyzed 2014–2020 Texas Cardiac Arrest Registry to Enhance Survival (TX-CARES) data for adult OHCAs. We linked TX-CARES data to census tract data and stratified OHCAs into urban and rural events. We created a mixed-model logistic regression to compare cardiac arrest characteristics, pre-hospital care, and post-arrest care between rural and urban settings. We adjusted for confounders and modeled census tract as a random intercept. We then compared different regression models evaluating the association between response time and bystander CPR. We included 1202 rural and 28,288 urban cardiac arrests. Comparing rural to urban OHCAs, rates of bystander CPR were significantly higher in rural communities (49.6% v 40.6%, aOR 1.3 95% CI 1.1–1.5). The median response time for rural (11.5 min) was longer than urban (7.3 min). The occurrence of an ambulance response time of <10 min was notably less common in rural communities when compared to urban areas (aOR 0.2, 95% CI 0.2–0.2). For post-arrest care the rates of percutaneous coronary intervention (PCI) were higher in rural than urban communities (aOR 1.7, 95% CI 1.01–2.8). The rates of AED and TTM were similar between urban and rural communities. Survival to hospital discharge was significantly lower in rural communities than urban communities (aOR 0.6, 95% CI 0.4–0.7). Although not significant, rural communities had lower rate of survival with a cognitive performance score (CPC) of 1 or 2 (aOR 0.7, 05% CI 0.6–1.003). We identified no association between response time and bystander CPR. Patients in rural areas of Texas have lower survival after OHCA compared to patients in urban areas, despite having significantly greater rates of bystander CPR and PCI. We did not find a link between response time and bystander CPR rates. [ABSTRACT FROM AUTHOR]

In patients with out-of-hospital cardiac arrest (OHCA), early and accurate outcome prediction is crucial for making treatment decisions and informing their relatives. A previous study reported an association between high phosphate levels and unfavorable neurological outcomes after return of spontaneous circulation (ROSC); however, its prognostic value was insufficient when used independently. Therefore, this study aimed to validate the usefulness of the phosphate-to-albumin ratio (PAR) in predicting neurological outcomes and in-hospital mortality by incorporating albumin, another known prognostic indicator. This multicenter observational study included adult OHCA survivors from October 2015 to June 2021. The primary endpoint was an unfavorable neurological outcome at hospital discharge, defined as a cerebral performance category score of 3–5. The in-hospital mortality rates were also evaluated. Of the 2397 adult OHCA survivors, PAR differed significantly between the unfavorable and favorable neurological outcome groups, as well as between the non-survival and survival to hospital discharge groups (2.4 vs 1.4, 2.5 vs 1.6, respectively). The area under the receiver operating characteristic curve (AUROC) value of the PAR for predicting unfavorable neurological outcome was 0.81 (95% confidence interval [CI], 0.79–0.83), and the AUROC value for predicting in-hospital mortality was 0.76 (95% CI, 0.74–0.78). In multivariable analysis, the PAR was independently associated with unfavorable neurological outcome (odds ratio [OR] 1.30, 95% CI 1.15–1.37; p < 0.001) and in-hospital mortality (OR 1.24, 95% CI 1.12–1.38; p < 0.001). The PAR is a readily obtainable and independent prognostic indicator for patients with ROSC after OHCA, helping healthcare providers in predicting outcomes. [ABSTRACT FROM AUTHOR]

Background: Pulmonary arterial hypertension (PAH) is a progressive, and eventually fatal complication of Systemic Sclerosis (SSc) that affects the prognosis, quality of life, and mortality rate. Non-specific manifestations of PAH can result in delayed diagnosis and therefore in poorer outcomes. Objectives: We aim to study the prevalence and epidemiology of pulmonary arterial hypertension in SSc, and the impact of PAH on SSc hospitalizations in the United States population. Methods: We utilized the National Inpatient Sample (NIS) from 2016-2019 to obtain adult hospitalizations with the primary/secondary diagnosis of SSc and coexistent PAH (SSc-PAH). Epidemiological variables, mortality rates, and secondary outcomes were studied including pulmonary embolism, atrial flutter, atrial and ventricular fibrillation, pneumonia, sepsis, cardiac arrest and cardiac & renal failure, and ventilator requirement. Healthcare burden was estimated from total hospital charges (THC) and length of stay (LOS). Statistical analysis was performed on STATA 16.1, using linear and logistic regression analyses. Results: Out of 126,685 adult systemic sclerosis hospitalizations, 16.89% had PAH (SSc-PAH). The SSc-PAH group had significantly more females (85.4 % vs. 83.8%) and higher mean age (64.85±13.29 vs. 62.56±14.51). More African Americans were in this group than in the control group (19.5% vs. 14.6, p-value<0.001) while Whites (61.3% vs. 65.6%, p<0.001) and Asians (18.0 % vs. 2.8%, p<0.001) were less common. Charlson comorbidity index was higher for the SSc-PAH population (3.42 vs. 2.94, p-value<0.001). SSc-PAH group had a higher adjusted odds ratio (aOR) for mortality (aOR: 1.39, p<0.001), increased LOS (6.64 vs. 6.0 days, p<0.001) increased THC ($83,813 vs. $71,016, p <0.001). For the SSc-PAH group, there were also significantly higher odds of cardiac failure (aOR 3.13), ventilator requirement (aOR 2.15), cardiac arrest (aOR 1.39), kidney failure (aOR 1.63), pulmonary embolism (aOR 1.84), atrial flutter (aOR 1.86) atrial fibrillation (aOR1.56) and pneumonia (aOR 1.22). No significant difference in ventricular fibrillation, sepsis, or respiratory failure was noted. Conclusion: Pulmonary arterial hypertension in SSc is associated with worse outcomes in terms of mortality and morbidity, and higher healthcare burden compared to SSc without PAH. Also, PAH disproportionately affects White, African American & Asian populations. There remains a pressing need to continue efforts for early diagnosis and management of PAH in SSc patients. [ABSTRACT FROM AUTHOR]

