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Introduction Overall survival of patients with out-of-hospital cardiac arrest (OHCA) remains low, even in those with return of spontaneous circulation (ROSC). In addition to usual prognostic characteristics, patients’ medical history may also influence their outcome. This study aimed to investigate the role of pre-arrest comorbidities on hospital survival, neurological outcome and mode of death in OHCA patients with successful ROSC. Methods From Jan 2012 to Sep 2017, all consecutive non-traumatic OHCA adults, admitted with a stable ROSC were included. Utstein characteristics, circumstances of arrest and interventions were prospectively recorded. Prior comorbidities were measured using the Charlson Comorbidity Index (CCI), and the population was divided into 3 groups (CCI 0, CCI 1–3 and CCI ≥ 4). The association of CCI with early and long-term mortality was assessed using logistic regression and association with withdrawal-of-life sustaining treatments (WLST) or another cause of death using multinomial regression. Results During the study period, 777 patients were analyzed and 483 (62%) died before hospital discharge, with death rate of 49%, 60% and 70% in CCI 0, CCI 1–3 and CCI ≥ 4 respectively. After adjustment, an increase CCI was significantly associated with in-hospital mortality (OR = 2.47 [1.35–4.52], p = 0.001 for CCI 1–3; OR = 2.82 [1.49–5.33], p = 0.003 for CCI ≥ 4; ref = CCI 0). Other independent predictors were non-shockable rhythm (OR = 3.23 [2.08–5]), lack of bystander CPR (OR = 1.96 [1.22–3.13]), epinephrine dose ≥ 2 mg (OR = 5.56 [3.70–8.33]), CA to CPR ≥ 5 min (OR = 1.96 [1.28–3.03]) and CPR to ROSC ≥ 20 min (OR = 2.13 [1.39–3.23]). Using multinomial regression, an increase in CCI was associated with all modes of in-hospital death, particularly with WLST-related death (RRadj = 2.48 [1.26–4.90], p = 0.01 for CCI = 1–3 and 3.75 [1.85−8.7.58], p Conclusion Alteration of chronic health status, as assessed by an elevated CCI, was associated with a higher mortality and a worse neurological outcome in OHCA patients. Presence and burden of comorbidities should be considered in the evaluation of the prognosis in patients admitted in hospital after cardiac arrest.

International audience; Purpose: Mesenteric ischaemia after successfully resuscitated cardiac arrest (CA) has been insufficiently studied. We aimed to assess the frequency, risk factors, and outcomes of non-occlusive mesenteric ischaemia (NOMI) after CA. Methods: We retrospectively included patients admitted to a CA centre with sustained return of spontaneous circulation between 2007 and 2017. NOMI was suspected based on clinical symptoms and classified as possible if no tests were feasible or the only test was a negative abdominal computed tomography (CT) scan and as confirmed if diagnosed by endoscopy, CT, or surgery. Results: Of 1343 patients, 82 (6%) had suspected NOMI, including 33 (2.5%) with confirmed NOMI. Investigations for suspected NOMI were done in 47/82 (57%) patients (CT, n = 30; lower digestive endoscopy, n = 14; and upper digestive endoscopy, n = 12); 11 patients underwent surgery. By multivariate analysis, factors associated with suspected NOMI were female sex (OR, 1.8; 95%CI, 1.1–2.9, p = 0.02), cardiovascular comorbidities (OR, 1.6; 95%CI, 1.0–2.7; p = 0.047), admission lactate >5 mmol/L (OR, 2.0; 95%CI, 1.2–3.4; p = 0.01), low flow >17 min (OR, 2.2; 95%CI, 1.3–3.8; p = 0.003), and inotropic score >7 μg/kg/min (OR, 1.8; 95%CI, 1.1–3.2; p = 0.03). ICU mortality was 96% (79/82), with 61% of patients dying from multi-organ failure (MOF) and 35% from post-anoxic brain injury. Of the eight patients who regained consciousness, 5 finally died from MOF, leaving 3 patients discharged alive from the ICU with a good neurologic outcome. Conclusions: NOMI may affect 2.5–6% of patients after CA. Mortality was extremely high in patients, and very few survived with a good neurological outcome.

International audience; Background: Data is scarce on hemorrhagic and thrombotic complications in patients with ST-elevation myocardial infarction (STEMI) associated with out-of-hospital cardiac arrest (OHCA).Methods: This is a monocentric, retrospective study conducted from January 2012 to December 2017 in a tertiary university hospital, which serves as a cardiac arrest center for a large urban area. Over the study period, all consecutive patients who were treated with stent implantation for STEMI with or without OHCA were included. Baseline characteristics, treatments, hemorrhagic and thrombotic events were compared between STEMI patients with and without OHCA. Univariate and multivariate analysis were performed in order to identify predictors of 30-day mortality, occurrence of major bleeding (MB), and early stent thrombosis (ST).Results: A total of 549 patients treated for STEMI without OHCA and 146 patients for STEMI with OHCA were included. The incidence of definite ST and MB after coronary angioplasty was significantly higher in patients with OHCA (2.6% vs. 7.5%, p = 0.004 and 3.3% vs. 19.2%, p < 0.001, respectively). Independent predictors of MB in OHCA patients were anticoagulation therapy (HR = 3.11, 95%CI [1.22-7.98], p = 0.02) and the use of glycoprotein IIb/IIIa inhibitors (HR = 4.16, 95%CI [1.61-10.79], p = 0.003). Independent predictors of mortality in OHCA patients were age (HR = 1.05, 95%CI [1.02-1.09], p = 0.004) and ST (HR = 5.62, 95%CI [1.61-19.65], p = 0.007, with a protective effect of new anti-P2Y12 treatments (HR = 0.20, 95%CI [0.08-0.46], p < 0.001).Conclusion: Patients treated for STEMI associated with OHCA are at higher-risk of ST and MB than those who did not experience cardiac arrest. In this subset of patients, prospective studies are needed to better evaluate the balance of thrombosis and hemorrhage.

A higher survival rate was observed in Sudden Cardiac Arrest (SCA) occurring during sports activities, although the underlying mechanisms remain unclear. We tested the hypothesis that better initial management, rather than sports per se, may account for the observed better outcomes during sports activities.Data was taken between May 2011 and March 2016 from a prospective ongoing registry that includes all SCA in Paris and suburbs (6.7 million inhabitants). Sports-related SCA (i.e. SCA occurring during sport activities or within one hour of cessation of the activity) were identified.Over the study period, 13,400 SCA occurred, of which 154 were sports-related (median age: 51.2 years, 96.1% males). At discharge, sports activity was associated with an 8-times higher survival rate (39.7% vs. 5.1%, P 0.001). Logistic regression showed that after considering potential confounders, including age, gender, SCA location, witness presence, time to response, and initial shockable rhythm, occurrence of SCA during sports was associated with a higher survival rate (OR 1.77, 95% CI 1.14-2.74, P = 0.01). However, after further adjustment for initial basic life support, i.e. bystander CPR and AED use, there was no association between sports setting and survival at hospital discharge (OR 1.43, 95% CI 0.91-2.23, P = 0.12).Sports-related SCA is a rare event, with an 8-times higher survival rate compared to non-sports-related SCA. Better initial management, including bystander CPR and AED use, rather than sports per se, mainly accounts this difference. This highlights the major importance of population education to basic life support in improving SCA outcome.

