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The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest. [ABSTRACT FROM AUTHOR]

Background: Time to initial treatment is important in any response to out-of-hospital cardiac arrest (OHCA). The purpose of this paper was to quantify the time delay for providing initial EMS treatments supplemented by comparison with those of other EMS systems conducting clinical trials.Methods: Data were collected between 1/1/16-2/15/19. Dispatched, EMS-worked, adult OHCA cases occurring before EMS arrival were included and compared with published treatment time data. Response time and time-to-treatment intervals were profiled in both groups. Time intervals were calculated by subtracting the following timepoints from 9-1-1 call receipt: ambulance in route; at curb; patient contact; first defibrillation; first epinephrine; and first antiarrhythmic.Results: 342 subjects met study inclusion/exclusion. Mean time intervals (min [95%CI]) from 9-1-1 call receipt to the following EMS endpoints were: dispatch 0.1 [0.05-0.2]; at curb 5.0 [4.5, 5.5]; at patient 6.7 [6.1, 7.2];, first defibrillation initially shockable 11.7 [10.1, 13.3]; first epinephrine (initially shockable 15.0 [12.8, 17.2], initially non-shockable 14.8 [13.5, 15.9]), first antiarrhythmic 25.1 [22.0, 28.2]. These findings were similar to data in 5 published clinical trials involving 12,954 subjects.Conclusions: Delay to EMS treatments are common and may affect clinical outcomes. Neither Utstein out-of-hospital guidelines [1] nor U.S. Cardiac Arrest Registry to Enhance Survival (CARES) databases require capture of these elements. EMS is often not providing treatments quickly enough to optimize clinical outcomes. Further regulatory change/research are needed to determine whether OHCA outcome can be improved by novel changes such as enhancing bystander effectiveness through drone-delivered drugs/devices & real-time dispatcher direction on their use. [ABSTRACT FROM AUTHOR]

Background: Currently, ≤5% of bystanders witnessing an opioid overdose (OD) in the US administer antidote to the victim. A possible model to mitigate this crisis would be a system that enables 9-1-1 dispatchers to both rapidly deliver naloxone by drone to bystanders at a suspected opioid OD and direct them to administer it while awaiting EMS arrival.Methods: A simulated 9-1-1 dispatcher directed thirty subjects via 2-way radio to retrieve naloxone nasal spray from atop a drone located outside the simulation building and then administer it using scripted instructions. The primary outcome measure was time from first contact with the dispatcher to administration of the medication.Results: All subjects administered the medication successfully. The mean time interval from 9 -1-1 contact until antidote administration was 122 [95%CI 109-134] sec. There was a significant reduction in time interval if subjects had prior medical training (p = 0.045) or had prior experience with use of a nasal spray device (p = 0.030). Five subjects had difficulty using the nasal spray and four subjects had minor physical impairments, but these barriers did not result in a significant difference in time to administration (p = 0.467, p = 0.30). A significant number of subjects (29/30 [97%], p = 0.044) indicated that they felt confident they could administer intranasal naloxone to an opioid OD victim after participating in the simulation.Conclusions: Our results suggest that bystanders can carry out 9-1-1 dispatcher instructions to fetch drone-delivered naloxone and potentially decrease the time interval to intranasal administration which supports further development and testing of a such a system. [ABSTRACT FROM AUTHOR]

Cardiac arrest in patients on mechanical support is a new phenomenon brought about by the increased use of this therapy in patients with end-stage heart failure. This American Heart Association scientific statement highlights the recognition and treatment of cardiovascular collapse or cardiopulmonary arrest in an adult or pediatric patient who has a ventricular assist device or total artificial heart. Specific, expert consensus recommendations are provided for the role of external chest compressions in such patients. [ABSTRACT FROM AUTHOR]

Aim: The post-cardiac arrest syndrome is a complex set of pathophysiological processes including a systemic inflammatory response. The goal of the current investigation was to test the hypothesis that early inflammatory markers are independently associated with in-hospital mortality and poor neurological outcome in patients initially resuscitated from out-of-hospital cardiac arrest.Methods: This was a preplanned analysis of data collected from a prospective observational multicenter study in adult out-of-hospital cardiac arrest patients. Blood was drawn at baseline, 12 and 24h after return of spontaneous circulation and plasma levels of interleukin (IL)-1β, IL-1 receptor antagonist (IL-1Ra), IL-6, IL-8, IL-10 and tumor necrosis factor (TNF)-α were measured. The primary outcome measure was survival to hospital discharge. We utilized a mixed linear model to compare the levels of cytokines in survivors and non-survivors over time. We used multivariable logistic regression to assess the association between IL-6 levels and mortality.Results: A total of 102 patients were analyzed. Non-survivors and patients with poor functional outcome had statistical significant higher IL-1Ra, IL-6, IL-8, and IL-10 levels (all p<0.001) at all time points (0, 12 and 24h) compared to survivors. Baseline IL-6 levels were a good predictor of mortality (AUC=0.83 [95%CI: 0.75-0.92]). Baseline IL-6 levels were strongly associated with mortality in multivariable analysis (OR: 2.58 [95%CI: 1.93-3.45], p<0.001) but were not associated with neurological outcome in multivariable analysis (OR: 1.33 [95%CI: 0.62-2.86], p=0.47).Conclusion: Early inflammatory markers, especially IL-6, are higher in patients with a poor outcome after OHCA. IL-6 remained associated with mortality, but not functional outcome, in multivariable analysis adjusting for patient and event characteristics. [ABSTRACT FROM AUTHOR]

