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Background: Airway management is a core component of the treatment of cardiac arrest. Where a rescuer cannot establish a patent airway to provide oxygenation and ventilation using standard basic and advanced airway techniques, there may be a need to consider emergency front-of-neck airway access (eFONA, e.g., cricothyroidotomy), but there is limited evidence to inform this approach. Objectives: This scoping review aims to identify the evidence for the use of eFONA techniques in patients with cardiac arrest. Methods: In November 2023, we searched Medline, Embase, and Cochrane Central to identify studies on eFONA in adults. We included randomised controlled trials, non-randomised studies, and case series with at least five cases that described any use of eFONA. We extracted data, including study setting, population characteristics, intervention characteristics, and outcomes. Our analysis focused on four key areas: incidence of eFONA, eFONA success rates, clinical outcomes, and complications. Results: The search identified 21,565 papers, of which 18,934 remained after de-duplication. After screening, we included 69 studies (53 reported incidence, 40 reported success rate, 38 reported clinical outcomes; 36 studies reported complications). We identified only one randomised controlled trial. Across studies, there was a total of 4,457 eFONA attempts, with a median of 31 attempts (interquartile range 16–56.5) per study. There was marked heterogeneity across studies that precluded any pooling of data. There were no studies that included only patients in cardiac arrest. Conclusion: The available evidence for eFONA is extremely heterogeneous, with no studies specifically focusing on its use in adults with cardiac arrest.

Background: The impact of extreme heat on out-of-hospital cardiac arrest (OHCA) incidence and outcomes is under-studied. We investigated OHCA incidence and outcomes over increasing temperatures. Methods: We included non-traumatic EMS (Emergency Medical Services)-assessed OHCAs in British Columbia during the warm seasons of 2020–2021. We fit a time-series quasi-Poisson generalized linear model to estimate the association between temperature and incidence of both EMS-assessed, EMS-treated, and EMS-untreated OHCAs. Second, we employed a logistic regression model to estimate the association between “heatwave” periods (defined as a daily mean temperature > 99th percentile for ≥ 2 consecutive days, plus 3 lag days) with survival and favourable neurological outcomes (cerebral performance category ≤ 2) at hospital discharge. Results: Of 5478 EMS-assessed OHCAs, 2833 were EMS-treated. OHCA incidence increased with increasing temperatures, especially exceeding a daily mean temperature of 25 °C Compared to the median daily mean temperature (16.9 °C), the risk of EMS-assessed (relative risk [RR] 3.7; 95%CI 3.0–4.6), EMS-treated (RR 2.9; 95%CI 2.2–3.9), and EMS-untreated (RR 4.3; 95%CI 3.2–5.7) OHCA incidence were higher during days with a temperature over the 99th percentile. Of EMS-treated OHCAs, during the heatwave (n = 179) and non-heatwave (n = 2654) periods, 4 (2.2%) and 270 (10%) survived and 4 (2.2%) and 241 (9.2%) had favourable neurological outcomes, respectively. Heatwave period OHCAs had decreased odds of survival (adjusted OR 0.28; 95%CI 0.10–0.79) and favourable neurological outcome (adjusted OR 0.31; 95%CI 0.11–0.89) at hospital discharge, compared to other periods. Conclusion: Extreme heat was associated with a higher incidence of OHCA, and lower odds of survival and favourable neurological status at hospital discharge.

Abstract Sudden cardiac arrest (SCA) is a leading cause of mortality worldwide. The SCA-to-resuscitation interval is a key determinant of patient outcomes, highlighting the clinical need for reliable and timely detection of SCA. Near-infrared spectroscopy (NIRS), a non-invasive optical technique, may have utility for this application. We investigated transcutaneous NIRS as a method to detect pentobarbital-induced changes during cardiac arrest in eight Yucatan miniature pigs. NIRS measurements during cardiac arrest were compared to invasively acquired carotid blood pressure and partial oxygen pressure (PO2) of spinal cord tissues. We observed statistically significant decreases in mean arterial pressure (MAP) 64.68 mmHg ± 13.08, p 0.99) and following pentobarbital administration (p = 0.97). Transcutaneous NIRS demonstrated the potential to identify rapid hemodynamic changes due to cardiac arrest in periods similar to invasive indices. We conclude that transcutaneous NIRS monitoring may present a novel, non-invasive approach for SCA detection, which warrants further investigation.