Purpose To explore diagnostic pitfalls and treatment issues in out-of-hospital cardiac arrest of neurological cause (OHCA-NC). Methods Retrospective analysis of all consecutive patients from the Paris Sudden Death Expertise Centre (France) registry from May 2011 to September 2015 presenting with a sustained return of spontaneous circulation (ROSC) at hospital admission and a final diagnosis of OHCA-NC. Description of the early diagnostic check-up performed to identify the cause of cardiac arrest. Logistic multivariate regression to identify factors associated with immediate coronary angiography (iCAG) in OHCA-NC patients. Results Among 3542 patients with ROSC, a final diagnosis of OHCA-NC was established in 247 (7%). The early diagnostic check-up consisted in a total of 207 (84%) immediate cranial CT-scan, 66 (27%) iCAG and 25 (10%) chest CT-scan. The brain CT-scan allowed identifying a neurovascular cause in 116 (47%) patients. An iCAG was performed as the first line exam in 57 (23%) patients, in whom a final diagnosis of neurovascular cause for OHCA-NC was later identified in 41 patients. By multivariate analysis, decision for iCAG was independently associated with ST-segment elevation on post-ROSC electrocardiogram (OR, 5.94; 95%CI, 2.14–18.28; P = 0.0009), whereas an obvious cause of cardiac arrest on scene was negatively associated with iCAG (OR, 0.14; 95%CI, 0.02–0.51; P = 0.01). Conclusions OHCA-NC is a rare event that is mainly related to neurovascular causes. The initial ECG pattern may be a confounder regarding triage for early diagnostic check-up. Further studies are required to explore the potential harmfulness associated with decision to perform an iCAG in this population.

Aim Out-of-hospital Cardiac Arrest (OHCA) carries a poor prognostic with high mortality rates and multiple scoring systems have been developed to assess its prognostic. This study sought to evaluate the performance of three prognostic scores to predict survival in OHCA patients due to acute coronary syndrome (ACS). Methods and results This is an observational, monocentric study including 386 consecutive patients treated for OHCA due to ACS, treated by percutaneous coronary intervention, between 2007 and 2019. The OHCA, NULL-PLEASE and CAHP scores were calculated respectively for 370 patients (95.9%), 371 patients (96.1%) and 350 patients (90.7%). A C-statistic analysis was performed to determine score performance. The areas under the curve for the OHCA, NULL-PLEASE and CAHP scores were 0.861 (95% CI, 0.823–0.898), 0.789 (95% CI, 0.744–0.834) and 0.830 (95% CI, 0.788–0.872) respectively demonstrating good performance. The OHCA score performed better than the NULL-PLEASE score (p = 0.001), and there was no difference between the CAHP and the NULL-PLEASE score (p = 0.062) nor between the OHCA and the CAHP score (p = 0.105). Conclusion The OHCA score, the NULL-PLEASE score and the CAHP score performed well in predicting in-hospital death in patients presenting OHCA secondary to ACS. The NULL-PLEASE score is the easiest to use but performed less accurately than the OHCA score.

Background Adrenal gland volume is associated with survival in septic shock. As sepsis and post-cardiac arrest syndrome share many pathophysiological features, we assessed the association between adrenal gland volume measured by computerized tomography (CT)-scan and post-cardiac arrest shock and intensive care unit (ICU) mortality, in a large cohort of out-of-hospital cardiac arrest (OHCA) patients. We also investigated the association between adrenal hormonal function and both adrenal gland volume and outcomes. Patients and Methods Prospective analysis of CT-scan performed at hospital admission in patients admitted after OHCA (2007–2012). A pair of blinded radiologist calculated manually adrenal gland volume. In a subgroup of patients, plasma cortisol was measured at admission and 60 min after a cosyntropin test. Factors associated with post-cardiac arrest shock and ICU mortality were identified using multivariate logistic regression. Results Among 775 patients admitted during this period after OHCA, 138 patients were included: 72 patients (52.2%) developed a post-cardiac arrest shock, and 98 patients (71.1%) died. In univariate analysis, adrenal gland volume was not different between patients with and without post-cardiac arrest shock: 10.6 and 11.3 cm3, respectively (p = 0.9) and between patients discharged alive or dead: 10.2 and 11.8 cm3, respectively (p = 0.4). Multivariate analysis confirmed that total adrenal gland volume was associated neither with post-cardiac arrest shock nor mortality. Neither baseline cortisol level nor delta between baseline and after cosyntropin test cortisol levels were associated with adrenal volume, post-cardiac arrest shock onset or mortality. Conclusion After OHCA, adrenal gland volume is not associated with post-cardiac arrest shock onset or ICU mortality. Adrenal gland volume does not predict adrenal gland hormonal response.

Little is known about the association between provision of post-resuscitation care and prognosis of out-of-hospital cardiac arrest (OHCA) in elderly patients. Previous studies have suggested futility after 65 years of age.We aimed to evaluate the association of early coronary angiogram (CAG) followed if necessary by percutaneous coronary intervention (PCI), with favorable outcome after OHCA among elderly patients, compared to younger patients.Using a large French registry, we included all OHCA patients with an initial shockable rhythm, transported to hospital from 2011 to 2015. Favorable outcome was defined as hospital discharge with Cerebral Performance Category (CPC) 1 or 2. and were evaluated by multivariate logistic regression. Subgroup analyses were performed according to age groups:65, 65-75 and75 years.Among 1502 included patients, 31% were older than 65 and 12% older than 75 years. An early CAG was performed in 79%, 88% and 76% of patients below 65, between 65 and 75 and above 75, respectively (P = 0.002). The rate of patients discharged with CPC1 or 2 was 42% below 65, 38% between 65 and 75 and 24% above 75 (P 0.001). Among the whole population, early CAG (OR = 6.4, 95% CI = 3.9-10.5, P 0.001) was associated with favorable outcome. In subgroups analysis, CAG was associated with favorable outcome among patients65 and 65-75. In patients75, there was a trend towards a favorable outcome (OR2.9, 95CI = 0.9-9.1).In a large registry of OHCA survivors, the early CAG use was associated with a better prognosis. This benefit was persistent up to 75 years of age, suggesting that age alone should not guide the decision for early invasive strategy.

Introduction Although the survival rate after out-of-hospital cardiac arrest (OHCA) has increased over time, little is known about the return to work of OHCA survivors. We aim to evaluate prevalence and factors associated with return to work (RTW) in OHCA survivors. Patients and methods All consecutive OHCA survivors aged 18–65 years and discharged alive from a Paris tertiary intensive care unit between 2000 and 2013 were included. Pre-hospital care, in-hospital care, and after-hospital discharge data, such as work description (work location, job classification, nature of the job) were compared relative to work status and RTW. Factors associated with RTW were evaluated using multivariable logistic regression. Results 153 OHCA survivors were included in the analysis. Among them, 96 (62.8%) returned to work an average of 714 days after OHCA (SD 1031); mostly to the same job (n = 72, 75%). Six patients changed jobs (4%) and 12 reduced their activity (10.6%). Factors associated with RTW were younger age (adjusted odds ratio (aOR) 3.64 [1.10; 12.02]), being managers and professionals, and service and sales workers (compared to technicians and associate professionals, clerical support workers, respectively aOR 3.43 [1.05; 11.22] and 4.69 [1.14; 19.37]), and workplace occurrence (aOR 11.72 [1.37; 99.93]). Conclusion Two thirds of OHCA survivors, in the present study, returned to work. Patients with a higher-level job, and with the arrest occurring in the workplace, were more likely to return to work. Further research should include more details of job contents, evolution, financial consequences, as well as prevention practices related to work location.

