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Summary Background Methods Results Conclusion We analysed the clinical practice of anaesthesia associates in the UK, as reported to the 7th National Audit Project of the Royal College of Anaesthetists, and compared these with medically qualified anaesthetists.We included data from our baseline survey, activity survey and case registry as with other reports from the project.Among 197 departments of anaesthesia, 52 (26%) employed anaesthesia associates. Of 10,009 responding anaesthesia care providers, 71 (< 1%) were anaesthesia associates, of whom 33 (47%) reporting working nights or weekends (compared with 97% of medically qualified anaesthetists in training and > 90% of consultants). Anaesthesia associates reported less training and confidence in managing peri‐operative cardiac arrest and its aftermath compared with medically qualified anaesthetists. Anaesthesia associates were less directly involved in the management and the aftermath of peri‐operative cardiac arrest than medically qualified anaesthetists, and the psychological impacts on professional and personal life appeared to be less. Among 24,172 cases, anaesthesia associates attended 432 (2%) and were the senior anaesthesia care provider in 63 (< 1%), with indirect supervision in 27 (43%). Anaesthesia associates worked predominantly in a small number of surgical specialties during weekdays and working daytime hours. Complication rates were low in cases managed by anaesthesia associates, likely reflecting case mix. However, activity and registry case mix data show anaesthesia associates do manage high‐risk cases (patients who are older, comorbid, obese and frail) with the potential for serious complications. Registry cases included higher risk cases with respect to the clinical setting and patient factors.Anaesthesia associates work in enhanced roles, relative to the scope of practice at qualification agreed by organisations. Recent changes mean the Royal College of Anaesthetists and Association of Anaesthetists do not currently support an enhanced scope of practice. [ABSTRACT FROM AUTHOR]

Background: There are limited practical advanced life support algorithms to aid teams in the management of cardiac arrest in patients on extracorporeal membrane oxygenation (ECMO). Methods: In our specialist tertiary referral centre we developed, by iteration, a novel resuscitation algorithm for ECMO emergencies which we validated through simulation and assessment of our multi-disciplinary team. A Mechanical Life Support course was established to provide theoretical and practical education combined with simulation to consolidate knowledge and confidence in algorithm use. We assessed these measures using confidence scoring, a key performance indicator (the time taken to resolve gas line disconnection) and a multiple choice question (MCQ) examination. Results: Following this intervention the median confidence scores increased from 2 (Interquartile range IQR 2, 3) to 4 (IQR 4, 4) out of maximum 5 (n = 53, p < 0.0001). Theoretical knowledge assessed by median MCQ score increased from 8 (6, 9) to 9 (7, 10) out of maximum 11 (n = 53, p0.0001). The use of the ECMO algorithm reduced the time taken by teams in a simulated emergency to identify a gas line disconnection and resolve the problem from median 128 s (65, 180) to 44 s (31, 59) (n = 36, p 0.001) and by a mean of 81.5 s (CI 34, 116, p = 0.001). Conclusions: We present an evidence based practical ECMO resuscitation algorithm that provides guidance to clinical teams responding to cardiac arrest in ECMO patients covering both patient and ECMO troubleshooting. [ABSTRACT FROM AUTHOR]