Abstract Objective We investigated sex differences in 1‐year survival in a cohort of patients who survived out‐of‐hospital cardiac arrest (OHCA) to hospital discharge. We hypothesized that female sex is associated with higher 1‐year posthospital discharge survival. Methods A retrospective analysis of linked data (2011–2017) from clinical databases in British Columbia (BC) was conducted. We used Kaplan–Meier curves, stratified by sex, to display survival up to 1‐year, and the log‐rank test to test for significant sex differences. This was followed by multivariable Cox proportional hazards analysis to investigate the association between sex and 1‐year mortality. The multivariable analysis adjusted for variables known to be associated with survival, including variables related to OHCA characteristics, comorbidities, medical diagnoses, and in‐hospital interventions. Results We included 1278 hospital‐discharge survivors; 284 (22.2%) were female. Females had a lower proportion of OHCA occurring in public locations (25.7% vs. 44.0%, P

Background: Increasing the interval between the first and second SARS-CoV-2 vaccine doses enhances vaccine immunogenicity, however the optimal timing of the third vaccine is unknown. In this study, we investigated how the time interval between the first and second (V1–V2), or second and third (V2–V3) doses affects immunogenicity after three doses of the BNT162b2 (Comirnaty, Pfizer-BioNTech) vaccine. Methods: This is an observational cohort consisting of 360 participants enrolled in the COVID-19 Occupational Risks, Seroprevalence, and Immunity among Paramedics in Canada (CORSIP) study. Immune responses to BA.1 and other variants were measured from serum using an ACE2 competitive binding assay for surrogate SARS-CoV-2 neutralization. We fit a multiple linear regression model to estimate the independent association between both the V1–V2 and V2–V3 intervals and serum SARS-CoV-2 neutralization, while adjusting for age, sex, and the V3-to-blood collection interval. We examined vaccine dosing intervals as continuous variables and categorized them into quartiles. Results: The mean age was 40 years, 45% were female sex (at birth), and the median BA.1 surrogate neutralization was 61% (IQR 38–77%). The multivariate analysis indicated that longer V1–V2 (β = 0.1292, 95% CI: 0.04807–0.2104) and V2–V3 (β = 0.2653, 95% CI: 0.2291–0.3015) intervals were associated with increased surrogate neutralization of BA.1. These results were consistent when examining responses against Spike from other SARS-CoV-2 strains. When categorized into V2–V3 quartiles, the first (56–231 days), and second (231–266 days) quartiles demonstrated decreased BA.1 surrogate neutralization compared to the longest V2–V3 quartile (282–329 days). There was no significant difference in surrogate neutralization between the long (266–282 days) and longest (282–329 days) V2–V3 intervals. Conclusion: Longer intervals between first, second and third doses are independently associated with increased immunogenicity for all tested SARS-CoV-2 strains. Increasing the intervals between the second and third vaccine doses up to 8.9 months provided additive benefits increasing the immunogenicity of BNT162b2 vaccine schedules.

Summary: Background: Refractory out-of-hospital cardiac arrest (OHCA) treated with standard advanced cardiac life support (ACLS) has poor outcomes. Transport to hospital followed by in-hospital extracorporeal cardiopulmonary resuscitation (ECPR) initiation may improve outcomes. We performed a pooled individual patient data analysis of two randomised controlled trials evaluating ECPR based approach in OHCA. Methods: The individual patient data from two published randomised controlled trials (RCTs) were pooled: ARREST (enrolled Aug 2019–June 2020; NCT03880565) and PRAGUE-OHCA (enrolled March 1, 2013–Oct 25, 2020; NCT01511666). Both trials enrolled patients with refractory OHCA and compared: intra-arrest transport with in-hospital ECPR initiation (invasive approach) versus continued standard ACLS. The primary outcome was 180-day survival with favourable neurological outcome (defined as Cerebral Performance Category 1–2). Secondary outcomes included: cumulative survival at 180 days, 30-day favourable neurological survival, and 30-day cardiac recovery. Risk of bias in each trial was assessed by two independent reviewers using the Cochrane risk-of-bias tool. Heterogeneity was assessed via Forest plots. Findings: The two RCTs included 286 patients. Of those randomised to the invasive (n = 147) and standard (n = 139) groups, respectively: the median age was 57 (IQR 47–65) and 58 years (IQR 48–66), and the median duration of resuscitation was 58 (IQR 43–69) and 49 (IQR 33–71) minutes (p = 0.17). In a modified intention to treat analysis, 45 (32.4%) in the invasive and 29 (19.7%) patients in the standard arm survived to 180 days with a favourable neurological outcome [absolute difference (AD), 95% CI: 12.7%, 2.6–22.7%, p = 0.015]. Forty-seven (33.8%) and 33 (22.4%) patients survived to 180 days [HR 0.59 (0.43–0.81); log rank test p = 0.0009]. At 30 days, 44 (31.7%) and 24 (16.3%) patients had favourable neurological outcome (AD 15.4%, 5.6–25.1%, p = 0.003), 60 (43.2%), and 46 (31.3%) patients had cardiac recovery (AD: 11.9%, 0.7–23%, p = 0.05), in the invasive and standard arms, respectively. The effect was larger in patients presenting with shockable rhythms (AD 18.8%, 7.6–29.4; p = 0.01; HR 2.26 [1.23–4.15]; p = 0.009) and prolonged CPR (>45 min; HR 3.99 (1.54–10.35); p = 0.005). Interpretation: In patients with refractory OHCA, the invasive approach significantly improved 30- and 180-day neurologically favourable survival. Funding: None.