The survival rate of out-of-hospital cardiac arrest (OHCA) remains extremely low, generally under 10%. Post-resuscitation care, and particularly early coronary reperfusion, may improve this outcome. The main objective of the present study was to determine whether patients with immediate coronary angiography at hospital admission (CAA) had a better outcome than patients without immediate CAA.This cohort analysis study was based on data extracted from the French National Cardiac Arrest registry (RéAC). To control for attribution bias, patients were matched using a propensity score, which included age clusters, low flow and no flow delays, initial rhythm and bystander cardiopulmonary resuscitation (CPR). The main endpoint was survival at day 30 (D30). Secondary endpoint was neurological recovery of survivors assessed by the Cerebral Performance Category (CPC) scale, with CPC 1 and 2 at D30 considered as a favorable outcome.From July 1st, 2011 to October 1st, 2016, 63394 OHCA were registered in the database, of which 39444 were of an unknown or suspected cardiac origin. After on-site resuscitation by a mobile medical team, 7584 patients were transported to a hospital facility. Among these patients, 4046 were retained in the analysis after matching for the aforementioned factors and constituted into 2 groups: immediate coronary angiography (iCAA) group (n = 2023) and non-immediate coronary angiography (niCAA) group (n = 2023). The survival rate at D30 after matching was 43.3% in the iCAA group versus 34.5% in the niCAA group (OD = 0.66 [0.58; 0.75], p 0.001). In the iCAA group, (n = 707) 36% of the patients at D30 were CPC 1-2 comparatively to (n = 539) 27.3% in the niCAA group (p 0.01).Both the survival and proportion of patients with favorable neurological recovery were significantly higher in patients who underwent an immediate coronary angiography after a resuscitated OHCA. These observational results warrant further exploration of the benefit of this invasive strategy in randomized studies.

Introduction The cumulative burden of chronic health conditions could contribute to out-of-hospital cardiac arrest (OHCA) physiology and response to attempted resuscitation. Yet little is known about how chronic health conditions influence prognosis. We evaluated the relationship between cumulative comorbidity and outcome following ventricular fibrillation OHCA using 3 different scales. Methods We performed a cohort investigation of persons >= 18 years who suffered non-traumatic OHCA and presented with ventricular fibrillation between January 1, 2007 and December 31, 2013 in a metropolitan emergency medical service (EMS) system. Chronic conditions were ascertained from EMS reports. The primary relationship between cumulative comorbidity and outcome (survival to hospital discharge) used the Charlson Index and two other scales. Analyses used logistical regression (LR), multiple imputation and inverse probability weighting. Results During the study period 1166/1488 potential patients were included. The median Charlson Index was 1 (25th-75th%: 0–2). Overall survival was 43.9%. Comorbidity was associated with a dose-dependent decrease in the likelihood of survival. ompared to Charlson Score of 0, the odds ratio of survival was 0.68 (0.48–0.96) for Charslon of 1, 0.49 (0.35–0.69) for Charlson of 2, and 0.43 (0.30–0.61) for Charlson of >= 3 after adjustment for Utstein predictors using multivariable LR. This inverse comorbidity-survival association was similar for the other 2 scales and was observed for different clinical outcomes (admission to hospital, functional survival, 30-day survival, and 1-year survival). Conclusion Based on these results, cumulative comorbidity can help explain survival variability and improve prognostic accuracy. Whether information about cumulative comorbidity or specific health conditions can inform resuscitation care is unknown though the results suggest comorbidity may influence acute pathophysiology and treatment response.

Background Respective proportions of final etiologies are disparate in cohorts of cardiac arrest patients, depending on examined population and diagnostic algorithms. In particular, prevalence and characteristics of sudden unexplained death syndrome (SUDS) are debated. We aimed at describing etiologies in a large cohort of aborted out-of-hospital cardiac arrest (OHCA) patients, in order to assess prevalence and outcome of SUDS. Patients and methods We analyzed data from our prospective registry of successfully resuscitated OHCA patients admitted to a cardiac arrest centre between January 2002 and December 2014. The in-ICU diagnostic strategy included early coronary angiogram, brain and chest CT scan. This was completed by an extensive diagnostic strategy, encompassing biological and toxicological tests, repeated electrocardiograms and echocardiography, MRI and pharmacologic tests. Two independent investigators reviewed each final diagnosis. Baseline characteristics were compared between subgroups of patients. Three-month mortality was compared between subgroups using univariate Kaplan-Meier curves. Results Over the study period, 1657 patients were admitted to our unit after an aborted OHCA. The event was attributed to a non-cardiac and a cardiac cause in 478 (32.0%) and 978 (65.5%) patients, respectively. The main cause of cardiac related OHCA was ischemic heart disease (76.7%) while primary electrical diseases accounted for only 2.5%. Sudden unexplained deaths (SUDS) were observed in 37 (2.5%) patients. Conclusion We observed that ischemic heart disease was by far the most common cause of cardiac arrest, while primary electrical diseases were much less frequent. SUDS accounted for a very small proportion of patients who suffered an aborted OHCA.

The impact of time of occurrence has been extensively evaluated for in-hospital cardiac arrests but less for Out-of-Hospital Cardiac Arrests (OHCA). We assessed the impact of the time of occurrence on the characteristics and prognosis of OHCA.Using data from the Paris Sudden Cardiac Death Expertise Center prospective study that includes all OHCA in the Paris Area, we compared characteristics and outcomes of off-hours OHCA (nights and days off) to regular-hours OHCA between 2011 and 2014.Among a total of 9834 OHCA (70.0±17years old, 62.1% males), off-hours OHCA accounted for 63.4%. Although bystanders were more often present (74.4 vs. 72.1%, P=0.01), rates of bystander CPR (46.7 vs. 50.6%, P=0.001) and AED use (1.0 vs. 1.9%, P=0.01) were lower during off-hours. While EMS arrival delays were similar, patients were less often in shockable rhythm (16.3 vs. 19.1%, P0.0001), and return of spontaneous circulation was less frequent (27.5 vs. 31.1%, P0.0001). There was no difference in rates of targeted temperature control (54.8 vs. 54.7%, P=0.75), coronary angiography (57.3 vs. 58.2%, P=0.68) and angioplasty use (32.2 vs. 35.6%, P=0.22). Survival at hospital discharge was lower (4.7 vs. 6.5%, P0.0001) during off-hours. After adjusting for potential confounders, time of occurrence was not associated with worse outcome (OR 0.85, 95% CI 0.69-1.06, P=0.15), and bystander-initiated CPR, shockable initial rhythm and AED use were the main survival predictors (P0.0001).Off-hours OHCA have a 30% lower survival rate, mainly due to differences in initial management (bystander CPR and AED use), illustrating the need to improve bystanders' responsiveness in all circumstances.

Background Even if a large majority of out-of-hospital cardiac arrest (OHCA) survivors appear to have a good neurological recovery with no important sequellae, whether health-related quality of life (HRQOL) is altered is less explored. Patients and methods HRQOL was evaluated by telephone interview using SF-36 questionnaire. Each OHCA case was age and gender-matched with 4 controls from the French general population. Association between current condition of the survivors with the 8 dimensions of the SF-36 questionnaire was investigated using MANCOVA. Cluster analysis was performed to identify patterns of HRQOL among CPC1 survivors. Results 255 patients discharged alive from our referral centre between 2000 and 2013 (median age of 55y [45,64], 73.7% males) were interviewed. Global physical and mental components did not differ between CPC 1 survivors and controls (47.0 vs. 47.1, p=0.88 and 46.4 vs. 46.9, p=0.45) but substantially differed between CPC2, CPC3 and the corresponding controls. Younger age, male gender, good neurological recovery and daily-life autonomy at telephone interview were significantly associated with better scores in each SF-36 dimensions. Cluster analysis individualized 4 distinct subgroups of CPC1 patients characterised by progressively increased score of SF-36. Return to work and daily-life autonomy were differently distributed across these 4 groups while pre-hospital Utstein variables were not. Conclusion HRQOL of CPC1 OHCA survivors appeared similar to that of the general population, but patients with CPC2 or 3 had altered HRQOL. Younger age, male gender, good neurological recovery and daily-life autonomy were independently associated with a better HRQOL.