[Display omitted] • True SD incidence may have been overestimated or may be underestimated in France. • Epidemiological methods of assessing SD incidence seem unreliable. • Prospective systematic nationwide studies needed to determine the true SD burden. The true incidence of sudden death remains undetermined, with controversial results from various publications over time and countries. To investigate if different estimations would reach the values usually reported for France. Three different kinds of estimations were used. First, the number of resuscitated sudden deaths and necropsies for sudden death in the Haute-Garonne French administrative department (i.e. county) over the last 10 years was expanded to the national level. Second, sudden death coding of death certificates was collected at the national level. Third, the total number of out-of-hospital cardiac arrests leading to any emergency call (with/without intervention) in Haute-Garonne over the last 10 years was expanded to the national level. There was a mean of 26 resuscitated sudden deaths and 145 necropsies for sudden death each year in Haute-Garonne, i.e. 12 to 14 sudden deaths for 100,000 inhabitants, and 7700 to 9400 sudden deaths yearly when related to the whole French population, according to the year of inclusion. Based on death certificates, a mean of 6584 sudden deaths was registered each year in France. Finally, there were about 600 yearly calls/interventions for out-of-hospital cardiac arrests in Haute-Garonne, i.e. 40 to 50 sudden deaths for 100,000 inhabitants, and 16,000 to 27,000 sudden deaths yearly for the whole French territory, according to the year of inclusion. The incidence of sudden death ranges from 6500 to 27,000 in France according to the calculation methods. This huge difference raises the question of the true current incidence of sudden death, which may have been overestimated previously or may be underestimated in France. More straight prospective surveys are needed to solve this question, because of relevant implications for priorities that should be given to sudden death. [ABSTRACT FROM AUTHOR]

Cardiovascular diseases are a major setback for human life and a critical problem in hospitals for public health. The sedentary lifestyle of every individual lead to various heart diseases. Cardio diseases malfunction the electrical beating of the heart and result in sudden death. Thus, a novel early warning system needed to be developed for cardio patients with higher sensitivity and lower false positive rates. This work helps in the early detection of cardiac arrest by analyzing the dataset. Our work has mainly two aspects: analyzing the dataset and deriving relations among features and early diagnosis of cardiac arrest with enhanced F1-score. A number of Machine Learning algorithms were applied to conduct the experiment. The work also compares various boosting algorithms named AdaBoost, LightGBM, CatBoost and XgBoost. We used different Machine Learning algorithms in which CatBoost gave an enhanced and best prediction score 98.08%. In the case of CatBoost the predicted positive value is 98 % and Sensitivity is 97.8%. [ABSTRACT FROM AUTHOR]

In 2023, the medical journal Resuscitation published the results of the latest study by Sam Parnia and his team, the AWARE II, in which they aimed to study consciousness after cardiac arrest and during the resuscitation process. Once again, the main objective was to detect any near-death experience (NDE) in which explicit memories occurred, either visual--of hidden images--or auditory. An important novelty was the measurement of EEG and cerebral oximetry during the brief pauses of CPR. Out of 28 interviews the researchers conducted with survivors, six patients reported NDEs, but none of them explicitly recalled either the hidden images or the auditory stimuli. However, in other patients from the study, some EEG activity that the authors deemed "compatible with consciousness" was detected during resuscitation, at least in some frequencies and brain areas. These data reopened the debate about whether the lucid consciousness of NDEs is generated by the dying brain. Parnia's own reflections in his earlier Bigelow contest essay denied this possibility. The AWARE II results did not resolve this question, but Parnia and his team suggested a possible explanation, still very theoretical, of NDEs based on brain disinhibition and ac-tivation of dormant brain circuits that would give access to "new dimensions of reality". [ABSTRACT FROM AUTHOR]