Background: Extracorporeal life support (ECLS) is associated with high morbidity and mortality. Complications and mortality are higher at lower-volume centres. Most Canadian ECLS institutions are low-volume centres. Protocols offer one way to share best practices among institutions to improve outcomes. Whether Canadian centres have ECLS protocols, and whether these protocols are comprehensive and homogenous across centres, is unknown. Methods: Purposeful sampling with mixed methods was used. A Delphi panel defined key elements relevant to the ECLS process. Documentation used in the delivery of ECLS services was requested from programs. Institutional protocols were assessed using deductive coding to determine the presence of key elements. Results: A total of 37 key elements spanning 5 domains (referral, initiation, maintenance, termination, and administration) were identified. Documentation from 13 institutions across 10 provinces was obtained. Institutions with heart or lung transplantation programs had more-complete documentation than did non-transplantation programs. Only 5 key elements were present in at least 50% of protocols (anticoagulation strategy, ventilation strategy, defined referral process, selection criteria, weaning process), and variation was seen in how institutions approached each of these elements. Conclusions: The completeness of ECLS protocols varies across Canada. Programs describe variable approaches to key elements. This variability might represent a lack of evidence or consensus in these areas and creates the opportunity for collaboration among institutions to share protocols and best practice. The key-element framework provides a common language that programs can use to develop ECLS programs, initiate quality-improvement projects, and identify research agendas. Résumé: Introduction: L’assistance cardiorespiratoire extracorporelle (ACRE) est associée à des taux élevés de morbidité et de mortalité. Les taux de complications et de mortalité sont plus élevés dans les centres à volume plus faible. La plupart des établissements qui offrent l’ACRE au Canada sont des centres à volume faible. Les protocoles constituent un moyen de partager des pratiques exemplaires entre les établissements afin d’améliorer les résultats. On ignore si les centres du Canada ont des protocoles d’ACRE, et si ces protocoles sont exhaustifs et homogènes dans tous les centres. Méthodes: Nous avons utilisé un échantillonnage dirigé par méthodes mixtes. Le panel Delphi a défini les éléments fondamentaux pertinents au processus d’ACRE. La documentation utilisée pour la prestation de services d’ACRE a été demandée aux programmes. Nous avons évalué les protocoles des établissements au moyen du processus inductif de codification pour déterminer la présence d’éléments fondamentaux. Résultats: Nous avons relevé un total de 37 éléments fondamentaux couvrant cinq domaines (aiguillage, amorce, maintien, cessation et administration). La documentation provenait de 13 établissements de 10 provinces. Les établissements qui ont des programmes de transplantation cardiaque ou pulmonaire avaient une documentation plus complète que les programmes sans transplantation. Seuls cinq éléments fondamentaux étaient présents dans au moins 50 % des protocoles (stratégie d’anticoagulation, stratégie de ventilation, processus défini d’aiguillage, critères de sélection, processus de sevrage), et une variation était observée dans la façon dont les établissements considéraient chacun de ces éléments. Conclusions: Au Canada, l’exhaustivité des protocoles d’ACRE varie. Les programmes décrivent la variabilité des approches des éléments fondamentaux. Cette variabilité qui pourrait représenter le manque de données probantes ou de consensus dans ces domaines ouvre la voie à la collaboration des établissements au partage des protocoles et des pratiques exemplaires. Le cadre des éléments fondamentaux contribue à offrir un langage commun que peuvent utiliser les programmes pour élaborer des programmes d’ACRE, amorcer des projets d’amélioration de la qualité et établir des programmes de recherche.