Purpose Cardiogenic shock due to post-resuscitation myocardial dysfunction is a major cause of mortality among patients hospitalized after cardiac arrest (CA). Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been proposed in the most severe cases but the level of evidence is very low. We assessed characteristics, outcome and prognostic factors of patients treated with VA-ECMO for post-CA shock. Methods Using a large regional registry, we focused on all CA admitted in ICU. Among those who developed a post-CA shock, prognostic was compared according to VA-ECMO use, using logistic regression and propensity score. Specific prognostic factors were identified among VA-ECMO patients. Results Among 2988 patients admitted after CA, 1489 developed a post-CA shock, and were included. They were mostly male (68%), with mean age 63 years (SD=15). Fiflty-two patients (3.5%) were treated with VA-ECMO, mostly patients with ischemic cause of CA (67%). Among patients with post-CA shock, 312 (21%) were discharged alive (25% in VA-ECMO group, 21% in control group, P=0.45). After adjustment for pre-hospital and in-hospital factors, survival did not differ among patients treated with VA-ECMO (OR for survival=0.9, 95%CI 0.4–2.3, P=0.84). After propensity-score matching, results were consistent. Among patients treated with VA-ECMO, initial arterial pH (OR=1.7 per 0.1 increase, 95%CI 1.0–2.8, P=0.04) and implantation of VA-ECMO over 24h after ROSC (OR=20.0, 95%CI 1.4–277.3, P=0.03) were associated with survival. Conclusions Post-CA shock is frequent and is associated with a high mortality rate. When used in selected patients, we observed that VA-ECMO could be an appropriate treatment.

Background Obesity prevalence has dramatically increased over recent years and is associated with cardiovascular diseases, but data are lacking on its prognostic impact in out-of-hospital cardiac arrest (OHCA) patients. Methods Data of all consecutive OHCA patients admitted in two cardiac arrest centers from Paris and suburbs between 2005 and 2012 were prospectively collected. Patients treated by therapeutic hypothermia (TH) were included in the analysis. Logistic and Cox regression analyses were used to quantify the association between body mass index (BMI) at hospital admission and day-30 and 1-year mortality respectively. Results 818 patients were included in the study (median age 60.9 [50.8–72.7] year, 70.2% male). Obese patients (BMI>30kgm −2 ) were older, more frequently male and evidenced more frequently cardiovascular risk factors than normally (18.5 −2 ) or overweight patients (25 −2 ). Post-resuscitation shock and therapeutic hypothermia failure were more frequent in obese patients. Overall mortality at day-30 and one-year was 63.8 and 67.2%, respectively. After multivariate adjustment, BMI>30kgm −2 was independently associated with day-30 mortality (Odds ratio [OR] in comparison with normally weight patients 2.45; 95% confidence interval [95%CI: 1.32–4.56; p Conclusion In the present study, obesity was independently associated with day-30 mortality in successfully resuscitated ICU TH OHCA patients. Further studies are needed to understand the mechanisms that underpin this finding.

International audience; Purpose: To evaluate the predictive value of EEG reactivity assessment and confounders for neurological outcome after cardiac arrest.Methods: All consecutive patients admitted in a tertiary cardiac arrest center between 2007 and 2016 still alive 48 h after admission with at least one EEG recorded during coma. EEG reactivity was defined as a reproducible waveform change in amplitude or frequency following standardized stimulation. Each EEG was classified based on American Clinical Neurophysiology Society nomenclatures and classified in highly malignant (including status epilepticus), malignant, or benign EEG. We assessed the predictive values of EEG reactivity and sedation effect for neurologic outcome at ICU discharge using the Cerebral Performance Category scale (with CPC 1-2 assumed as favorable outcome and CPC 3-4-5 considered as poor outcome).Results: Among 428 patients, a poor outcome was observed in 80% patients. The median time to EEG recording was 3 (1-4) days and 51% patients had a non-reactive EEG. The positive predictive value (PPV) of a non-reactive EEG to predict an unfavorable outcome was 97.1% (IC95% 93.6-98.9), increasing to 98.3% (IC95 94.1-99.8) when the EEG had been performed without sedation. In multivariate analysis, a non-reactive EEG was associated with poor outcome (OR 12.6 IC95% 4.7-33.6; p < 0.001). In multivariate analysis, concomitant sedation was not statistically associated with EEG non-reactivity. The PPV of a benign EEG to predict favorable outcome was 49.7% (IC95% 41.5-57.9), increasing to 66.2% (IC95% 54.3-76.8) when EEG was recorded earlier, with ongoing sedation.Conclusions: After cardiac arrest, absence of EEG reactivity was predictive of unfavorable outcome. By contrast, a benign EEG was slightly predictive of a favorable outcome. Reactivity assessment may have important implications in the neuroprognostication process after cardiac arrest and could be influenced by sedation.

Evaluate long-term neurologic outcome for paediatric survivors of OHCA.Subjects19 years who experienced OHCA from 1976-2007 and survived to hospital discharge were included. Demographics, neurologic outcomes and years of survival were determined using the King County Emergency Medical Service cardiac arrest database, Seattle Children's Hospital medical records, Washington State Death Database and National Death Index. A Paediatric Cerebral Performance Category (PCPC) score (1-6) was determined for the index hospitalization discharge and all subsequent visits.From 1976-2007, 1683 cases of OHCA resulted in 91 survivors to hospital discharge. 18/91 survivors identified had pre-morbid conditions. 72/91 survivors had follow-up PCPC scores. Patients were: ≤5 years (53%) and 54% female. 33/35 patients with initial favorable neurologic outcomes (PCPC 1-2) maintained favorable neurologic status in long-term follow-up. 14/37 patients with initial unfavorable neurologic outcomes (PCPC 3-5) remained unfavorable over long-term follow-up. Six unfavorable patients showed some improvement, three of whom achieved favorable PCPC scores at last evaluation. One unfavorable patient declined from PCPC 4 to PCPC 5. Twenty patients with an initial unfavorable neurologic outcome died in long-term follow-up.In this cohort study of neurologic outcomes for paediatric OHCA survivors, a favorable initial PCPC score was highly associated with stable long-term neurological outcomes. Those with poor neurologic status at initial discharge were unlikely to improve and were at greatest risk to die in follow-up. Future studies should focus on improving neurologic outcomes and prospectively evaluating the long-term neurologic course.