The evidence about the associations of leukocyte telomere length (LTL) and intermediary cardiovascular phenotypes with adverse cardiovascular outcomes is inconclusive. This study assessed these relationships with cardiovascular imaging, electrocardiography, and the risks of sudden cardiac death (SCD), coronary events, and heart failure (HF) admission. We conducted a cross-sectional analysis of UK Biobank participants enrolled between 2006 and 2010. LTL was measured using quantitative polymerase chain reactions. Electronic health records were used to determine the incidence of SCD, coronary events, and HF admission. Cardiovascular measurements were made using cardiovascular magnetic resonance imaging and machine learning. The associations of LTL with SCD, coronary events, and HF admission and cardiac magnetic resonance imaging, electrocardiogram parameters of 33,043 and 19,554 participants were evaluated by multivariate regression. The median (interquartile range) follow-up period was 11.9 (11.2–12.6) years. Data was analyzed from January to May 2023. Among the 403,382 white participants without coronary artery disease or HF, 181,637 (45.0%) were male with a mean age of 57.1 years old. LTL was independently negatively associated with a risk of SCD (LTL third quartile vs first quartile: hazard ratio [HR]: 0.81, 95% confidence interval [CI]: 0.72–0.92), coronary events (LTL third quartile vs first quartile: HR: 0.88, 95% CI: 0.84–0.92), and HF admission (LTL fourth quartile vs first quartile: HR: 0.84, 95% CI: 0.74–0.95). LTL was also independently positively associated with cardiac remodeling, specifically left ventricular mass index, left-ventricular-end systolic and diastolic volumes, mean left ventricular myocardial wall thickness, left ventricular stroke volume, and with electrocardiogram changes along the negative degree of T-axis. Cross-sectional study results showed that LTL was positively associated with heart size and cardiac function in middle age, but electrocardiography results did not show these associations, which could explain the negative association between LTL and risk of SCD, coronary events, and HF admission in UK Biobank participants. [ABSTRACT FROM AUTHOR]

Summary: The 7th National Audit Project of the Royal College of Anaesthetists studied peri‐operative cardiac arrest. An activity survey estimated UK paediatric anaesthesia annual caseload as 390,000 cases, 14% of the UK total. Paediatric peri‐operative cardiac arrests accounted for 104 (12%) reports giving an incidence of 3 in 10,000 anaesthetics (95%CI 2.2–3.3 per 10,000). The incidence of peri‐operative cardiac arrest was highest in neonates (27, 26%), infants (36, 35%) and children with congenital heart disease (44, 42%) and most reports were from tertiary centres (88, 85%). Frequent precipitants of cardiac arrest in non‐cardiac surgery included: severe hypoxaemia (20, 22%); bradycardia (10, 11%); and major haemorrhage (9, 8%). Cardiac tamponade and isolated severe hypotension featured prominently as causes of cardiac arrest in children undergoing cardiac surgery or cardiological procedures. Themes identified at review included: inappropriate choices and doses of anaesthetic drugs for intravenous induction; bradycardias associated with high concentrations of volatile anaesthetic agent or airway manipulation; use of atropine in the place of adrenaline; and inadequate monitoring. Overall quality of care was judged by the panel to be good in 64 (62%) cases, which compares favourably with adults (371, 52%). The study provides insight into paediatric anaesthetic practice, complications and peri‐operative cardiac arrest. [ABSTRACT FROM AUTHOR]

Background: Insulin resistance (IR) significantly contributes to cardiovascular disease (CVD) development. Triglyceride glucose (TyG) index and triglyceride glucose-body mass index (TyG-BMI) are recognised as convenient proxies for IR. However, their relationship with sudden cardiac arrest (SCA) remains unclear. Methods: This prospective cohort analysis included 355,242 UK Biobank participants with available TyG index and TyG-BMI data and no history of CVD. Cox proportional risk models assessed the association between the TyG index, TyG-BMI and SCA risk. Additionally, Accelerated Failure Time (AFT) models were employed to investigate the timing of SCA onset. The impact of dynamic increases in TyG index and TyG-BMI levels on SCA risk was examined using restricted cubic spline. Results: Over a median follow-up period of 165.4 months (interquartile range 156.5–174 months), 1,622 cases of SCA were recorded. Multivariate Cox regression analysis revealed a 9% increase in SCA risk per standard deviation increase in TyG index (adjusted hazard ratio (aHR) = 1.09, 95% confidence interval (CI) 1.04–1.15) and an 14% increase per standard deviation increase in TyG-BMI (aHR 1.14, 95% CI 1.09–1.2). AFT models indicated earlier median times to SCA occurrence with increasing quintiles of TyG index and TyG-BMI compared to the lowest quintile (P for trend < 0.05). SCA risk was linearly (P = 0.54) and non-linearly (P = 0.007) correlated with gradual increases in TyG index and TyG-BMI levels, respectively. Sex-stratified analyses showed stronger associations in women. Conclusions: Higher TyG index and TyG-BMI levels are associated with an increased SCA risk and earlier onset, particularly in women. [ABSTRACT FROM AUTHOR]