ABSTRACT SARS-CoV-2 anti-spike antibody concentrations and angiotensin converting enzyme-2 (ACE-2) inhibition have been used as surrogates to live viral neutralizing antibody titers; however, validity among vaccinated individuals is unclear. We tested the correlation of these measures among vaccinated participants, and examined subgroups based on duration since vaccination and vaccine dosing intervals. We analyzed 120 samples from two-dose mRNA vaccinees without previous COVID-19. We calculated Spearman correlation coefficients between wild-type viral neutralizing antibody titers and: anti-spike (total and IgG), anti-receptor-binding-domain (RBD), and anti-N-terminal-domain (NTD) antibodies; and ACE-2 binding by RBD. We performed three secondary analyses, dichotomizing samples by the first vaccination-to-blood collection interval, second vaccination-to-blood collection interval, and by the vaccine dosing interval (all groups divided by the median), and compared correlation coefficients (Fisher’s Z test). Of 120 participants, 63 (53%) were women, 91 (76%) and 29 (24%) received BNT162b2 and mRNA-1273 vaccines, respectively. Overall, live viral neutralization was correlated with anti-spike total antibody (correlation coefficient = 0.80), anti-spike IgG (0.63), anti-RBD IgG (0.62), anti-NTD IgG (0.64), and RBD ACE2 binding (0.65). Samples with long (>158 days) first vaccination-to-blood collection and long (>71 days) second vaccination-to-blood collection intervals demonstrated higher correlation coefficients, compared with short groups. When comparing cases divided by short (≤39 days) versus long vaccine dosing intervals, only correlation with RBD-ACE-2 binding inhibition was higher in the long group. Among COVID-negative mRNA vaccinees, anti-spike antibody and ACE-2 inhibition concentrations are correlated with live viral neutralizing antibody titers. Correlation was stronger among samples collected at later durations from vaccination. IMPORTANCE Live viral neutralizing antibody titers are an accepted measure of immunity; however, testing procedures are labor-intensive. COVID-19 antibody and angiotensin converting enzyme-2 (ACE-2) levels have been used as surrogates to live viral neutralizing antibody titers; however, validity among vaccinated individuals is unclear. Using samples from 120 two-dose mRNA vaccinees without previous COVID-19, we found that live viral neutralization was correlated with COVID-19 antibody and ACE2 binding levels. When grouping samples by the time interval between vaccination and sample blood collection, samples collected over 158 days after the first vaccine and over 71 days from the second vaccine demonstrated stronger correlation between live viral neutralization titers and both antibody and ACE2 levels, in comparison to those collected earlier.

Aim: Cardiac arrest (CA) is the cessation of circulation to vital organs that can only be reversed with rapid and appropriate interventions. Sensor technologies for early detection and activation of the emergency medical system could enable rapid response to CA and increase the probability of survival. We conducted a systematic review to summarize the literature surrounding the performance of sensor technologies in detecting OHCA. Methods: We searched the academic and grey literature using keywords related to cardiac arrest, sensor technologies, and recognition/detection. We included English articles published up until June 6, 2022, including investigations and patent filings that reported the sensitivity and specificity of sensor technologies to detect cardiac arrest on human or animal subjects. (Prospero# CRD42021267797). Results: We screened 1666 articles and included four publications examining sensor technologies. One tested the performance of a physical sensor on human participants in simulated CA, one tested performance on audio recordings of patients in cardiac arrest, and two utilized a hybrid design for testing including human participants and ECG databases. Three of the devices were wearable and one was an audio detection algorithm utilizing household smart technologies. Real-world testing was limited in all studies. Sensitivity and specificity for the sensors ranged from 97.2 to 100% and 90.3 to 99.9%, respectively. All included studies had a medium/high risk of bias, with 2/4 having a high risk of bias. Conclusions: Sensor technologies show promise for cardiac arrest detection. However, current evidence is sparse and of high risk of bias. Small sample sizes and databases with low external validity limit the generalizability of findings.

The SARS-CoV-2 belongs to the coronavirus family, which also includes common endemic coronaviruses (HCoVs). We hypothesized that immunity to HCoVs would be associated with stronger immunogenicity from SARS-CoV-2 vaccines. The study included samples from the COSRIP observational cohort study of adult paramedics in Canada. Participants provided blood samples, questionnaire data, and results of COVID-19 testing. Samples were tested for anti-spike IgG against SARS-CoV-2, HCoV-229E, HCoV-HKU1, HCoV-NL63, and HCoV-OC43 antigens. We first compared samples from vaccinated and unvaccinated participants, to determine which HCoV antibodies were affected by vaccination. We created scatter plots and performed correlation analysis to estimate the extent of the linear relationship between HCoVs and SARS-CoV-2 anti-spike antibodies. Further, using adjusted log-log multiple regression, we modeled the association between each strain of HCoV and SARS-CoV-2 antibodies. Of 1510 participants (mean age of 39 years), 94 (6.2%) had a history of COVID-19. There were significant differences between vaccinated and unvaccinated participant in anti-spike antibodies to HCoV-HKU1, and HCoV-OC43; however, levels for HCoV-229E and HCoV-NL63 were similar (suggesting that vaccination did not affect these baseline values). Among vaccinated individuals without prior COVID-19 infection, SARS-COV-2 anti-spike IgG demonstrated a weak positive relationship between both HCoV-229E (r = 0.11) and HCoV-NL63 (r = 0.12). From the adjusted log-log multiple regression model, higher HCoV-229E and HCoV-NL63 anti-spike IgG antibodies were associated with increased SARS-COV-2 anti-spike IgG antibodies. Vaccination appears to result in measurable increases in HCoV-HKU1, and HCoV-OC43 IgG levels. Anti-HCoV-229E and HCoV-NL63 antibodies were unaffected by vaccination, and higher levels were associated with significantly higher COVID-19 vaccine-induced SARS-COV-2 antibodies.