Background: Although rapid response teams have been widely promoted as a strategy to reduce unexpected hospital deaths, most studies of rapid response teams have not adjusted for secular trends in mortality before their implementation. We examined whether implementation of a rapid response team was associated with a reduction in hospital mortality after accounting for preimplementation mortality trends.Methods: Among 56 hospitals in Get With The Guidelines-Resuscitation linked to Medicare, we calculated the annual rates of case mix-adjusted mortality for each hospital during 2000 to 2014. We constructed a hierarchical log-binomial regression model of mortality over time (calendar-year), incorporating terms to capture the effect of rapid response teams, to determine whether implementation of rapid response teams was associated with reduction in hospital mortality that was larger than expected based on preimplementation trends, while adjusting for hospital case mix index.Results: The median annual number of Medicare admissions was 5214 (range, 408-18 398). The median duration of preimplementation and postimplementation period was 7.6 years (≈2.5 million admissions) and 7.2 years (≈2.6 million admissions), respectively. Hospital mortality was decreasing by 2.7% annually during the preimplementation period. Implementation of rapid response teams was not associated with a change in mortality during the initial year (relative risk for model intercept, 0.98 [95% CI, 0.94-1.02]; P=0.30) or in the mortality trend (relative risk for model slope, 1.01 per year [95% CI, 0.99-1.02]; P=0.30). Among individual hospitals, implementation of a rapid response team was associated with a lower-than-expected mortality at only 4 (7.1%) and higher-than-expected mortality at 2 (3.7%) hospitals.Conclusions: Among a large and diverse sample of US hospitals, we did not find implementation of rapid response teams to be associated with reduction in hospital mortality. Studies are needed to understand best practices for rapid response team implementation, to ensure that hospital investment in these teams improves patient outcomes. [ABSTRACT FROM AUTHOR]

The article discusses a scientific statement from the American Heart Association on the impact of percutaneous coronary intervention performance reporting on cardiac resuscitation centers. The policy statement that was issued in 2013 recommends a comprehensive, regionalized approach to postresuscitation care. Two levels of cardiac resuscitation centers (CRCs) are also defined by the policy statement.

Abstract: Background: An estimated 350,000–750,000 adult, in-hospital cardiac arrest (IHCA) events occur annually in the United States. The impact of resuscitation system errors on survival during IHCA resuscitation has not been evaluated. The purpose of this paper was to evaluate the impact of resuscitation system errors on survival to hospital discharge after IHCA. Methods and results: We evaluated subjective and objective errors in 118,387 consecutive, adult, index IHCA cases entered into the Get with the Guidelines National Registry of Cardiopulmonary Resuscitation database from January 1, 2000 through August 26, 2008. Cox regression analysis was used to determine the relationship between reported resuscitation system errors and other important clinical variables and the hazard ratio for death prior to hospital discharge. Of the 108,636 patients whose initial IHCA rhythm was recorded, resuscitation system errors were committed in 9,894/24,467 (40.4%) of those with an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) and in 22,599/84,169 (26.8%) of those with non-VF/pVT. The most frequent system errors related to delay in medication administration (>5min time from event recognition to first dose of a vasoconstrictor), defibrillation, airway management, and chest compression performance errors. The presence of documented resuscitation system errors on an IHCA event was associated with decreased rates of return of spontaneous circulation, survival to 24h, and survival to hospital discharge. The relative risk of death prior to hospital discharge based on hazard ratio analysis was 9.9% (95% CI 7.8, 12.0) more likely for patients whose initial documented rhythm was non-VF/pVT when resuscitation system errors were reported compared to when no errors were reported. It was 34.2% (95% CI 29.5, 39.1) more likely for those with VF/pVT. Conclusions: The presence of resuscitation system errors that are evident from review of the resuscitation record is associated with decreased survival from IHCA in adults. Hospitals should target the training of first responders and code team personnel to emphasize the importance of early defibrillation, early use of vasoconstrictor medication, and compliance with ACLS protocols. [Copyright &y& Elsevier]

The article focuses on a study which evaluated the association between automated external defibrillators (AEDs) use and survival for in-hospital cardiac arrest. The researchers examined 11,695 hospitalized patients who experienced cardiac arrests between January 1, 2000 to August 26, 2008 at U.S. hospitals following the introduction of AEDs on general and hospital wards. Study results indicated that hospitalized patients with cardiac arrest and use of AED were not associated with improved survival.

Abstract: Context: Hypothermia improves neurological outcome for comatose survivors of out-of-hospital cardiac arrest. Use of computer controlled high surface area devices for cooling may lead to faster cooling rates and potentially improve patient outcome. Objective: To compare the effectiveness of surface cooling with the standard blankets and ice packs to the Arctic Sun, a mechanical device used for temperature management. Design, setting, and patients: Multi-center randomized trial of hemodynamically stable comatose survivors of out-of-hospital cardiac arrest. Intervention: Standard post-resuscitative care inducing hypothermia using cooling blankets and ice (n =30) or the Arctic Sun (n =34). Main outcome measures: The primary end point was the proportion of subjects who reached a target temperature within 4h of beginning cooling. The secondary end points were time interval to achieve target temperature (34°C) and survival to 3 months. Results: The proportion of subjects cooled below the 34°C target at 4h was 71% for the Arctic Sun group and 50% for the standard cooling group (p =0.12). The median time to target was 54min faster for cooled patients in the Arctic Sun group than the standard cooling group (p <0.01). Survival rates with good neurological outcome were similar; 46% of Arctic Sun patients and 38% of standard patients had a cerebral performance category of 1 or 2 at 30 days (p =0.6). Conclusions: While the proportion of subjects reaching target temperature within 4h was not significantly different, the Arctic Sun cooled patients to a temperature of 34°C more rapidly than standard cooling blankets. Trial registration: ClinicalTrials.gov NCT00282373, registered January 24, 2006. [Copyright &y& Elsevier]