The preferred vasopressor in post-cardiac arrest shock has not been established with robust clinical outcomes data. Our goal was to perform a systematic review and meta-analysis comparing rates of in-hospital mortality, refractory shock, and hemodynamic parameters in post-cardiac arrest patients who received either norepinephrine or epinephrine as primary vasopressor support. We conducted a search of PubMed, Cochrane Library, and CINAHL from 2000 to 2022. Included studies were prospective, retrospective, or published abstracts comparing norepinephrine and epinephrine in adults with post-cardiac arrest shock or with cardiogenic shock and extractable post-cardiac arrest data. The primary outcome of interest was in-hospital mortality. Other outcomes included incidence of arrhythmias or refractory shock. The database search returned 2646 studies. Two studies involving 853 participants were included in the systematic review. The proposed meta-analysis was deferred due to low yield. Crude incidence of in-hospital mortality was numerically higher in the epinephrine group compared with norepinephrine in both studies, but only statistically significant in one. Risk of bias was moderate to severe for in-hospital mortality. Additional outcomes were reported differently between studies, minimizing direct comparison. The vasopressor with the best mortality and hemodynamic outcomes in post-cardiac arrest shock remains unclear. Randomized studies are crucial to remedy this. [ABSTRACT FROM AUTHOR]

This study aimed to investigate the association between blood glucose levels on arrival at the hospital and 1-month survival and favorable neurological outcomes in patients with OHCA using a large Japanese dataset. This study was a secondary analysis of data from the JAAM-OHCA Registry. Adult (≥18 years) patients with witnessed OHCA transported to emergency departments and registered in the database from June 2014 to December 2019 were included in the study. The primary and secondary endpoints were 1-month survival and 1-month favorable neurological outcomes (Glasgow-Pittsburgh Cerebral Performance Category score 1 or 2), respectively. Patients were categorized into the following four groups based on blood glucose levels on arrival at the hospital: <80 mg/dL, 80–179 mg/dL, 180–299 mg/dL, and ≥300 mg/dL. This study included 11,387 patients. Survival rates were 1.3%, 3.1%, 7.0%, and 5.7% in the <80 mg/dL, 80–179 mg/dL, 180–299 mg/dL, and ≥ 300 mg/dL blood glucose groups, respectively. The rates of favorable neurological outcomes in each group were 0.4%, 1.5%, 3.3%, and 2.5%, respectively. Multivariable analysis showed that 180–299 mg/dL glucose was significantly associated with 1-month survival and favorable neurological outcomes compared with 80–179 mg/dL glucose (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.34–2.31; p < 0.001 and OR, 1.52; 95 % Cl, 1.02–2.25; p = 0.035, respectively). In this study, blood glucose levels with the best outcomes likely ranged from 200 to 250 mg/dL based on the cubic spline regression model. Blood glucose level of 180–299 mg/dL on arrival at the hospital was significantly associated with 1-month survival and favorable neurological outcomes compared to blood glucose level of 80–179 mg/dL in patients with OHCA. • The association between blood glucose levels and outcomes in OHCA patients has not been thoroughly examined. • Mild-to-moderate hyperglycemia on arrival at the hospital was significantly associated with 1-month good outcomes. • Blood glucose levels with the best outcomes likely ranged from 200 to 250 mg/dL based on the cubic spline regression model. [ABSTRACT FROM AUTHOR]

