Search

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 Sex‐specific risk management may improve outcomes in congenital long QT syndrome (LQTS). We recently developed a prediction score for cardiac events (CEs) and life‐threatening events (LTEs) in postadolescent women with LQTS. In the present study, we aimed to develop personalized risk estimates for the burden of CEs and LTEs in male adolescents with potassium channel‐mediated LQTS. Methods and Results The prognostic model was derived from the LQTS Registry headquartered in Rochester, NY, comprising 611 LQT1 or LQT2 male adolescents from age 10 through 20 years, using the following variables: genotype/mutation location, QTc‐specific thresholds, history of syncope, and β‐blocker therapy. Anderson‐Gill modeling was performed for the end point of CE burden (total number of syncope, aborted cardiac arrest, and appropriate defibrillator shocks). The applicability of the CE prediction model was tested for the end point of the first LTE (excluding syncope and adding sudden cardiac death) using Cox modeling. A total of 270 CEs occurred during follow‐up. The genotype–phenotype risk prediction model identified low‐, intermediate‐, and high‐risk groups, comprising 74%, 14%, and 12% of the study population, respectively. Compared with the low‐risk group, high‐risk male subjects experienced a pronounced 5.2‐fold increased risk of recurrent CEs (P

Background Telecommunicator CPR (T‐CPR), whereby emergency dispatch facilitates cardiac arrest recognition and coaches CPR over the telephone, is an important strategy to increase early recognition and bystander CPR in adult out‐of‐hospital cardiac arrest (OHCA). Little is known about this treatment strategy in the pediatric population. We investigated the role of T‐CPR and related performance among pediatric OHCA. Methods and Results This study was a retrospective cohort investigation of OHCA among individuals 8), the older age group was less likely to receive CPR before emergency medical services arrival (88% versus 69%, P=0.002). For those receiving T‐CPR, bystanders spent a median of 207 seconds (133–270) performing CPR. The median compression rate was 93 per minute (82–107) among those receiving T‐CPR. Conclusions T‐CPR is an important strategy to increase early recognition and early CPR among pediatric OHCA.

Abstract Background Congenital Long QT Syndrome (LQTS) is a hereditary arrhythmic disorder. We aimed to assess the performance of current genetic variant annotation scores among LQTS patients and their predictive impact. Methods We evaluated 2025 patients with unique mutations for LQT1–LQT3. A patient‐specific score was calculated for each of four established genetic variant annotation algorithms: CADD, SIFT, REVEL, and PolyPhen‐2. The scores were tested for the identification of LQTS and their predictive performance for cardiac events (CE) and life‐threatening events (LTE) and then compared with the predictive performance of LQTS categorization based on mutation location/function. Score performance was tested using Harrell's C‐index. Results A total of 917 subjects were classified as LQT1, 838 as LQT2, and 270 as LQT3. The identification of a pathogenic variant occurred in 99% with CADD, 92% with SIFT, 100% with REVEL, and 86% with PolyPhen‐2. However, none of the genetic scores correlated with the risk of CE (Harrell's C‐index: CADD = 0.50, SIFT = 0.51, REVEL = 0.50, and PolyPhen‐2 = 0.52) or LTE (Harrell's C‐index: CADD = 0.50, SIFT = 0.53, REVEL = 0.54, and PolyPhen‐2 = 0.52). In contrast, high‐risk mutation categorization based on location/function was a powerful independent predictor of CE (HR = 1.88; p

We investigated the risk of coronavirus disease (COVID-19)­ patients transmitting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to emergency medical service (EMS) providers, stratified by aerosol-generating procedures (AGP), in King County, Washington, USA, during February 16–July 31, 2020. We conducted a retrospective cohort investigation using a statewide COVID-19 registry and identified 1,115 encounters, 182 with ≥1 AGP. Overall, COVID-19 incidence among EMS personnel was 0.57 infections/10,000 person-days. Incidence per 10,000 person-days did not differ whether or not infection was attributed to a COVID-19 patient encounter (0.28 vs. 0.59; p>0.05). The 1 case attributed to a COVID-19 patient encounter occurred within an at-risk period and involved an AGP. We observed a very low risk for COVID-19 infection attributable to patient encounters among EMS first responders, supporting clinical strategies that maintain established practices for treating patients in emergency conditions.