Aim Due to collapse and cardiopulmonary resuscitation (CPR) maneuvers, major traumatic injuries may complicate the course of resuscitation for out-of-hospital cardiac arrest patients (OHCA). Our goals were to assess the prevalence of these injuries, to describe their characteristics and to identify predictive factors. Methods We conducted an observational study over a 9-year period (2007–2015) in a French cardiac arrest (CA) center. All non-traumatic OHCA patients admitted alive in the ICU were studied. Major injuries identified were ranked using a functional two-level scale of severity (life-threatening or consequential) and were classified as CPR-related injuries or collapse-related injuries, depending of the predominant mechanism. Factors associated with occurrence of a CPR-related injury and ICU survival were identified using multivariable logistic regression. Results A major traumatic injury following OHCA was observed in 91/1310 patients (6.9%, 95%CI: 5.6, 8.3%), and was classified as a life-threatening injury in 36% of cases. The traumatic injury was considered as contributing to the death in 19 (21%) cases. Injuries were related to CPR maneuvers in 65 patients (5.0%, (95%CI: 3.8, 6.1%)). In multivariable analysis, age [OR 1.02; 95%CI (1.00, 1.04); p = 0.01], male gender [OR 0.53; 95%CI (0.31, 0.91); p = 0.02] and CA occurring at home [OR 0.54; 95%CI (0.31, 0.92); p = 0.02] were significantly associated with the occurrence of a CPR-related injury. CPR-related injuries were not associated with the ICU survival [OR 0.69; 95%CI (0.36, 1.33); p = 0.27]. Conclusions Major traumatic injuries are common after cardiopulmonary resuscitation. Further studies are necessary to evaluate the interest of a systematic traumatic check-up in resuscitated OHCA patients in order to detect these injuries.

Although guidelines on post-resuscitation care recommend the use of short-acting agents for sedation during targeted temperature management (TTM) after cardiac arrest (CA), the potential advantages of this strategy have not been clinically demonstrated.We compared two sedation regimens (propofol-remifentanil, period P2, vs midazolam-fentanyl, period P1) among comatose TTM-treated CA survivors. Management protocol, apart from sedation and neuromuscular blockers use, did not change between the two periods. Baseline severity was assessed with Cardiac-Arrest-Hospital-Prognosis (CAHP) score. Time to awakening was measured starting from discontinuation of sedation at the end of rewarming. Awakening was defined as delayed when it occurred after more than 48 h.460 patients (134 in P2, 326 in P1) were included. CAHP score did not significantly differ between P2 and P1 (P = 0.93). Sixty percent of patients awoke in both periods (81/134 vs. 194/326, P = 0.85). Median time to awakening was 2.5 (IQR 1-9) hours in P2 vs. 17 (IQR 7-60) hours in P1. Awakening was delayed in 6% of patients in P2 vs. 29% in P1 (p 0.001). After adjustment, P2 was associated with significantly lower odds of delayed awakening (OR 0.08, 95% CI 0.03-0.2; P 0.001). Patients in P2 had significantly more ventilator-free days (25 vs. 24 days; P = 0.007), and lower catecholamine-free days within day 28. Survival and favorable neurologic outcome at discharge did not differ across periods.During TTM following resuscitation from CA, sedation with propofol-remifentanil was associated with significantly earlier awakening and more ventilator-free days as compared with midazolam-fentanyl.

Pulmonary Embolism (PE) is a relatively common cardiovascular condition, occasionally and tragically manifesting as Sudden Cardiac Arrest (SCA). The natural history of SCA complicating PE has been poorly evaluated.In this study, we described the management and outcome of PE-related SCA.In this prospective population--based study, we included all patients admitted at hospital alive after out- of- hospital SCA, in Paris and suburbs, France (6.6 million inhabits), from May 2011 to September 2015.Of 2926 patients hospitalized after SCA, 82 cases were diagnosed as PE-related SCA (2.8%, 95%CI=2.2-3.4). Systemic thrombolysis was performed in 47 patients (57%), without significant increased risk of major bleeding among patients treated with thrombolysis. 12 patients (15%) were treated with ECLS, 29 patients (36%) had targeted temperature management, and 20 patients (24%) underwent coronary angiography. 94% of PE-related SCA had initial non-shockable rhythm, and were associated with better survival compared with other non-shockable SCA (crude OR=3.0, 95%CI=1.7-5.4, P0.001; adjusted OR=4.1, 95%CI 2.0-8.3, P0.001). Among PE-related SCA, thrombolysis was independently associated with survival (OR=12.5, 95%CI=1.8-89.1, P=0.01). Multiple sensitivity analysis was performed, with consistent results.PE is responsible of approximately 3% of hospitalizations for SCA. Thrombolysis was associated with an increased survival in this population, reinforcing current guidelines advocating for such treatment in PE-related SCA.

Out of hospital cardiac arrest (OHCA) mortality rates remain very high with poor neurological outcome in survivors. Extracorporeal cardiopulmonary resuscitation (ECPR) is one of the treatments of refractory OHCA. This study used data from the mobile intensive care unit (MOICU) as part of the emergency medical system of Paris, and included all consecutive patients treated with ECPR (including pre-hospital ECPR) from 2011 to 2015 for the treatment of refractory OHCA, comparing two historical ECPR management strategies.We consecutively included refractory OHCA patients. In Period 1, ECPR was indicated in selected patients after 30min of advanced life support; in- or pre-hospital implementation depended on estimated transportation time and ECPR team availability. In Period 2, patient care relied on early ECPR initiation after 20min of resuscitation, stringent patient selection, epinephrine dose limitation and deployment of ECPR team with initial response team. Primary outcome was survival with good neurological function Cerebral Performance Category score (CPC score) 1 and 2 at ICU discharge or day 28.A total of 156 patients were included. (114 in Period 1 and 42 in Period 2). Baseline characteristics were similar. Mean low-flow duration was shorter by 20min (p0.001) in Period 2. Survival was significantly higher in Period 2: 29% vs 8% (P0.001), as confirmed by the multivariate analysis and propensity score. When combining stringent patient selection with an aggressive strategy, the survival rate increased to 38%. Pre-hospital ECPR implementation in itself was not an independent predictor of improved survival, but it was part of the strategy in Period 2.Our data suggest that ECPR in specific settings in the management of refractory OHCA is feasible and can lead to a significant increase in neurological intact survivors. These data, however, need to be confirmed by a large RCT.

As post-cardiac arrest care may influence patients' outcome, characteristics of receiving hospitals should be integrated in the evaluation of survival. We aimed at assessing the influence of care level center on patients' survival at hospital discharge using a regional registry of out-of-hospital cardiac arrest patients (OHCA).We retrospectively analysed a Utstein and in-hospital data prospectively collected for all non-traumatic OHCA patients, in whom a successful return of spontaneous circulation (ROSC) had been obtained, from a large metropolitan area (Great Paris). Receiving hospitals were categorized in 3 groups as follows: A centers (High-case volume with cath-lab 24/7), B centers (Intermediate-case volume with cath-lab partly available) and C centers (Low-case volume and no cath-lab) We compared patients' characteristics and outcome in the 3 groups and performed a multivariate logistic regression using survival to discharge as primary endpoint.Between May 2011 and December 2013, 1476 patients were admitted in 48 hospitals (group A: n=917; group B: n=428; group C: n=91). Overall survival rate at discharge was 433/1436 (30%). Patients' baseline characteristics significantly differed, as hospitals from group A received younger patients with a higher rate of shockable cardiac rhythms (p0.001). Unadjusted survival rate differed significantly among the 3 groups of hospitals (respectively 34%, 25% and 15.4% for A-C, p0.01). In multivariate analysis, the category of receiving hospital was no longer associated with survival, even in the subgroup of witnessed arrest and shockable patients.In this population-based study, characteristics of receiving hospitals are not associated with survival rate at discharge. This might be partially explained by the prehospital triage organization used in France.