ABSTRACT While mRNA vaccines are highly efficacious against short-term COVID-19, long-term immunogenicity is less clear. We compared humoral immunogenicity between BNT162b2 and mRNA-1273 vaccines 6 months after the first vaccine dose, examining the wild-type strain and multiple Delta-variant lineages. Using samples from a prospective observational cohort study of adult paramedics, we included COVID-19-negative participants who received two BNT162b2 or mRNA-1273 vaccines, and provided a blood sample 170 to 190 days post first vaccine dose. We compared wild-type spike IgG concentrations using the Mann-Whitney U test. We also compared secondary outcomes of: receptor binding domain (RBD) wild-type antibody concentrations, and inhibition of angiotensin-converting enzyme 2 (ACE-2) binding to spike proteins from the wild-type strain and five Delta-variant lineages. We included 571 adults: 475 BNT162b2 (83%) and 96 mRNA-1273 (17%) vaccinees, with a mean age of 39 (SD = 10) and 43 (SD = 10) years, respectively. Spike IgG antibody concentrations were significantly higher (P

Background: Extracorporeal cardiopulmonary resuscitation (ECPR) is a therapeutic option for refractory cardiac arrest. We sought to perform an environmental scan to describe ECPR utilization in Canada and perceived barriers for application to out-of-hospital cardiac arrest (OHCA). Methods: This was a national cross-sectional study. We identified all cardiovascular surgery- and extracorporeal membrane oxygenation (ECMO)-capable hospitals in Canada and emergency medical services (EMS) agencies delivering patients to those centres. We requested the medical lead from each hospital’s ECMO service and each EMS agency to submit data regarding ECMO and ECPR utilization, as well as perceived barriers to ECPR provision for OHCA. Results: We identified and received survey data from 39 of 39 Canadian hospital institutions and 21 of 22 EMS agencies. Of hospitals, 38 (97%) perform ECMO and 27 (69%) perform ECPR (74% of which perform ≤5 cases per year). Of the 18 (46%) sites offering ECPR for OHCA, 8 apply a formal protocol for eligibility and initiation procedures. EMS agencies demonstrate heterogeneity with intra-arrest transport practices. The primary rationale for nontransport of refractory OHCA is that hospital-based care offers no additional therapies. Perceived barriers to the use of ECPR for OHCA were primarily related to limited evidence supporting its use, rather than resources required. Conclusion: Many Canadian cardiovascular surgery- or ECMO-equipped hospitals use ECPR; roughly half employ ECPR for OHCAs. Low case volumes and few formal protocols indicate that this is not a standardized therapy option in most centres. Increased application may be dependent on a stronger evidence base including data from randomized clinical trials currently underway. Résumé: Contexte: La réanimation cardiorespiratoire (RCR) extracorporelle est une option thérapeutique en cas d'arrêt cardiaque réfractaire. Nous avons voulu faire une analyse contextuelle de l'utilisation de la RCR extracorporelle au Canada et des obstacles perçus quant à son emploi dans les cas d'arrêt cardiaque en dehors de l'hôpital. Méthodologie: Il s’agissait d’une étude nationale transversale. Nous avons repéré tous les hôpitaux en mesure d'effectuer des chirurgies cardiovasculaires et d'offrir l'oxygénation extracorporelle au Canada et les fournisseurs de services médicaux d'urgence (SMU) transportant les patients vers ces centres. Nous avons demandé au chef médical du service d'oxygénation extracorporelle de chacun des hôpitaux et de chacun des fournisseurs de SMU de présenter leurs données concernant l'utilisation de l'oxygénation extracorporelle et de la RCR extracorporelle, ainsi que les obstacles perçus quant à l'emploi de la RCR extracorporelle dans les cas d'arrêt cardiaque en dehors de l'hôpital. Résultats: Nous avons obtenu les données de 39 des 39 établissements hospitaliers canadiens ciblés, et de 21 des 22 fournisseurs de SMU. Parmi les hôpitaux, 38 (97%) utilisent l'oxygénation extracorporelle et 27 (69 %), la RCR extracorporelle (74 % ayant eu recours à celle-ci dans ≤ 5 cas par année). Parmi les 18 (46 %) centres offrant la RCR extracorporelle en cas d'arrêt cardiaque en dehors de l'hôpital, 8 appliquaient un protocole officiel pour l'admissibilité et les procédures de mise en place. Les fournisseurs de SMU ont montré des pratiques hétérogènes concernant la réanimation en déplacement. La principale raison justifiant de ne pas transporter les patients présentant un arrêt cardiaque réfractaire en dehors de l'hôpital est que les soins en milieu hospitalier n'offrent pas de traitements additionnels. Les obstacles perçus quant à l'emploi de la RCR extracorporelle dans les cas d'arrêt cardiaque en dehors de l'hôpital étaient principalement liés au peu de données appuyant son utilisation, plutôt qu'aux ressources nécessaires. Conclusion: De nombreux hôpitaux canadiens équipés pour la chirurgie cardiovasculaire et l'oxygénation extracorporelle utilisent la RCR extracorporelle; environ la moitié d'entre eux utilisent la RCR extracorporelle en cas d'arrêt cardiaque en dehors de l'hôpital. Le faible nombre de cas et le peu de protocoles officiels indiquent qu'il ne s'agit pas d'une option de traitement standardisée dans la plupart des centres. Une utilisation plus fréquente pourrait nécessiter davantage de données probantes, y compris les résultats des études cliniques à répartition aléatoire qui sont en cours.