Abstract: Background: Patients with heart failure (HF) have abnormal cellular anatomy and myocardial mechanics that may impact the initial rhythm and subsequent outcomes in cardiac arrest (CA). Hypothesis: Patients with pre-existing HF are less likely to have ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) as the first documented rhythm in CA and have poorer survival than patients without pre-existing HF. Purpose: Identify the first documented cardiac arrest rhythm (FDR) in hospitalized patients with and without a pre-existing history of HF. Methods: We evaluated 60,389 consecutive, adult, index, pulseless CA events with documented initial rhythm in the National Registry of Cardiopulmonary Resuscitation. The primary endpoint was the FDR in patients with and without a history of pre-existing HF. Secondary endpoints were return of spontaneous circulation (ROSC), survival to discharge, and neurological outcome. Results: Thirty three percent of patients had a pre-existing diagnosis of HF. HF patients were more likely to have VF/pVT (25.9 vs. 23.2%) and less likely to have asystole (34.4 vs. 35.3%, p =<.0001) than non-HF. There was no difference in survival to discharge (18.3 vs. 18.2%, p =.66), or good neurological outcomes (82.2 vs. 83.2%, p =.23) between the groups. Women were less likely to have VF/pVT as the first documented rhythm in both HF and non-HF groups. Conclusions: Hospitalized patients with HF are more likely than those without HF to have VF/pVT as the FDR in CA, however the clinical magnitude of this difference is small. Overall survival and neurological outcomes are no different than hospitalized arrest patients without HF. [Copyright &y& Elsevier]

This study tested the hypothesis that increasing levels of maximal dyspnea on exertion (DOE) during cardiopulmonary exercise testing (CPX) is associated with heart failure (HF) disease severity and worsening prognosis. Three hundred seventy-six HF patients underwent CPX where ventilatory efficiency (minute ventilation/carbon dioxide production; VE/VCO2 slope), peak oxygen consumption (VO2), and maximal DOE were determined. A subgroup of 243 patients underwent echocardiography with tissue Doppler imaging to measure the ratio between mitral early (E) to mitral annular (E′) velocity as well as other variables. Maximal DOE was significantly correlated with E/E′ (rs=.49; P<.001). In the multivariate Cox regression, the VE/VCO2 slope was the strongest prognostic marker obtained from CPX (Multivariate chi-square, 48.0; P<.001) while maximal DOE (residual chi-square, 17.4; P<.001) and peak VO2 (residual chi-square, 7.5; P=.006) added predictive value. These results suggest that increasing DOE reflects the degree of disease severity and adds prognostic value to established CPX variables. [ABSTRACT FROM AUTHOR]

Abstract: Background: Quality of chest compressions (CC) is an important determinant of resuscitation outcome for cardiac arrest patients. Purpose: To characterize the quality of CC performed by hospital personnel, evaluate for predictors of CC performance, and determine the effects of audiovisual feedback on CC performance. Methods: Seven hundred and fifty four individuals participated in a CPR quality improvement challenge at 30 US hospitals. Participants performed 2min of CC on a manikin with an accelerometer-based system for measuring both rate (CC/min) and depth (in.) of CC (AED Plus:ZOLL Medical). Real-time audiovisual feedback was disabled. A subset of participants performed a second trial of CC with the audiovisual feedback prompts activated. Results: Mean depth of CC was below AHA minimum guidelines (<1.5in.) for 34% (1.30±0.14in.) and above maximum guidelines (>2.0in.) for 12% of participants (2.20±0.22in.). Depth of CC was greater for male vs. female (p <0.001) and younger vs. older (p =0.009) but did not differ between ACLS, BCLS, and non-certified participants (p =0.6). Predictors of CC depth included CC rate (r part =−0.34, p <0.0001), gender (r part =0.13, p =0.001), and age (r part =−0.09, p =0.02). Mean depth of CC increased, mean rate decreased, and variance in CC depth and rate declined when feedback was used (p ≤0.0001 vs. without feedback). The percentage of CC performed within AHA guidelines (1.5–2in.) improved from 15 to 78% with feedback. Conclusions: The quality of CC performed by personnel at US hospitals as judged by their performance on a manikin is often suboptimal. Quality of CC can be improved with use of CPR feedback technologies. [Copyright &y& Elsevier]

The article focuses on research which examined whether outcomes after in-hospital cardiac arrest differ during nights and weekends compared with days, evenings and weekdays. The research examined rates of survival and involved 58,593 cases of cardiac arrest during day time and 28,155 cases during night hours. Researchers found that survival rates from in-hospital cardiac arrest are lower during nights and weekends, even when adjusted for potentially confounding patient, event and hospital characteristics.