Early invasive strategy, including percutaneous coronary intervention (PCI), may improve survival in out-of-hospital-cardiac-arrest (OHCA) due to coronary artery disease but selection of suitable patients is challenging. Differences and results across gender remain unknown. We aimed to assess the relationship between gender and the use of an early invasive strategy after OHCA, and the relationship with outcome according to gender.All patients admitted after OHCA were prospectively included (2000-2013). Using a gender-independent algorithm for its indication, we assessed the association between the use of an early invasive strategy and the outcome at hospital discharge (using the Cerebral Performance Category scale), according to gender.1817 patients were included (520 women, 29%). Women were older (62.8 vs 59.1 years, P0.0001). They had less shockable rhythm (42% vs 61%, P0.001). After multivariate logistic regression, female gender was negatively associated with early coronary angiogram (OR=0.57, 95%CI 0.41-0.79, P=0.001). Results after propensity-score matching were consistent (P=0.02). Among 1157 patients who underwent coronary angiogram, rates of PCI did not differ between men and women (adjusted OR=1.26, 95%CI 0.87-1.82, P=0.23). Early invasive strategy was associated with favorable outcome in multivariate logistic regression (OR=1.43, 95%IC 1.02-2.0, P=0.04) with no interaction between gender and PCI (P for interaction=0.11). Association between PCI and outcome was consistent across genders.After OHCA, women are less likely to undergo early invasive strategy. However, rates of PCI after coronary angiogram do not differ across gender, and the association between PCI and outcome is similar across gender.

Aims Identification of the cause of out-of-hospital cardiac arrest (OHCA) is of paramount importance. We investigated the ability of our imaging strategy to provide an early etiological diagnosis of OHCA and the influence of this strategy on ICU survival. Methods Retrospective review of a prospectively acquired ICU database (01/2000–12/2010) including all OHCA patients without obvious extracardiac cause, for which an early diagnosis research was conducted (coronary angiography and/or brain and chest CT scan) within 24h after resuscitation. These procedures could be performed separately or be combined, according to a decision algorithm. Results Of the 1274 patients admitted after OHCA during this 10-year period, the imaging strategy was applied in 896 patients. Patients who benefited from coronary angiography and/or CT scan were admitted to our ICU after a median delay of 180 [130–220]min after resuscitation. Seven hundred and forty-five coronary angiographies were performed, of which 452 (61%) identified at least one significant coronary lesion deemed responsible for the OHCA. CT-scan was performed in 355 patients and provided a diagnosis in 72 patients (20%), mainly stroke ( n =38) and pulmonary embolism ( n =19). Overall, this strategy allowed early diagnosis in 524 patients (59%). ICU survival was significantly higher for patients with a diagnosis identified by coronary angiography as compared with CT-scan (43% vs 10%, p Conclusion The use of an early diagnosis protocol with immediate coronary angiography and/or CT scan provided the etiology of nearly two thirds of OHCA cases. In this large retrospective database, coronary angiography yielded a better diagnostic value than brain and/or chest CT-scan.

Cardiogenic shock due to post-resuscitation myocardial dysfunction is a major cause of mortality among patients hospitalized after cardiac arrest (CA). Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been proposed in the most severe cases but the level of evidence is very low. We assessed characteristics, outcome and prognostic factors of patients treated with VA-ECMO for post-CA shock.Using a large regional registry, we focused on all CA admitted in ICU. Among those who developed a post-CA shock, prognostic was compared according to VA-ECMO use, using logistic regression and propensity score. Specific prognostic factors were identified among VA-ECMO patients.Among 2988 patients admitted after CA, 1489 developed a post-CA shock, and were included. They were mostly male (68%), with mean age 63 years (SD=15). Fiflty-two patients (3.5%) were treated with VA-ECMO, mostly patients with ischemic cause of CA (67%). Among patients with post-CA shock, 312 (21%) were discharged alive (25% in VA-ECMO group, 21% in control group, P=0.45). After adjustment for pre-hospital and in-hospital factors, survival did not differ among patients treated with VA-ECMO (OR for survival=0.9, 95%CI 0.4-2.3, P=0.84). After propensity-score matching, results were consistent. Among patients treated with VA-ECMO, initial arterial pH (OR=1.7 per 0.1 increase, 95%CI 1.0-2.8, P=0.04) and implantation of VA-ECMO over 24h after ROSC (OR=20.0, 95%CI 1.4-277.3, P=0.03) were associated with survival.Post-CA shock is frequent and is associated with a high mortality rate. When used in selected patients, we observed that VA-ECMO could be an appropriate treatment.

Hypoxic hepatitis (HH) may complicate the course of resuscitated out-of-hospital cardiac arrest (OHCA) patients admitted in intensive care unit (ICU). Aims of this study were to assess the prevalence of HH, and to describe the factors associated with HH occurrence and outcome.We conducted an observational study over a 6-year period (2009-2014) in a cardiac arrest center. All non-traumatic OHCA patients admitted in the ICU after return of spontaneous circulation (ROSC) and who survived more than 24h were included. HH was defined as an elevation of alanine aminotransferase over 20 times the upper limit of normal during the first 72h after OHCA. Factors associated with HH and ICU mortality were picked up by multivariate logistic regression.Among the 632 OHCA patients included in the study, HH was observed in 72 patients (11.4% (95% CI: 9.0%, 14.1%)). In multivariate analysis, time from collapse to ROSC [OR 1.02 per additional minute; 95% CI (1.00, 1.04); p=0.01], male gender [OR 0.53; 95% CI (0.29, 0.95); p=0.03] and initial shockable rhythm [OR 0.35; 95% CI (0.19, 0.65); p0.01] were associated with HH occurrence. After adjustment for confounding factors, HH was associated with ICU mortality [OR 4.39; 95% CI (1.71, 11.26); p0.01] and this association persisted even if occurrence of a post-CA shock was considered in the statistical model [OR 3.63; 95% CI (1.39, 9.48); p=0.01].HH is not a rare complication after OHCA. This complication is mainly triggered by the duration of resuscitation and is associated with increased ICU mortality.

Optimal care for out-of hospital cardiac arrest (OHCA) patients may depend on the underlying aetiology of OHCA. Specifically chest compression only bystander CPR may provide greater benefit among those with cardiac aetiology and chest compressions plus rescue breathing may provide greater benefit among those with non-cardiac aetiology. The aim of this study was to generate a simple predictor model to identify OHCA patients with non-cardiac aetiology in order to accurately allocate rescue breathing.We used two independent cohorts of OHCA patients from a randomized pre-hospital trial and a prospective hospital registry (total n=3086) to assess whether the characteristics of age, gender and arrest location (private versus public) could sufficiently discriminate non-cardiac aetiology. We used logistic regression models to generate a receiver operator curve and likelihood ratios.Overall, 965/3086 (31%) had a final diagnosis of a non-cardiac cause. Using 8 exclusive groups according to age, gender, and location, the frequency of non-cardiac aetiology varied from a low of 16% (55/351) among menage 50 in a public location up to 58% (199/346) among women60 in a private location. Although each characteristic was predictive in the logistic regression model, the area under the curve in the receiver operating curve was only 0.66. The associated positive likelihood ratios ranged from 1 to 3 and the negative likelihood ratios ranged from 1 to 0.4.The results highlight the challenge of accurately identifying non-cardiac aetiology by characteristics that could be consistently used to allocate bystander rescue breathing.