Background Patients resuscitated from out‐of‐hospital circulatory arrest (OHCA) frequently have cardiopulmonary resuscitation injuries identifiable by computed tomography, although the prevalence, types of injury, and effects on clinical outcomes are poorly characterized. Methods and Results We assessed the prevalence of resuscitation‐associated injuries in a prospective, observational study of a head‐to‐pelvis sudden‐death computed tomography scan within 6 hours of successful OHCA resuscitation. Primary outcomes included total injuries and time‐critical injuries (such as organ laceration). Exploratory outcomes were injury associations with mechanical cardiopulmonary resuscitation and survival to discharge. Among 104 patients with OHCA (age 56±15 years, 30% women), 58% had bystander cardiopulmonary resuscitation, and total cardiopulmonary resuscitation time was 15±11 minutes. The prevalence of resuscitation‐associated injury was high (81%), including 15 patients (14%) with time‐critical findings. Patients with resuscitation injury were older (58±15 versus 46±13 years; P

Current resuscitation protocols require pausing chest compressions during cardiopulmonary resuscitation (CPR) to check for a pulse. However, pausing CPR when a patient is pulseless can worsen patient outcomes. Our objective was to design and evaluate an ECG-based algorithm that predicts pulse presence with or without CPR. We evaluated 383 patients being treated for out-of-hospital cardiac arrest with real-time ECG, impedance and audio recordings. Paired ECG segments having an organized rhythm immediately preceding a pulse check (during CPR) and during the pulse check (without CPR) were extracted. Patients were randomly divided into 60% training and 40% test groups. From training data, we developed an algorithm to predict the clinical pulse presence based on the wavelet transform of the bandpass-filtered ECG. Principal component analysis was used to reduce dimensionality, and we then trained a linear discriminant model using three principal component modes as input features. Overall, 38% (351/912) of checks had a spontaneous pulse. AUCs for predicting pulse presence with and without CPR on test data were 0.84 (95% CI (0.80, 0.88)) and 0.89 (95% CI (0.86, 0.92)), respectively. This ECG-based algorithm demonstrates potential to improve resuscitation by predicting the presence of a spontaneous pulse without pausing CPR with moderate accuracy.

Background Air travel affords an opportunity to evaluate resuscitation performance and outcome in a setting where automated external defibrillators (AEDs) are readily available. Methods and Results The study cohort included people aged ≥18 years with out of hospital cardiac arrest (OHCA) traveling through Seattle‐Tacoma International Airport between January 1, 2004 and December 31, 2019 treated by emergency medical services (EMS). The primary outcomes were pre‐EMS therapies (cardiopulmonary resuscitation, application of AED), return of spontaneous circulation, and survival to hospital discharge. Over the 16‐year study period, there were 143 OHCA occurring before EMS arrival, 34 (24%) on‐plane and 109 (76%) off‐plane. Cardiac etiology (81%) was the most common mechanism of arrest. The majority of arrests were bystander‐witnessed and presented with a shockable rhythm; these characteristics were more common in off‐plane OHCA compared with on‐plane (witnessed: 89% versus 74% and shockable: 72% versus 50%). Pre‐EMS therapies including cardiopulmonary resuscitation and AED application were common regardless of arrest location. Compared with on‐plane OHCA, off‐plane OHCA was associated with greater rates of return of spontaneous circulation (68% versus 44%) and 3‐fold higher rate of survival to hospital discharge (44% versus 15%). All survivors of on‐plane OHCA had AED application with defibrillation before EMS arrival. Conclusions When applied to air travel volumes, we estimate 350 air travel‐associated OHCA occur in the United States and 2000 OHCA worldwide each year, nearly a quarter of which happen on‐plane. These events are survivable when early arrest interventions including rapid arrest recognition, AED application, and CPR are deployed.

Brain and heart injury cause most out-of-hospital cardiac arrest deaths but limited pharmacotherapy exists to protect these tissues. Nitrite is a nitric oxide precursor that is protective in pre-clinical models of ischemic injury and safe in Phase I testing. Protection may occur by cGMP generation via the sGC pathway or through S-nitrosothiol and nitrated conjugated linoleic acid (NO2-CLA) formation. We hypothesized that nitrite provided during CPR signals through multiple pathways and that activation of signals is associated with OHCA outcome. To this end, we performed a secondary analysis of a phase 1 study of intravenous nitrite administration during resuscitation in adult out-of-hospital cardiac arrest. Associations between whole blood nitrite and derived plasma signals (cGMP and NO2-CLA) with patient characteristics and outcomes were defined using Chi-square or t-tests and multiple logistic regression. Whole blood nitrite levels correlated inversely with plasma NO2-CLA (p = 0.039) but not with cGMP. Patients with shockable rhythms had higher cGMP (p = 0.027), NO2-CLA (p

BackgroundBystander cardiopulmonary resuscitation (CPR) is associated with increased survival from cardiac arrest, yet bystander CPR rates are low in many communities. The overall prevalence of CPR training in the United States and associated individual‐level disparities are unknown. We sought to measure the national prevalence of CPR training and hypothesized that older age and lower socioeconomic status would be independently associated with a lower likelihood of CPR training. Methods and ResultsWe administered a cross‐sectional telephone survey to a nationally representative adult sample. We assessed the demographics of individuals trained in CPR within 2 years (currently trained) and those who had been trained in CPR at some point in time (ever trained). The association of CPR training and demographic variables were tested using survey weighted logistic regression. Between September 2015 and November 2015, 9022 individuals completed the survey; 18% reported being currently trained in CPR, and 65% reported training at some point previously. For each year of increased age, the likelihood of being currently CPR trained or ever trained decreased (currently trained: odds ratio, 0.98; 95% CI, 0.97–0.99; P