Background: Jurisdictions have reported COVID-19-related increases in the incidence and mortality of non-traumatic out-of-hospital cardiac arrest (OHCA). We hypothesized that changes in suicide incidence during the COVID-19 pandemic may have contributed to these changes. We investigated whether the COVID-19 pandemic was associated with changes in the: (1) incidence of suicide-related OHCA, and (2) characteristics and outcomes of such cases. Methods: We used the provincial British Columbia Cardiac Arrest Registry, including non-traumatic emergency medical system (EMS)-assessed OHCA, to compare suicide-related OHCA (defined as clear self-harm or a priori communication of intent) one-year prior to, and one year after, the start of the COVID-19 pandemic (March 15, 2020). We calculated differences in incidence (with 95% CI), overall and within subgroups of mechanism (hanging, suffocation, poisoning, or unclear mechanism), and in case characteristics and hospital-discharge favourable neurological outcomes (CPC 1–2). Results: Of 13,785 EMS-assessed OHCA, we included 274/6430 (4.3%) pre-pandemic and 221/7355 (3.0%) pandemic-period suicide-related cases. The median age was 43 years (IQR 30–57), 157 (32%) were female, and 7 (1.4%) survived with favourable neurological status. Suicide-related OHCA incidence decreased from 5.4 pre-pandemic to 4.3 per 100 000 person-years (-1.1, 95% CI −2.0 to −0.28). Hanging-related OHCA incidence also decreased. Patient characteristics and hospital discharge outcomes between periods were similar. Conclusion: Suicide-related OHCA incidence decreased with the COVID-19 pandemic and we did not detect changes in patient characteristics or outcomes, suggesting that suicide is not a contributor to increases in COVID-related OHCA incidence or mortality. Overall suicide-related OHCA outcomes in both time periods were poor.

ABSTRACT SARS-CoV-2 seroprevalence studies may be complicated by vaccination efforts. It is important to characterize the ability of serology methods to correctly distinguish prior infection from postvaccination seroreactivity. We report the performance of the Meso Scale Discovery (MSD) V-PLEX COVID-19 Coronavirus Panel 2 IgG assay. Using serum samples from a prospective cohort of paramedics, we calculated the performance of the V-PLEX nucleocapsid (“N”) assay to classify prior SARS-CoV-2 infections, defined as a (i) history of a positive SARS-CoV-2 PCR test or (ii) positive serology results using the Roche Elecsys total nucleocapsid anti-SARS-Cov-2 assay. We calculated sensitivity and specificity at the optimal threshold (defined by the highest Youden index). We compared subgroups based on vaccination status, and between models that excluded prior infections 3 to 12 months before sample collection. Of 1119 participants, 914 (81.7%) were vaccinated and 60 (5.4%) had evidence of a preceding SARS-CoV-2 infection. Overall and within vaccinated and unvaccinated subgroups, the optimal thresholds were 828 AU/mL, 827 AU/mL, and 1324 AU/mL; with sensitivities of 0.95 (95% CI: 0.94 to 0.96), 0.95 (0.94 to 0.96), 0.94 (0.92 to 0.96) and specificities of 0.88 (0.86 to 0.90), 0.87 (0.85 to 0.89), and 0.94 (0.89 to 0.98), respectively. N-assay specificity was significantly better in unvaccinated (versus vaccinated) individuals (P = 0.005). Overall optimal thresholds based on the AUC values were higher for samples from unvaccinated participants, especially when examining infections within the preceding 9 months (5855 versus 1704 AU/mL). Overall, V-PLEX nucleocapsid assay cutoff values were higher among unvaccinated individuals. Specificity was also significantly higher among unvaccinated individuals. Different thresholds were required to achieve optimal test performance, especially for detecting SARS-CoV-2 infections within the preceding 9 months. IMPORTANCE Among a cohort of adult paramedics in Canada, we investigated the performance of nucleocapsid (N) antibody detection (measured with a V-PLEX assay) to identify previous COVID-19 infections and compared differences among vaccinated and unvaccinated. Our data indicate that vaccinated and unvaccinated groups require different thresholds to achieve optimal test performance, especially for detecting COVID-19 within the preceding 9 months. Overall, specificity was significantly higher among unvaccinated, compared to vaccinated individuals.