Summary: The adverse event (AE) profile of lay volunteer CPR and public access defibrillation (PAD) programs is unknown. We undertook to investigate the frequency, severity, and type of AE''s occurring in widespread PAD implementation. Design: A randomized-controlled clinical trial. Setting: One thousand two hundred and sixty public and residential facilities in the US and Canada. Participants: On-site, volunteer, lay personnel trained in CPR only compared to CPR plus automated external defibrillators (AEDs). Intervention: Persons experiencing possible cardiac arrest receiving lay volunteer first response with CPR+AED compared with CPR alone. Main outcome measure: An AE is defined as an event of significance that caused, or had the potential to cause, harm to a patient or volunteer, or a criminal act. AE data were collected prospectively. Results: Twenty thousand three hundred and ninety six lay volunteers were trained in either CPR or CPR+AED. One thousand seven hundred and sixteen AEDs were placed in units randomized to the AED arm. There were 26,389 exposure months. Only 36 AE''s were reported. There were two patient-related AEs: both patients experienced rib fractures. There were seven volunteer-related AE''s: one had a muscle pull, four experienced significant emotional distress and two reported pressure by their employee to participate. There were 27 AED-related AEs: 17 episodes of theft involving 20 devices, three involved AEDs that were placed in locations inaccessible to the volunteer, four AEDs had mechanical problems not affecting patient safety, and three devices were improperly maintained by the facility. There were no inappropriate shocks and no failures to shock when indicated (95% upper bound for probability of inappropriate shock or failure to shock=0.0012). Conclusions: AED use following widespread training of lay-persons in CPR and AED is generally safe for the volunteer and the patient. Lay volunteers may report significant, usually transient, emotional stress following response to a potential cardiac arrest. Within the context of this prospective, randomized multi-center study, AEDs have an exceptionally high safety profile when used by trained lay responders. [Copyright &y& Elsevier]

The article discusses the use of an automated load-distributing band-cardiopulmonary resuscitation device (LDB-CPR) for resuscitating patients who have out-of-hospital cardiac arrest (OHCA). The study was designed for a patient population serviced by an urban emergency medical services (EMS) system that switched from manual CPR. Outcome measures included return to spontaneous circulation (ROSC) and survival to hospital discharge. Research methods for the study in Richmond, Virginia are mentioned. The authors found improved survival when the LDB-CPR device was used on EMS ambulances.

Abstract: Background: Cardiopulmonary exercise testing (CPET) variables provide valuable prognostic information in the heart failure (HF) population. The purpose of the present study is to assess the ability of resting end-tidal carbon dioxide partial pressure (PETCO2) to predict cardiac-related events in patients with HF. Methods: 121 subjects diagnosed with compensated HF underwent CPET on an outpatient basis. Mean age and ejection fraction were 49.3 years (±14.7) and 28.4% (±13.4), respectively. Resting PETCO2 was determined immediately prior to the exercise test in the seated position. Peak oxygen consumption (VO2) and the minute ventilation-carbon dioxide production (VE/VCO2) slope were also acquired during CPET. Results: There were 41 cardiac-related hospitalizations and 9 cardiac-related deaths in the year following CPET. Mean resting PETCO2, peak VO2 and VE/VCO2 slope were 34.1 mmHg (±4.6), 14.5 ml•kg−1•min−1 (±5.1) and 35.9 (±8.7) respectively. Univariate Cox regression analysis revealed that resting PETCO2 (Chi-square=28.4, p <0.001), peak VO2 (Chi-square=21.6, p <0.001) and VE/VCO2 slope (Chi-square=54.9, p <0.001) were all significant predictors of cardiac related events. Multivariate Cox regression analysis revealed resting PETCO2 added to the prognostic value of VE/VCO2 slope in predicting cardiac related events (residual Chi-square=4.4, p =0.04). Peak VO2 did not add additional value and was removed (residual Chi-square=3.2, p =0.08). Conclusions: These results indicate a resting ventilatory expired gas variable possesses prognostic value independently and in combination with an established prognostic marker from the CPET. Resting PETCO2 may therefore be a valuable objective measure to obtain during both non-exercise and exercise evaluations in patients with HF. [Copyright &y& Elsevier]

Context: Cardiac arrests in adults are often due to ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), which are associated with better outcomes than asystole or pulseless electrical activity (PEA). Cardiac arrests in children are typically asystole or PEA. Objective: To test the hypothesis that children have relatively fewer in-hospital cardiac arrests associated with VF or pulseless VT compared with adults and, therefore, worse survival outcomes. Design, Setting, and Patients: A prospective observational study from a multicenter registry (National Registry of Cardiopulmonary Resuscitation) of cardiac arrests in 253 US and Canadian hospitals between January 1, 2000, and March 30, 2004. A total of 36 902 adults ( 18 years) and 880 children (<18 years) with pulseless cardiac arrests requiring chest compressions, defibrillation, or both were assessed. Cardiac arrests occurring in the delivery department, neonatal intensive care unit, and in the out-of-hospital setting were excluded. Main Outcome Measure: Survival to hospital discharge. Results: The rate of survival to hospital discharge following pulseless cardiac arrest was higher in children than adults (27% [236/880] vs 18% [6485/36 902]; adjusted odds ratio [OR], 2.29; 95% confidence interval [CI], 1.95-2.68). Of these survivors, 65% (154/236) of children and 73% (4737/6485) of adults had good neurological outcome. The prevalence of VF or pulseless VT as the first documented pulseless rhythm was 14% (120/880) in children and 23% (8361/36 902) in adults (OR, 0.54; 95% CI, 0.44-0.65; P<.001). The prevalence of asystole was 40% (350) in children and 35% (13 024) in adults (OR, 1.20; 95% CI, 1.10-1.40; P = .006), whereas the prevalence of PEA was 24% (213) in children and 32% (11 963) in adults (OR, 0.67; 95% CI, 0.57-0.78; P<.001). After adjustment for differences in preexisting conditions, interventions in place at time of arrest, witnessed and/or monitored status, time to defibrillation of VF or pulseless VT, intensive care unit location of arrest, and duration of cardiopulmonary resuscitation, only first documented pulseless arrest rhythm remained significantly associated with differential survival to discharge (24% [135/563] in children vs 11% [2719/24 987] in adults with asystole and PEA; adjusted OR, 2.73; 95% CI, 2.23-3.32). Conclusions: In this multicenter registry of in-hospital cardiac arrest, the first documented pulseless arrest rhythm was typically asystole or PEA in both children and adults. Because of better survival after asystole and PEA, children had better outcomes than adults despite fewer cardiac arrests due to VF or pulseless VT. [ABSTRACT FROM AUTHOR]