To evaluate if the change in end-tidal carbon dioxide (ETCO2) over time has improved discriminatory value for determining resuscitation futility compared to a single ETCO2 value in prolonged, refractory non-shockable out-of-hospital cardiac arrest (OHCA). This is a retrospective analysis of adult refractory non-shockable, non-traumatic OHCA patients in the Portland Cardiac Arrest Epidemiologic Registry (PDX Epistry) from 2018 to 2021. We defined refractory non-shockable OHCA cases as patients with lack of a shockable rhythm at any time or return of spontaneous circulation at any time prior to 30-min of on-scene resuscitation. We abstracted ETCO2 values first recorded after advanced airway placement and nearest to the 30-min mark of on-scene resuscitation (30 min-ETCO2) from EMS charts. The primary outcome was survival to hospital discharge. We compared 30 min-ETCO2 cutoffs of 10 mmHg and 20 mmHg to the trend (increasing or not) from initial to 30 min-ETCO2 (delta-ETCO2) using sensitivity, specificity, and area under the receiver operating curves (AUROC). Of 3837 adult OHCA, 2850 were initially non-shockable, and there were 617 (16.1%) cases of refractory non-shockable OHCA at 30-min. We excluded 320 cases without at least two ETCO2 recordings in the EMS chart, leaving 297 cases that met inclusion criteria. Of these, 176 (59.3%) were transported and 2 (0.7%) survived to discharge. Using absolute 30 min-ETCO2 cutoffs, both survivors were in the >10 mmHg group (sensitivity 100.0%, specificity 12.5%), whereas only one survivor was identified in the >20 mmHg group (sensitivity 50.0%, specificity 32.5%). Using delta-ETCO2, both survivors were in the increasing ETCO2 group (sensitivity 100.0%, specificity 60.7%). In comparing the two tests that did not misclassify survivors, the AUROC [95% CI] was higher when using delta-ETCO2 (0.803 [0.775–0.831]) compared to an absolute cutoff of 10 mmHg (0.563 [0.544–0.582]). Nearly one-sixth of EMS-treated adult OHCA patients had refractory non-shockable arrests after at least 30 min of ongoing resuscitation. In this group, the ETCO2 trend following advanced airway placement may be more accurate in guiding termination of resuscitation than an absolute ETCO2 cutoff of 10 or 20 mmHg. [ABSTRACT FROM AUTHOR]

Medical emergency teams (METs) are in place in some hospitals in Finland to respond to critical emergency events. However, in hospitals without dedicated METs, staff are instructed to call emergency medical services (EMS) to deal with emergencies. This study examined the reasons for calling EMS to hospitals and the outcomes of these calls. Descriptive retrospective register-based study of the response and management of in-hospital emergencies by EMS in the wellbeing services county of Southwest Finland. Patient care reports of the EMS and those of the hospitals were analysed. In total, 138 medical emergencies managed by EMS were included in this study. 108 of these related to patients, and 25 related to hospital personnel. Cardiac arrest (n = 36) and a reduced level of consciousness (n = 29) were the most common in-hospital emergencies. In 68% of in-hospital emergencies managed by the EMS team, after calling 112, hospital personnel implemented various treatment measures. In 72% of cases, follow-up treatment was required. Hospital personnel are able to initiate medical measures in emergencies, even when no MET is available. Although EMS are important in responding to in-hospital emergencies, they seem to be performing the same role as METs. [ABSTRACT FROM AUTHOR]

[Display omitted] • Proteomics analysis was used to explore post-cardiac arrest (CA) pathology. • Significant protein alterations specific to each organ were observed. • The study provides proteomic evidence for impaired brain function after CA. • The data suggest that sustained energy supply is crucial for neuroprotection. [ABSTRACT FROM AUTHOR]

Background: The current status of wearable cardiovascular defibrillators (WCD) use in Japan is unclear. Methods: Using a nationwide claims database of Japan, we assessed characteristics of patients using WCD and factors influencing subsequent implantable cardioverter‐defibrillator (ICD) implantation. Results: In 1049 cases, those with prior cardiopulmonary arrest (CPA) or ventricular arrhythmia, cardiomyopathy, or device‐related issues were more likely to require permanent ICDs, whereas females were less likely. Conclusions: Prior CPA or fatal arrhythmia, underlying cardiomyopathy, or device‐related issues were associated with future permanent ICD implantation. These findings offer insights into the current status of WCD use in Japan. [ABSTRACT FROM AUTHOR]

A growing body of evidence suggests outcomes for cardiac arrest in adults are worse during nights and weekends when compared with daytime and weekdays. Similar research has not yet been carried out in the infant setting. We examined the National Emergency Medical Services Information System (NEMSIS), a database containing millions of emergency medical services (EMS) runs in the United States. Inclusion criteria were infant out-of-hospital cardiac arrests (patients <1 years old) taking place prior to EMS arrival between January 2021 and December 2022 where EMS documented whether return of spontaneous circulation (ROSC) was achieved. Cardiac arrests were classified as occurring during either the day (defined as 0800–1959) or the night (defined as 2000–0759) and weekends (Saturday/Sunday) or weekdays (Monday-Friday). Rates of ROSC achievement were compared. A total of 8549 infant cardiac arrests met inclusion criteria: 5074 (59.4%) took place during daytime compared with 3475 (40.6%) during nighttime, and 5989 (70.1%) arrests occurred on weekdays compared with 2560 (29.9%) on weekends. Rates of ROSC achievement were significantly lower on weekends versus weekdays (16.8% vs. 14.1%; p = 0.00097). A difference in ROSC rates when comparing daytime and nighttime was seen, but this difference was not statistically significant (16.4% vs. 15.3%; p = 0.08076). ROSC achievement rates for infant out-of-hospital cardiac arrest are significantly lower on weekends when compared with weekdays. Further study and quality improvement work is needed to better understand this. [ABSTRACT FROM AUTHOR]