Aim of the study To study the determinants and the evolution of cerebral oximetry determined by near-infrared spectroscopy after out-of-hospital cardiac arrest of cardiac origin during therapeutic hypothermia and rewarming, and to compare cerebral oximetry values between patients with good and bad prognosis. Methods In this prospective, non-interventional, single center study, all consecutive patients between 18 and 80 years admitted for out-of-hospital cardiac arrest (OHCA) with a no flow less than 10min, a low flow of less than 50min and a persistent coma after ROSC with Glasgow score equal or less than seven at baseline were included. Results Between February 2012 and January 2013, 43 patients were admitted for OHCA in our ICU. Twenty-two patients (51%) were discharged with no or minimal neurologic complications (CPC 1–2). Mortality rate in the ICU was 46.5%. Cerebral oximetry (rSO 2 ) was correlated with temperature, heart rhythm, PaO 2 , hemoglobin, and mean arterial pressure. Mean rSO 2 during the 48 first hours was not different between patients with good and bad neurologic outcomes, respectively, 61.8 (5.9) vs. 58.1 (8.8), P =0.13, as during the period of hypothermia. The minimal value of rSO 2 during the first 48h was significantly different between patients with good prognosis and those with bad prognosis, respectively, 45.0 (6.8) vs. 31.7 (15.0), P =0.0009. Conclusions In this prospective cohort of OHCA patients, main determinants of rSO 2 were systemic variables. Monitoring of rSO 2 does not allow discriminating patients with good or bad outcome, but could be useful for identifying vulnerable periods for the development of neurologic injury.

Aim High rates of stent thrombosis (ST) have been reported in patients with out-of-hospital cardiac arrest (OHCA) who require a primary percutaneous coronary intervention (PCI). The aim of this study was to assess risk factors of ST in this population with a special focus on antiplatelet therapy administered during the acute phase. Materials and methods We conducted a retrospective observational study in patients treated with primary PCI after OHCA between 2011 and 2013 in our center. All consecutive patients were treated with mild therapeutic hypothermia and dual antiplatelet therapy after primary angioplasty. Results A total of 101 consecutive patients were included in the present analysis. Mean age was 61.3 ± 12.7 years and 75% of patients had an initial ventricular fibrillation. All patients received aspirin before PCI. P2Y12 inhibitors were administered after PCI and included clopidogrel (47.5%), prasugrel (21.8%) or ticagrelor (29.7%). The survival rate at discharge was 44.5%. We identified 11 cases (10.9%) of definite or probable ST (clopidogrel (n = 2), prasugrel (n = 4) and ticagrelor (n = 5)) occurring at a median of 2 days after PCI. No specific predictors were found to be significantly associated with ST. New P2Y12 inhibitors were associated with more ST compared to clopidogrel (17.3% vs. 4.2%; respectively, p = 0.05). ST was associated with a decreased left ventricular ejection fraction (p = 0.007) and with a trend toward a higher mortality compared to patients without ST (82% vs. 52%, p = 0.06). Conclusion The incidence of ST in OHCA survivors is high and associated with poor clinical outcome. The use of new oral P2Y12 inhibitors does not appear to be associated with a reduction in ST compared to clopidogrel.

Background Conflicting results exist regarding the impact of gender on early survival after sudden cardiac arrest (SCA). We aimed to assess the association between female gender and early SCA survival. Methods We searched Embase, MEDLINE, EBM Reviews, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews (between 1948 and January 2014) for studies evaluating the association between gender and survival after SCA. Two independent reviewers selected studies of any design or language. Pooled odds-ratios (OR) and 95% confidence intervals (CIs) were estimated using a random-effects model. Additional sensitivity analyses and meta-regression were carried out to explore heterogeneity. Results Thirteen studies were included involving 409,323 patients. Women were more likely to present with SCA at home, less likely to have witnessed SCA, had a lower frequency of initial shockable rhythm but were more likely to receive bystander CPR. After adjustment for these differences, women were more likely to survive at hospital discharge (OR 1.1, 95% CI 1.03–1.20, p =0.006, I 2 =61%). This association persisted in multiple sensitivity analyses. Conclusion This meta-analysis of observational studies demonstrates that women have increased odds of survival after SCA. Further studies are needed to address mechanisms explaining this discrepancy.

Rationale: Early PCI is associated with improved survival in out-of-hospital cardiac arrest (OHCA) patients resuscitated from a cardiac arrest of ischemic cause. However it is still unclear if this benefit is restricted to STEMI patients or if it can be extended to patients without STEMI on post-resuscitation ECG. We aimed to assess the influence of early PCI in this specific population. Methods: Providing that there is no obvious extra-cardiac cause, an immediate coronary angiogram is usually performed in all OHCA patients admitted in our hospital and all characteristics are prospectively collected in a computerized database. We isolated data from the subgroup of patients without STEMI on initial ECG. Using logistical regression, we investigated the association between early PCI and favourable outcome (defined with CPC 1 or CPC2) and we searched predictive factors for PCI requirement. Results: During the 10-years study period (2004-2013), 946 post-CA patients were explored by immediate coronary angiogram after OHCA. Among them, 704/946 (74%), mostly male (75%) and average age of 60 y.o. have no STEMI on the post-resuscitation ECG. PCI was deemed necessary in 203/704 (29%). A favourable outcome was observed in 86/203 (42%) in patients with PCI compared with 167/501 (33%) in patients without PCI (p=0.02). After adjustment on other covariates, PCI was associated with a better outcome (ORadj=1.79[1.08-2.95], p=0.02). Initial shockable rhythm (ORadj=3.03 [1.97-4.66], p Conclusion: We found a culprit coronary lesion requiring PCI in nearly one third of OHCA patients without STEMI. In these patients, PCI was associated with a nearly two-fold increase in the rate of favourable outcome. Identification of candidates of such strategy relies mostly on age and first observed rhythm. Our findings encourage the use of immediate coronary angiography in patients resuscitated from OHCA, even if there is no STEMI pattern on initial ECG.

Daniel Jost1,∗, Pascal Dang Minh1, Nicolas Genotelle1, Stephane Travers1, Olga Maurin1, Florence Dumas2, Michel Bignand1, Jean-Pierre Tourtier1 1 Fire Brigade of Paris, Paris, France 2 Sudden Death Expertise Center, Paris, France Purpose:Cardiopump® (CP) is a deviceusedbyprofessional rescuer teams to perform chest compression (CC) on out-of-hospital cardiac arrest (OHCA). It allowsperforming a compression followed by an active decompression, and has a gauge to assess the depth of the full compression and decompression. This study aimed to identify chest injuries induced by CC performed with CP. Materials andmethods:Prospectiveobservational study. Inclusion criteria: patients with non-traumatic OHCA>15 years, for whom CP was used. Collected data: epidemiological (age, gender, location, bystander, CPR duration), clinical (skin lesions linked to CP, rib fracture caused by CC, subcutaneous emphysema) and prognosis (return of spontaneous circulation (ROSC), “beating-heart” on arrival at the hospital). We performed uni and multivariate statistical analysis (logistic regression). Results: A total of 3385 patients were included in 2013. Of these, 590 (17%) had chest skin lesions, 121 (4%) rib fractures, and 30 (0.89%) suffered subcutaneous emphysema. Mean age of injured patients was comparable to that of non-injured (66±17 years vs 67±19, p =0.28), and so was their sex-ratio. Three logistic regression models were performed: 1. Skin lesions were linked to low-flow>30min (OR=3.1 [1.6–5.8]) and regurgitation (OR=2.1 [0.9–4.9]). 2. Rib fractures were linked to low-flow>60min (OR=7.1 [1.3–30.1]) and less frequent in OHCA at home (OR=0.38 [0.2–0.8]). 3. Subcutaneous emphysema was less frequent at home (OR=0.09 [0.01–0.48]. None of the other variableswas significantly linked to the occurrence of injury by CP. Conclusions: Chest injuries from CC performed with CP were frequent, and it was impossible to show their harmful effect on early patient outcome. A study should be conducted to compare the frequency and severity of lesions induced by CC performed by CP or no.