The National Registry of Cardiopulmonary Resuscitation (NRCPR) is an American Heart Association (AHA)-sponsored, prospective, multisite, observational study of in-hospital resuscitation. The NRCPR is currently the largest registry of its kind. The purpose of this article is to describe the NRCPR and to provide the first comprehensive, Utstein-based, standardized characterization of in-hospital resuscitation in the United States. All adult (≥18 years of age) and pediatric (<18 years of age) patients, visitors, employees, and staff within a facility (including ambulatory care areas) who experience a resuscitation event are eligible for inclusion in the NRCPR database. Between January 1, 2000, and June 30, 2002, 14 720 cardiac arrests that met inclusion criteria occurred in adults at the 207 participating hospitals. An organized emergency team is available 24 h a day, 7 days a week in 86% of participating institutions. The three most common reasons for cardiac arrest in adults were (1) cardiac arrhythmia, (2) acute respiratory insufficiency, and (3) hypotension. Overall, 44% of adult in-hospital cardiac arrest victims had a return of spontaneous circulation (ROSC); 17% survived to hospital discharge. Despite the fact that a primary arrhythmia was one of the precipitating events in nearly one half of adult cardiac arrests, ventricular fibrillation (VF) was the initial pulseless rhythm in only 16% of in-hospital cardiac arrest victims. ROSC occurred in 58% of VF cases, yielding a survival-to-hospital discharge rate of 34% in this subset of patients. An automated external defibrillator was used to provide initial defibrillation in only 1.4% of patients whose initial cardiac arrest rhythm was VF. Neurological outcome in discharged survivors was generally good. Eighty-six percent of patients with Cerebral Performance Category-1 (CPC-1) at the time of hospital admission had a postarrest CPC-1 at the time of hospital discharge. [Copyright &y& Elsevier]

The author reflects on changes which have been seen in the resuscitation methods which are used on cardiac arrest patients. He suggests that a new approach which is used on cardiac arrest patients highlights the importance of high quality, minimally interrupted chest compressions to maximize tissue oxygen delivery and intracellular high energy phosphate levels. He argues that improvements in CPR are a meaningful development in the evolution of resuscitation science.

The authors comment on the study "Timing of Neuroprognostication in Pot-Cardiac Arrest Therapeutic Hypothermia," by S. M. Perman and colleagues. They express disappointment over the fact that overall survival to discharge remains dismally low. They then note that the study brings forward some important and controversial issues on end-of-life care in critical care in a retrospective study of 55 consecutive patients treated with hypothermia after cardiac arrest resuscitation.

The article presents a reply to a letter to the editor discussing the article "Survival from in-hospital cardiac arrest during nights and weekends," by MA Peberdy, JP Ornato, and GL Larkin et al, published in a previous issue.

Background: The rate in which heart rate recovers from exercise has recently been shown to be a strong predictor of mortality in patients suspected of having coronary disease, but its prognostic value in patients with heart failure (HF) has not been explored. We sought to assess the prognostic utility of heart rate recovery (HRR) in patients with HF. Methods: Eighty-seven subjects diagnosed with compensated HF underwent cardiopulmonary exercise testing (CPX). Mean age and ejection fraction were 50.0 (±13.9) years and 28.1% (±13.6%), respectively. Heart rate at 1-minute post-CPX was subtracted from maximal heart rate during the exercise test to produce a measure of HRR1 in beats per minute. Subjects were followed for a combined death/hospitalization end point for 1-year after CPX. Results: The mean peak respiratory exchange ratio, peak oxygen consumption (Vo 2), minute ventilation/carbon dioxide production (VE/Vco 2) slope, and HRR1 were 1.06 (±0.11), 14.8 (±4.7) mL · kg−1 · min−1, 36.6 (±8.6), and 11.0 (±10.4) beat/min, respectively. Although all three variables were significant univariate predictors of the composite end point (P < .001), multivariate Cox regression analysis only retained the VE/Vco 2 slope (χ2 = 33.5, P < .001) and HRR1 (residual χ2 = 15.0, P < .001) in the equation. The hazard ratio for subjects having both an abnormal VE/Vco 2 slope (>34.4) and HRR1 (<6.5 beat/min) value was 9.2 (95% CI 4.5-18.5, P < .0001). Conclusions: These results indicate that HRR provides additional prognostic information in patients with HF undergoing CPX. Moreover, given the independent prognostic value of HRR, this variable alone may provide valuable clinical information when ventilatory expired gas analysis is not available. [Copyright &y& Elsevier]

The article presents the authors' comments on the widespread implementation of public access to defibrillators in the U.S. According to the author, the number of cases of unexpected cardiac arrest occurring annually in the U.S. is about 450,000. Some of these events occur in public places. The author claims that the most important determinant of survival is prompt defibrillation.