Objective: There is currently no existing data examining the opinions of patients and families after treatment with extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA). We sought to interview family members and patients to learn from their experiences and satisfaction with treatment. Methods: We contacted family members and survivors for all cases treated with ECPR for refractory OHCA at St. Paul’s Hospital between January 2014 and July 2018. We performed semi-structured interviews with participants, specifically within the topics of: information sharing (including impressions of an ECPR informational pamphlet), prognostication, organ donation, and perceived value of ECPR. Due to low participant enrolment, we described all interviews in a narrative approach. Results: Within the study period, there were 23 OHCAs treated with ECPR; two survivors and three family members agreed to participate. Participants were satisfied with the treatment provided, including information sharing and prognostication. There were mixed opinions about the best method of information-sharing (verbal vs written), as well as the timing of organ donation conversations. All participants believed ECPR for OHCA to be of high value. Conclusion: Patient’s conveyed satisfaction with ECPR treatment, with mixed views on the best information sharing strategy. Further study is needed to define the optimal methods and timing for discussions of organ donation, especially for treatments of with a relatively low likelihood success.

Abstract Background The rapid control of patients presenting to the emergency department (ED) with psychomotor agitation and violent behavior is paramount for the safety of patients and ED staff. The use of intramuscular (IM) ketamine in the pre-hospital and ED settings has demonstrated promising preliminary results to provide rapid and safe behavioral control. A prospective, randomized controlled trial is required to measure the potential superiority of IM ketamine compared to current standard care (IM benzodiazepines plus antipsychotics). Methods This will be a parallel, prospective, randomized, controlled trial of 5 mg/kg IM ketamine compared to a combination of 5 mg IM midazolam and 5 mg IM haloperidol. The study will enroll approximately 184 patients, randomized equally to two study arms. There will be one study visit during which study medication will be administered and assessments will be completed. A follow-up safety visit will occur on day 3. The primary objective of this study is to compare IM ketamine to a combination of IM midazolam and haloperidol with regards to the time required for adequate behavioral control, in minutes, in patients presenting to the ED with psychomotor agitation and violent behavior, as measured by the Richmond Agitation-Sedation Scale (RASS). Discussion We present a novel study to determine whether ketamine is a rapid and safe option, compared to a combination of midazolam and haloperidol for the sedation of patients presenting to the ED with psychomotor agitation and violent behavior. To our knowledge, this study is the first randomized controlled trial to compare ketamine to current standard care for this indication. We have attempted to address numerous logistical issues with the design of this study including a waiver of consent, ensuring adequate blinding of outcome assessors, patient enrolment, and data monitoring. Trial registration Clinicaltrials.gov, NCT03375671. Registered on 18 December 2017.

Objectives: We evaluated the effect of sex and age on out-of-hospital cardiac arrest (OHCA) outcomes in a Canadian population. Methods: This study was a retrospective analysis of the British Columbia (BC) Cardiac Arrest Registry (2011–16). We included adult, non-traumatic, EMS-treated OHCA. We stratified the cohort into four groups by age and sex: younger females (18–47 years of age), younger males (18–47 years of age), older females, and older males (>53 years old). We used logistic regression to examine the effect of sex and interaction effect of sex and age on ROSC and survival to hospital discharge. Results: We included 8115 patients; 31.4% were females. Females had a lower proportion of OHCA in public locations, bystander witnessed arrests, and with initial shockable rhythms. Overall, females had greater adjusted odds of ROSC (OR 1.29, 95% CI 1.15–1.42, p < 0.001). The ROSC advantage was significant in females with non-shockable rhythms (OR 1.48, 95% CI 1.24–1.78, p < 0.001) and females of premenopausal age. However, there was no significant difference in survival to hospital discharge between females and males overall or by sex-age groups. Both younger females and younger males have higher odds of survival to hospital discharge compared to older females and males. Older females had the lowest survival rate among all other sex-age groups. Conclusions: Female sex was associated with ROSC but not survival to hospital discharge. In the post-arrest phase, females, specifically those in the older age group, had a higher death rate, demonstrating the need for sex- and age-specific research in pre-and-post-OHCA care.

Aim: The COVID-19 pandemic may influence the willingness of bystanders to engage in resuscitation for out-of-hospital cardiac arrest. We sought to determine if and how the pandemic has changed willingness to intervene, and the impact of personal protective equipment (PPE). Methods: We distributed a 12-item survey to the general public through social media channels from June 4 to 23, 2020. We used 100-point scales to inquire about participants’ willingness to perform interventions on “strangers or unfamiliar persons” and “family members or familiar persons”, and compared mean willingness during time periods prior to and during the COVID-19 pandemic using paired t-tests. Results: Survey participants (n = 1360) were from 26 countries; the median age was 38 years (IQR 24–50) and 45% were female. Compared to prior to the pandemic, there were significant decreases in willingness to check for breathing or a pulse (mean difference −10.7% [95%CI −11.8, −9.6] for stranger/unfamiliar persons, −1.2% [95%CI −1.6, −0.8] for family/familiar persons), perform chest compressions (−14.3% [95%CI −15.6, −13.0], −1.6% [95%CI −2.1, −1.1]), provide rescue breaths (−19.5% [95%CI −20.9, −18.1], −5.5% [95%CI −6.4, −4.6]), and apply an automated external defibrillator (−4.8% [95%CI −5.7, −4.0], −0.9% [95%CI −1.3, −0.5]) during the COVID-19 pandemic. Willingness to intervene increased significantly if PPE was available (+8.3% [95%CI 7.2, 9.5] for stranger/unfamiliar, and +1.4% [95%CI 0.8, 1.9] for family/familiar persons). Conclusion: Willingness to perform bystander resuscitation during the pandemic decreased, however this was ameliorated if simple PPE were available.