Summary: The 7th National Audit Project of the Royal College of Anaesthetists studied peri‐operative cardiac arrest in the UK. We report the results of the vascular surgery cohort from the 12‐month case registry, from 16 June 2021 to 15 June 2022. Anaesthesia for vascular surgery accounted for 2% of UK anaesthetic caseload and included 69 (8%) reported peri‐operative cardiac arrests, giving an estimated incidence of 1 in 670 vascular anaesthetics (95%CI 1 in 520–830). The high‐risk nature of the vascular population is reflected by the proportion of patients who were ASA physical status 4 (30, 43%) or 5 (19, 28%); the age of patients (80% aged > 65 y); and that most cardiac arrests (57, 83%) occurred during non‐elective surgery. The most common vascular surgical procedures among patients who had a cardiac arrest were: aortic surgery (38, 55%); lower‐limb revascularisation (13, 19%); and lower‐limb amputation (8, 12%). Among patients having vascular surgery and who had a cardiac arrest, 28 (41%) presented with a ruptured abdominal aortic aneurysm. There were 48 (70%) patients who had died at the time of reporting to NAP7 and 11 (16%) were still in hospital, signifying poorer outcomes compared with the non‐vascular surgical cohort. The most common cause of cardiac arrest was major haemorrhage (39, 57%), but multiple other causes reflected the critical illness of the patients and the complexity of surgery. This is the first analysis of the incidence, management and outcomes of peri‐operative cardiac arrest during vascular anaesthesia in the UK. [ABSTRACT FROM AUTHOR]

The discontinuation of life-sustaining therapy has been the subject of dispute for many years. Despite the guidelines, which were created to facilitate the resolution of disputes between the doctor (hospital) and the patient (family, surrogate), new cases of seriously ill patients continue to emerge and stir up controversy. One such case was the RS case. A Polish citizen living in the UK suffered severe brain damage as a result of cardiac arrest. The hospital applied to the court to withdraw ventilation, hydration, and nutrition for RS. The judge ultimately ruled that it was in RS’s best interest to withdraw ventilation and nutrition, but he left the decision on hydration to RS’s wife and the hospital. The court’s ruling has stirred up controversy among the Polish public. Some Polish doctors assessed the UK court’s decision as “legal murder” and “euthanasia”. I believe that it is worth examining the RS case for at least two reasons. Firstly, it provides a better understanding of the difference in approaches to therapy cessation in the UK and Poland. Secondly, many Poles live in the UK, and therefore similar disputes may arise in the future. In this paper, I point out several differences between the British and Polish approaches to discontinuing life-sustaining therapy. These differences are focused on the definitions of medical futility and persistent therapy, best interest and dignity, and quality of life and sanctity of life. [ABSTRACT FROM AUTHOR]

An implantable left ventricular assist device (LVAD) is indicated as a bridge to transplantation or recovery in the United Kingdom (UK). The mechanism of action of the LVAD results in a unique state of haemodynamic stability with diminished arterial pulsatility. The clinical assessment of an LVAD recipient can be challenging because non-invasive blood pressure, pulse and oxygen saturation measurements may be hard to obtain. As a result of this unusual situation and complex interplay between the device and the native circulation, resuscitation of LVAD recipients requires bespoke guidelines. Through collaboration with key UK stakeholders, we assessed the current evidence base and developed guidelines for the recognition of clinical deterioration, inadequate circulation and time-critical interventions. Such guidelines, intended for use in transplant centres, are designed to be deployed by those providing immediate care of LVAD patients under conditions of precipitous clinical deterioration. In summary, the Joint British Societies and Transplant Centres LVAD Working Group present the UK guideline on management of emergencies in implantable LVAD recipients for use in advanced heart failure centres. These recommendations have been made with a UK resuscitation focus but are widely applicable to professionals regularly managing patients with implantable LVADs. [ABSTRACT FROM AUTHOR]