Abstract: Background: The development of advanced life support (ALS) termination of resuscitation (TOR) guidelines for out-of-hospital cardiac arrest (OHCA) seeks to improve the efficiency of scarce pre-hospital resources. However, as pre-hospital treatment for OHCA evolves and survival improves, these TOR guidelines must be reevaluated in the contemporary context of emergency medical services (EMS) providing access to advanced resuscitation care. Methods: Retrospective review of all adult (>18 years old), non-traumatic, OHCA patients (defined as patients with absence of pulse who received either CPR and/or defibrillation) treated by EMS in Richmond, VA, from January 1, 2009 to December 31, 2010. In addition to standard ALS, intra-arrest cold saline, mechanical CPR, and transportation to a comprehensive post-resuscitation center (CPRC) was provided. Patient treatment and outcomes were recorded via prehospital patient care reports and data were evaluated against previously established criteria for termination of resuscitation in an ALS EMS system. According to the aforementioned previously described criteria for TOR, patients meeting a single criterion for transport are recommended to be transported emergently to a comprehensive post-resuscitation care facility. Conversely, patients failing to meet any of the TOR criteria can be presumed to be expired without exception. Survival at 180 days was presumed when death could not be verified from publically reportable sources. Results: Of the 322 OHCA patients enrolled, the majority were male (59%), unwitnessed (52%), received no bystander CPR (67%), and presented in a non-shockable initial rhythm (79%), with an average age of 62.5 years. Overall survival was 17%, 14%, 12%, and 11% at 7, 14, 30, and 180 days, respectively. Of the 75 patients for which TOR guidelines recommended termination, none survived yielding both 100% specificity (95% CI 100–92.8%) and positive predictive value (95% CI 100–94.1%). However, TOR guidelines recommended transport of 208 of the 283 patients who died within 30 days, resulting in a sensitivity of 26.5% (95% CI 34.5–23.4%). Conclusion: The TOR guidelines continue to have a reliable positive predictive value for death even in the setting of advanced EMS resuscitation methods and access to a CPRC. However, as the potential for survival from OHCA improves, the efficiency gained from their use is impacted greatly. [Copyright &y& Elsevier]

Abstract: Objectives: Identify the occurrence rate of post-arrest psychological distress; evaluate methodological approaches; suggest future research priorities; address clinical implications. Methods: The electronic databases PubMed/MEDLINE and PsychInfo/APA PsycNET were utilized to search for terms including ‘Cardiac Arrest’, ‘Therapeutic Hypothermia’ and ‘Depression’, ‘Anxiety’, ‘Quality of Life’, ‘Posttraumatic Stress Disorder (PTSD)’, ‘Psychological Outcomes’, ‘Hospital Anxiety and Depression Scale (HADS)’, and ‘Beck Depression Inventory (BDI)’. Results: High rates of psychological distress have been reported after OHCA. Specifically, incidence rates of depression have ranged from 14% to 45%; anxiety rates have ranged from 13% to 61%; PTSD rates reportedly range from 19% to 27%. Variability between studies is likely attributable to methodological variations relating to measures used, time since arrest, and research setting. Discussion: Given the occurrence rate of psychological distress after OHCA, psychological screening and early intervention seems indicated in the cardiac arrest population. Further studies are needed to better establish occurrence rates in both inpatient and outpatient settings, determine appropriate measures and normative cut off scores, and decide on the most appropriate method of intervention. [Copyright &y& Elsevier]

Abstract: Objectives: To determine the rate of appropriate documentation of endotracheal tube (ET) position confirmation in the American Heart Association''s Get With the Guidelines-Resuscitation (GWTG-R) and to determine whether outcomes of patients who experience in-hospital cardiac arrest differ in relation to documentation rate. Design: Analysis of data from the GWTG-R, a prospective observational registry of in-hospital cardiac arrest and resuscitation. Setting: Database containing clinical information from the 507 hospitals participating in the GWTG-R. Patients: Adults resuscitated after in-hospital cardiac arrest. Measurements: The rate of appropriate documentation of ET position confirmation, defined as the use of capnography or an esophageal detector device (EDD); relationship between appropriate documentation of ET position confirmation and return of spontaneous circulation (ROSC) or survival to hospital discharge. Proportions with 95% CI are reported for prevalence data. Binary logistic regression was used to determine the relationship between appropriate documentation of ET position confirmation and outcome (ROSC, survival to hospital discharge). Adjusted and unadjusted odds ratios are reported. Main results: Of the 176,054 patients entered into the GWTG-R database, 75,777 had an ET placed. For 13,263 (17.5%) of these patients, ET position confirmation was not documented in the chart. Auscultation alone was documented in 19,480 (25.7%) cases. Confirmation of ET position by capnography or EDD was documented in 43,034 (56.8%) cases. ROSC occurred in 39,063 (51.6%), and 13,474 (17.8%) survived to discharge. Patients whose ET position was confirmed by capnography or EDD were more likely to have ROSC (adjusted OR 1.229 [1.179, 1.282]) and to survive to hospital discharge (adjusted OR 1.093 [1.033, 1.157]). Conclusion: Documentation of ET position confirmation in patients who experience cardiac arrest is suboptimal. Appropriate documentation of ET position confirmation in the GWTG-R is associated with greater likelihood of ROSC and survival to hospital discharge. [Copyright &y& Elsevier]