Background Targeted temperature management (TTM) is a recommended treatment modality to improve neurological outcomes in patients with out‐of‐hospital cardiac arrest. The impact of the duration from hospital admission to TTM initiation (door‐to‐TTM; DTT) on clinical outcomes has not been well elucidated. We hypothesized that shorter DTT initiation intervals would be associated with improved survival with favorable neurological outcome. Methods and Results We performed a post hoc analysis of nontraumatic paramedic‐treated out‐of‐hospital cardiac arrests. The primary outcome was favorable neurological status at hospital discharge, with a secondary outcome of survival to discharge. We fit a logistic regression analysis to determine the association of early compared with delayed DTT, dichotomized by the median DTT duration, and outcomes. Of 3805 patients enrolled in the CCC (Continuous Chest Compressions) Trial in British Columbia, 570 were included in this analysis. There was substantial variation in DTT among patients receiving TTM. The median DTT duration was 122 minutes (interquartile range 35‐218). Favorable neurological outcomes in the early and delayed DTT groups were 48% and 38%, respectively. Compared with delayed DTT (interquartile range 167‐319 minutes), early DTT (interquartile range 20‐81 minutes) was associated with survival (adjusted odds ratio 1.56, 95% CI 1.02‐2.38) but not with favorable neurological outcomes (adjusted odds ratio 1.45, 95% CI, 0.94‐2.22) at hospital discharge. Conclusions There was wide variability in the initiation of TTM among comatose out‐of‐hospital cardiac arrest survivors. Initiation of TTM within 122 minutes of hospital admission was associated with improved survival. These results support in‐hospital efforts to achieve early DTT among out‐of‐hospital cardiac arrest patients admitted to the hospital.

Background: Acute kidney injury (AKI) is associated with increased mortality and dialysis in hospitalized patients but has been little explored in the emergency department (ED) setting. Objective: The objective of this study was to describe the risk factors, prevalence, management, and outcomes in the ED population, and to identify the proportion of AKI patients who were discharged home with no renal-specific follow-up. Design: This is a retrospective cohort study using administrative and laboratory databases. Setting: Two urban EDs in Vancouver, British Columbia, Canada. Patients: We included all unique ED patients over a 1-week period. Methods: All patients had their described demographics, comorbidities, medications, laboratory values, and ED treatments collected. AKI was defined pragmatically, based upon accepted guidelines. The cohort was then probabilistically linked to the provincial renal database to ascertain renal replacement (transplant or dialysis) and the provincial vital statistics database to obtain mortality. The primary outcome was the prevalence of AKI; secondary outcomes included (1) the proportion of AKI patients who were discharged home with no renal-specific follow-up and (2) the combined 30-day rate of death or renal replacement among AKI patients. Results: There were 1651 ED unique patients, and 840 had at least one serum creatinine (SCr) obtained. Overall, 90 patients had AKI (10.7% of ED patients with at least one SCr, 95% confidence interval [CI], 8.7%-13.1%; 5.5% of all ED patients, 95% CI, 4.4%-6.7%) with a median age of 74 and 70% male. Of the 31 (34.4%) AKI patients discharged home, 4 (12.9%) had renal-specific follow-up arranged in the ED. Among the 90 AKI patients, 11 died and none required renal replacement at 30 days, for a combined outcome of 12.2% (95% CI, 6.5%-21.2%). Limitations: Sample sizes may be small. Nearly half of ED patients did not obtain an SCr. Many patients did not have sequential SCr testing, and a modified definition of AKI was used.

Increased emergency medical services (EMS) response times and areas of low socioeconomic status are both associated with poorer outcomes for several time-sensitive medical conditions attended to by medical personnel before a patient is hospitalized. We evaluated the association between EMS response times, area deprivation level, and on-scene access constraints encountered by EMS in a large urban area in France. We conducted a multicenter prospective cohort study of EMS dispatches occurring in the forty-seven cities in a region southeast of Paris. We fit multilevel mixed-effects linear regression models for multivariate assessment of the predictors of EMS response times and then used multivariate logistic regression on outcomes among a subgroup of patients presenting with out-of-hospital cardiac arrest. We found evidence that access constraints were more frequently encountered by EMS in the most deprived areas compared to less deprived ones, and were associated with increased EMS response times until patient contact and with poorer outcomes from cardiac arrest. Strategies to anticipate and overcome access constraints should be implemented to improve outcomes for emergent conditions attended to by prehospital medical teams.