Aims: This study aimed to describe the natural history and predictors of all‐cause mortality and sudden cardiac death (SCD)/equivalent events in children with a RASopathy syndrome and hypertrophic cardiomyopathy (HCM). Methods and results: This is a retrospective cohort study from 14 paediatric cardiology centres in the United Kingdom and Ireland. We included children <18 years with HCM and a clinical and/or genetic diagnosis of a RASopathy syndrome [Noonan syndrome (NS), NS with multiple lentigines (NSML), Costello syndrome (CS), cardiofaciocutaneous syndrome (CFCS), and NS with loose anagen hair (NS‐LAH)]. One hundred forty‐nine patients were recruited [111 (74.5%) NS, 12 (8.05%) NSML, 6 (4.03%) CS, 6 (4.03%) CFCS, 11 (7.4%) Noonan‐like syndrome, and 3 (2%) NS‐LAH]. NSML patients had higher left ventricular outflow tract (LVOT) gradient values [60 (36–80) mmHg, P = 0.004]. Over a median follow‐up of 197.5 [inter‐quartile range (IQR) 93.58–370] months, 23 patients (15.43%) died at a median age of 24.1 (IQR 5.6–175.9) months. Survival was 96.45% [95% confidence interval (CI) 91.69–98.51], 90.42% (95% CI 84.04–94.33), and 84.12% (95% CI 75.42–89.94) at 1, 5, and 10 years, respectively, but this varied by RASopathy syndrome. RASopathy syndrome, symptoms at baseline, congestive cardiac failure (CCF), non‐sustained ventricular tachycardia (NSVT), and maximal left ventricular wall thickness were identified as predictors of all‐cause mortality on univariate analysis, and CCF, NSVT, and LVOT gradient were predictors for SCD or equivalent event. Conclusions: These findings highlight a distinct category of patients with Noonan‐like syndrome with a milder HCM phenotype but significantly worse survival and identify potential predictors of adverse outcome in patients with RASopathy‐related HCM. [ABSTRACT FROM AUTHOR]

Background: Advanced paramedic practitioners in critical care (APPCCs) are advanced clinical practitioners focused on the delivery of pre-hospital critical care. While working in an ambulance control room setting, APPCCs seek to identify emergency calls appropriate for operational APPCCs to attend. These would include out-of-hospital cardiac arrest (OHCA). Through interrogation of incoming emergency calls they are also able to identify OHCA calls where resuscitation may be futile. In these cases, and within a governance framework, they stand down multiple ambulance responders, leaving only the closest responding resource to attend, thereby ‘saving resources’ that can be re-directed to other waiting emergency calls. It is believed that this is the first initiative of this nature in the United Kingdom. Methods: A three-year retrospective service evaluation of data was undertaken. The aim was to quantify the number of ‘saved resources’, including both double crewed ambulances (DCAs) and solo (single-person) responders, and furthermore to equate those savings into potential hours saved, using average known job cycle times (JCTs). Additionally, safety was assessed by searching all mandated incident reports for occasions where, despite cancellation of resources by an APPCC, resuscitation was commenced by the first response to scene. Results: A total of 13,356 ambulance resources were saved. Of these, 6593 (49.4%) were DCAs and 6763 (50.6%) were solo responders. Using the average JCT for deceased patients of 104.8 minutes, the total time saving equated to 23,328.48 hours of work or 1944.04 12-hour shifts. When considering DCAs alone, the average JCT for obviously deceased patients was 110.9 minutes. This equates to 12,186.1 hours of work or 1015.5 12-hour shifts. A total of 15 incident reports were identified. All had been investigated, revealing appropriate decision making in cancelling ambulance resources. No patient harm was identified. [ABSTRACT FROM AUTHOR]