Summary: Background: Little is known about cardiac arrests (CA) in the Emergency Department (ED). The objective of this study was to determine the characteristics of ED CAs. Methods: 60,852 adult, in-patient CA events in the National Registry of Cardiopulmonary Resuscitation were included. Multiple regression analysis compared ED CA with those occurring in the ICU, telemetry, or general floors. Subgroup analysis examined traumatic vs. non-traumatic ED CA and ED CA occurring after a successful pre-hospital resuscitation (recurrent) vs. primary ED event. Results: In multivariate analysis, ED location predicted improved survival to discharge (OR 0.74, 95%CI [0.67–0.82]). ED CAs had higher survival to discharge rates (ED 22.2, ICU 15.5, Tele 19.8, Floor 10.8, p <0.0001), better cerebral performance category scores (ED 1.59, ICU 1.73, Tele 1.96, Floor 1.69, p <0.0001), and shorter post-event length of stays (ED 8.6, ICU 17.5, Tele 16.5, Floor 14.2 days, p <0.0001) than other locations. Recurrent ED CAs were less likely to survive to discharge (10.1% vs. 24.6%, p <0.0001) than primary events. Trauma-related ED CAs had a lower survival to discharge rate (7.5% vs. 23.8%, p <0.0001), were less likely to be caused by an arrhythmia (23.6% vs. 32.5%, p <0.0008), and more likely to be preceded by hypotension or shock (41.6% vs. 29.0%, p <0.0001) than non-trauma ED events. Conclusions: ED CAs have unique characteristics, and better survival and neurologic outcomes compared to other hospital locations. Primary ED CAs have a better chance of survival to discharge than recurrent events. Traumatic ED CAs have worse outcomes than non-traumatic CA. [Copyright &y& Elsevier]

Background: Several prospective studies have demonstrated that the echocardiographic detection of any myocardial activity during PEA is strongly associated with higher rates of return of spontaneous circulation (ROSC). We hypothesized that PEA represents a spectrum of disease in which not only the presence of myocardial activity, but more specifically that the degree of left ventricular (LV) function would be a predictor of outcomes. The purpose of this study was to retrospectively assess the association between LV function and outcomes in patients with OHCA.Materials and Methods: Using prospectively obtained data from an observational cohort of patients receiving focused echocardiography during cardiopulmonary resuscitation (CPR) in the Emergency Department (ED) setting, we analyzed 312 consecutive subjects with available echocardiography images with initial rhythm of PEA. We used left ventricular systolic fractional shortening (LVFS), a unidimensional echocardiographic parameter to perform the quantification of LV function during PEA. Regression analyses were performed independently to evaluate for relationships between LVFS and a primary outcome of ROSC and secondary outcome of survival to hospital admission. We analyzed LVFS both as a continuous variable and as a categorial variable using the quartiles and the median to perform multiple different comparisons and to illustrate the relationship of LVFS and outcomes of interest. We performed survival analysis using Cox proportional hazards model to evaluate the hazard corresponding to length of resuscitation.Results: We found a positive association between LVFS and the primary outcome of ROSC (OR 1.04, 95%CI 1.01-1.08), but not with the secondary outcome of survival to hospital admission (OR 1.02, 95%CI 0.96-1.08). Given that the relationship was not linear and that we observed a threshold effect in the relationship between LVFS and outcomes, we performed an analysis using quartiles of LVFS. The predicted probability of ROSC was 75% for LVFS between 23.4-96% (fourth quartile) compared to 47% for LVFS between 0-4.7% (first quartile). The hazard of not achieving ROSC was significantly greater for subjects with LVFS below the median (13.1%) compared to the subgroup with LVFS greater than 13.1% (p < 0.05), with the separation of the survival curves occurring at approximately 40 min of resuscitation duration.Conclusions: Left ventricular function measured by LVFS is positively correlated with higher probability of ROSC and may be associated with higher chances of survival in patients with PEA arrest. [ABSTRACT FROM AUTHOR]

Abstract: The purpose of this investigation was to examine the ability of heart rate recovery (HRR) to predict mortality secondary to pump failure or sudden cardiac death (SCD) in patients with heart failure (HF). Kaplan–Meier analysis revealed a significant difference in survival for both SCD (100% vs. 73.9%, log-rank: 50.5, p <0.001) and pump failure (96.1% vs. survival=78.4%, log-rank: 24.4, p <0.001) endpoints according to a

Focused transthoracic echocardiography (TTE) during cardiac arrest resuscitation can enable the characterization of myocardial activity, identify potentially treatable pathologies, assist with rhythm interpretation, and provide prognostic information. However, an important limitation of TTE is the difficulty obtaining interpretable images due to external and patient-related limiting factors. Over the last decade, focused transesophageal echocardiography (TEE) has been proposed as a tool that is ideally suited to image patients in extremis-those in cardiac arrest and periarrest states. In addition to the same diagnostic and prognostic role provided by TTE images, TEE provides unique advantages including the potential to optimize the quality of chest compressions, shorten cardiopulmonary resuscitation interruptions, guide resuscitative procedures, and provides a continuous image of myocardial activity. This review discusses the rationale, supporting evidence, opportunities, and challenges, and proposes a research agenda for the use of focused TEE in cardiac arrest with the goal to improve resuscitation outcomes. [ABSTRACT FROM AUTHOR]

Significant improvements have been achieved in cardiac arrest resuscitation and postarrest resuscitation care, but mortality remains high. Most of the poor outcomes and deaths of cardiac arrest survivors have been attributed to widespread brain injury. This brain injury, commonly manifested as a comatose state, is a marker of poor outcome and a major basis for unfavorable neurological prognostication. Accurate prognostication is important to avoid pursuing futile treatments when poor outcome is inevitable but also to avoid an inappropriate withdrawal of life-sustaining treatment in patients who may otherwise have a chance of achieving meaningful neurological recovery. Inaccurate neurological prognostication leading to withdrawal of life-sustaining treatment and deaths may significantly bias clinical studies, leading to failure in detecting the true study outcomes. The American Heart Association Emergency Cardiovascular Care Science Subcommittee organized a writing group composed of adult and pediatric experts from neurology, cardiology, emergency medicine, intensive care medicine, and nursing to review existing neurological prognostication studies, the practice of neurological prognostication, and withdrawal of life-sustaining treatment. The writing group determined that the overall quality of existing neurological prognostication studies is low. As a consequence, the degree of confidence in the predictors and the subsequent outcomes is also low. Therefore, the writing group suggests that neurological prognostication parameters need to be approached as index tests based on relevant neurological functions that are directly related to the functional outcome and contribute to the quality of life of cardiac arrest survivors. Suggestions to improve the quality of adult and pediatric neurological prognostication studies are provided. [ABSTRACT FROM AUTHOR]