Objective Little is known about long-term prognosis following resuscitation from out-of-hospital cardiac arrest, especially as it relates to the presenting rhythm or arrest aetiology. We investigated long-term survival among those discharged alive following resuscitation according to presenting rhythm and arrest aetiology. Methods We conducted a cohort investigation of all non-traumatic adult out-of-hospital cardiac arrest patients resuscitated and discharged alive from hospital between January 1, 2001 and December 31, 2009 in a large metropolitan emergency medical service system. Information about demographics, circumstances, presenting arrest rhythm and aetiology was collected using the dispatch, EMS, and hospital records. Long-term vital status was ascertained using state death records and the Social Security Death Index through 31st December 2010. We used Kaplan Meier to evaluate survival. Results During the study period, a total of 1001/5958 (17%) persons were resuscitated and discharged alive, of whom 313/1001 (31%) presented with a non-shockable rhythm and 210/1001 (21%) had a non-cardiac aetiology. Overall median survival was 9.8 years with 64% surviving >5 years. Five-year survival was 43% for non-shockable rhythms compared to 73% for shockable rhythms, and 45% for non-cardiac aetiology compared to 69% for cardiac aetiology ( p Conclusion Cardiac arrest due to non-shockable rhythm or non-cardiac aetiology comprises a substantial proportion of those who survive to hospital discharge. Although long-term survival in these groups is less than their shockable or cardiac aetiology counterparts, nearly half are alive 5 years following discharge. The findings support efforts to improve resuscitation care for those with non-shockable rhythms or non-cardiac cause.

Background —Little is known about the long-term survival effects of type-specific bystander CPR in the community. We hypothesized that dispatcher instruction consisting of chest compression alone would be associated with better overall long-term prognosis compared to chest compression plus rescue breathing. Methods and Results —The investigation was a retrospective cohort study that combined 2 randomized trials comparing the short-term survival effects of dispatcher CPR instruction consisting either of chest compression alone or chest compression plus rescue breathing. Long-term vital status was ascertained using the respective National and State death records through 31st July 2011. We performed Kaplan Meier method and Cox regression to evaluate survival according to the type of CPR instruction. Of the 2496 subjects included in the current investigation, 1243 (50%) were randomized to chest compression alone and 1253 (50%) were randomized to chest compression plus rescue breathing. Baseline characteristics were similar between the two CPR groups. During the 1153.2 person-years of follow-up, there were 2260 deaths and 236 long-term survivors. Randomization to chest compression alone compared to chest compression plus rescue breathing was associated with a lower risk of death after adjustment for potential confounders (adjusted HR=0.91; 95% CI [0.83-0.99], p=0.02). Conclusions —The findings provide strong support for long-term mortality benefit of dispatcher CPR instruction strategy consisting of chest compression alone rather than chest compression plus rescue breathing among adult cardiac arrest patients requiring dispatcher assistance.

s / Resuscitation 85S (2014) S15–S121 S101 provide high scientific, technical and human quality nursing care. In conclusion, we “can” andwe “must” provide integral and holistic care in out-of-hospital emergencies. Methods/material: Retrospective and descriptive study, analyzing nursing interventions (recorded under NIC Taxonomy) in CPR patients assisted by Emergency Medical Service EPES 061, Department of Jaen, during 2013. Total study population=65 cases. Objetive: To evidence interventions recorded under NIC Taxonomy in CPR patients assisted by Emergency Medical Service EPES 061, Department of Jaen, during 2013. NIC=Nursing Interventions Classification. Results: 65 medical records were analyzed (100%). The results show a significant prevalence of interventions that belong to the Domains: Physiological (basic and complex) and Security. However wemust recognize as notable other interventions like “Family support”, “Facilitate family presence” or “Protecting patient rights”, from Family and Health System domains. These nursing interventions appear in 72.9% of the analyzed records. Conclusions: Although most of the recorded interventions result predictable (in fact, they are recommended as essentials for emergencies by the NIC Taxonomy) there is also a strong presence of interventions from another domains, which might result unthinkable to appear in the emergency context in previous stages. These nursing interventions show an integral and holistic out-ofhospital critical care provided to patients and families.

Background: Out-of-hospital cardiac arrest (OHCA) carries a very poor prognosis. Early prognostication of patients admitted in ICU after resuscitated OHCA is a key issue but remains challenging. The aim of that study was to establish a new scoring system to predict poor neurological outcome in these patients. Materials and Methods: The CAHP (Cardiac Arrest Hospital Prognosis) score was developed from the Sudden Death Expertise Center registry (SDEC, Paris, France). Objective risk factors were weighted on the basis of a logistic regression analysis. The primary outcome was poor neurological outcome defined as Cerebral Performance Category 3, 4 or 5. Thresholds were defined to distinguish low, moderate and high-risk groups. The CAHP score was then validated in an external dataset (Parisian OHCA Registry). Score calibration and discrimination characteristics were assessed in the validation dataset. Results: The developmental dataset included 819 patients admitted in ICU from May 2011 to December 2012. After logistic regression, 7 variables were independently associated with poor neurological outcome: age, initial shockable rhythm, time form collapse to basic life support (BLS), time from BLS to return of spontaneous circulation (ROSC), location of cardiac arrest, epinephrine dose during resuscitation and arterial pH at admission. These variables were included in the CAHP score. 3 risks groups were identified: a low risk group (score ≤ 150, 39 % of unfavorable outcome), medium risk group (score 150-200, 81% of unfavorable outcome) and high-risk group (CAHP score ≥ 200, 100 % of unfavorable outcome). AUC of the CAHP score was 0.93. In the external validation dataset, discrimination value of the CAHP score was consistent with an AUC of 0.85. Conclusion: The CAHP score is a simple and objective tool for early assessment of prognosis in patients admitted to ICU after OHCA. Moreover it allows to stratify the probability of poor neurological outcome by identifying a very high-risk category of patients (score ≥ 200).

We thank Dr. Rottenberg for his interesting commentary. We gree that age and agonal respirations are associated with aetiolgy. Since the foundation of bystander CPR is chest compressions, he goal is to identify the minority with non-cardiac aetiology who ay benefit from the additional component and more complex sychomotor task of rescue breathing. The challenge is whether his information provides enough discrimination to identify those ith a non-cardiac aetiology. We evaluated age, sex, and location ince we felt these are relatively easy to routinely identify. We ound that the combination of these characteristics or any single haracteristic (i.e. age strata) – while predictive – did not suffiiently distinguish non-cardiac etiology so as to be useful for clinical ractice. We did not have the presence or absence of agonal respirations vailable in the study data set. Although we agree agonal respiations may improve prediction, the reported relative difference etween the cardiac and non-cardiac was not profound, 46% for ardiac cause versus 32% for non-cardiac cause. Hence we believe t is unlikely that agonal respirations even in combination would mprove prediction in a manner that would adequately identify on-cardiac cause. Moreover, the recognition of agonal respiraions can be a challenge for the dispatcher and the layperson. hus inclusion of such a criteria could potentially impede the start f any CPR – namely chest compressions. The overarching goal s for laypersons to start chest compressions in all cardiac arrest ictims. We applaud Dr. Rottenberg’s thought process and agree that here may be strategies that can target type-specific CPR at the ayperson and even the professional rescuer level. Our challenge