Background: Black patients have worse in-hospital survival than white patients after in-hospital cardiac arrest (IHCA), but less is known about long-term outcomes. We sought to assess among IHCA survivors whether there are additional racial differences in survival after hospital discharge and to explore potential reasons for differences.Methods: This was alongitudinal study of patients ≥65 years of age who had an IHCA and survived until hospital discharge between 2000 and 2011 from the national Get With The Guidelines-Resuscitation registry whose data could be linked to Medicare claims data. Sequential hierarchical modified Poisson regression models evaluated the proportion of racial differences explained by patient, hospital, and unmeasured factors. Our exposure was black or white race. Our outcome was survival at 1, 3, and 5 years.Results: Among 8764 patients who survived to discharge, 7652 (87.3%) were white and 1112 (12.7%) were black. Black patients with IHCA were younger, more frequently female, sicker with more comorbidities, less likely to have a shockable initial cardiac arrest rhythm, and less likely to be evaluated with coronary angiography after initial resuscitation. At discharge, black patients were also more likely to have at least moderate neurological disability and less likely to be discharged home. Compared with white patients and after adjustment only for hospital site, black patients had lower 1-year (43.6% versus 60.2%; relative risk [RR], 0.72), 3-year (31.6% versus 45.3%; RR, 0.71), and 5-year (23.5% versus 35.4%; RR, 0.67; all P<0.001) survival. Adjustment for patient factors explained 29% of racial differences in 1-year survival (RR, 0.80; 95% confidence interval, 0.75-0.86), and further adjustment for hospital treatment factors explained an additional 17% of racial differences (RR, 0.85; 95% confidence interval, 0.80-0.92). Approximately half of the racial difference in 1-year survival remained unexplained, and the degree to which patient and hospital factors explained racial differences in 3-year and 5-year survival was similar.Conclusions: Black survivors of IHCA have lower long-term survival compared with white patients, and about half of this difference is not explained by patient factors or treatments after IHCA. Further investigation is warranted to better understand to what degree unmeasured but modifiable factors such as postdischarge care account for unexplained disparities. [ABSTRACT FROM AUTHOR]

Background: Prior studies have reported higher in-hospital survival with prompt defibrillation and epinephrine treatment in patients with in-hospital cardiac arrest (IHCA). Whether this survival benefit persists after discharge is unknown.Methods: We linked data from a national IHCA registry with Medicare files and identified 36 961 patients ≥65 years of age with an IHCA at 517 hospitals between 2000 and 2011. Patients with IHCA caused by pulseless ventricular tachycardia or ventricular fibrillation were stratified by prompt (≤2 minutes) versus delayed (>2 minutes) defibrillation, whereas patients with IHCA caused by asystole or pulseless electric activity were stratified by prompt (≤5 minutes) versus delayed (>5 minutes) epinephrine treatment. The association between prompt treatment and long-term survival for each rhythm type was assessed with multivariable hierarchical modified Poisson regression models.Results: Of 8119 patients with an IHCA caused by ventricular tachycardia or ventricular fibrillation, the rate of 1-year survival was higher in those treated with prompt defibrillation than with delayed defibrillation (25.7% [1466 of 5714] versus 15.5% [373 of 2405]; adjusted relative risk [RR], 1.49; 95% confidence interval [CI] 1.32-1.69; P<0.0001). This survival advantage persisted at 3 years (19.1% versus 11.0%; adjusted RR, 1.45; 95% CI, 1.23-1.69; P<0.0001) and at 5 years (14.7% versus 7.9%; adjusted RR, 1.50; 95% CI, 1.22-1.83; P<0.0001). Of 28 842 patients with an IHCA caused by asystole/pulseless electric activity, the rate of 1-year survival with prompt epinephrine treatment was higher than with delayed treatment (5.4% [1341 of 24 885] versus 4.3% [168 of 3957]; adjusted RR, 1.20; 95% CI, 1.02-1.41; P=0.02), but this survival benefit was no longer present at 3 years (3.5% versus 2.9%; adjusted RR, 1.17; 95% CI, 0.95-1.45; P=0.15) and at 5 years (2.3% versus 1.9%; adjusted RR, 1.18; 95% CI, 0.88-1.58; P=0.27).Conclusions: Prompt defibrillation for IHCA caused by ventricular tachycardia or ventricular fibrillation was associated with higher rates of long-term survival throughout 5 years of follow-up, whereas prompt epinephrine treatment for asystole/pulseless electric activity was associated with greater survival at 1 year but not at 3 or 5 years. By quantifying the greater survival associated with timely defibrillation and epinephrine administration, these findings provide important insights into the durability of survival benefits for 2 process-of-care measures in current resuscitation guidelines. [ABSTRACT FROM AUTHOR]

The article focuses on the post-cardiac arrest care in patients during cardiac arrest based on the 2015 guidelines for cardiopulmonary resuscitation and emergency cardiovascular care from U.S. nonprofit organization American Heart Association (AHA). It highlights the use of AHA Class of Recommendation (COR) and Level of Evidence (LOE) system in systematic review for patient compliance. An overview on the recommended standardized methodological approach in cardiovascular care, is also given.