Patients in the UK who suffer an out-of-hospital cardiac arrest are treated with cardiopulmonary resuscitation in the pre-hospital environment. Current survival outcomes are low in out-of-hospital cardiac arrest. Extracorporeal cardiopulmonary resuscitation is a technique which is offered to patients in specialised centres which provides better blood flow and oxygen delivery than conventional chest compressions. Shortening the interval between cardiac arrest and restoration of circulation is associated with improved outcomes in extracorporeal cardiopulmonary resuscitation. Delivering extracorporeal cardiopulmonary resuscitation in the pre-hospital environment can shorten this interval, improving outcomes in out-of-hospital cardiac arrest. This article will review recently published studies and summarise studies currently being undertaken in pre-hospital extracorporeal cardiopulmonary resuscitation. It will also discuss the potential application of a pre-hospital extracorporeal cardiopulmonary resuscitation programme in the North East of England. [ABSTRACT FROM AUTHOR]

This article discusses the findings of the 7th National Audit Project (NAP7) of the Royal College of Anaesthetists, which focuses on the organization and preparedness for peri-operative cardiac arrest in UK hospitals. The study found that while peri-operative cardiac arrests are relatively rare, they are significant for healthcare providers, with nearly half of respondents having managed at least one in the past two years. The study also highlighted areas for improvement in organizational preparedness, such as the availability of emergency equipment and the provision of training. The article emphasizes the importance of addressing these challenges to ensure optimal patient care. [Extracted from the article]

The article discusses the occurrence of peri-operative cardiac arrests, which are critical life-threatening events that can happen during or after a surgical procedure. The study, called the 7th National Audit Program of the Royal College of Anaesthetists (NAP7), provides insights into the epidemiology, causes, management, and outcomes of peri-operative cardiac arrests in the UK. The incidence of cardiac arrest in the study was found to be lower compared to previous data, suggesting a potential decrease in frequency. However, patient factors, resources, and practitioner skills all contribute to the risk of cardiac arrest. The study emphasizes the importance of timely interventions, adequate patient monitoring, and skilled clinical care to prevent and mitigate morbidity associated with peri-operative cardiac arrests. [Extracted from the article]

Summary: The 7th National Audit Project of the Royal College of Anaesthetists studied peri‐operative cardiac arrest in the UK, a topic of importance to patients, anaesthetists and surgeons. We report the results of the 12‐month registry phase, from 16 June 2021 to 15 June 2022, focusing on management and outcomes. Among 881 cases of peri‐operative cardiac arrest, the initial rhythm was non‐shockable in 723 (82%) cases, most commonly pulseless electrical activity. There were 665 (75%) patients who survived the initial event and 384 (52%) who survived to hospital discharge. A favourable functional outcome (based on modified Rankin Scale score) was reported for 249 (88%) survivors. Outcomes varied according to arrest rhythm. The highest rates of survival were seen for bradycardic cardiac arrests with 111 (86%) patients surviving the initial event and 77 (60%) patients surviving the hospital episode. The lowest survival rates were seen for patients with pulseless electrical activity, with 312 (68%) surviving the initial episode and 156 (34%) surviving to hospital discharge. Survival to hospital discharge was worse in patients at the extremes of age with 76 (40%) patients aged > 75 y and 9 (45%) neonates surviving. Hospital survival was also associated with surgical priority, with 175 (88%) elective patients and 176 (37%) non‐elective patients surviving to discharge. Outcomes varied with the cause of cardiac arrest, with lower initial survival rates for pulmonary embolism (5, 31%) and bone cement implantation syndrome (9, 45%), and hospital survival of < 25% for pulmonary embolism (0), septic shock (13, 24%) and significant hyperkalaemia (1, 20%). Overall care was rated good in 464 (53%) cases, and 18 (2%) cases had overall care rated as poor. Poor care elements were present in a further 245 (28%) cases. Care before cardiac arrest was the phase most frequently rated as poor (92, 11%) with elements of poor care identified in another 186 (21%) cases. These results describe the management and outcomes of peri‐operative cardiac arrest in UK practice for the first time. [ABSTRACT FROM AUTHOR]

Objective Sodium-glucose cotransporter-2 inhibitors (SGLT2Is) reduce cardio-metabolic and renal outcomes in patients with type 2 diabetes (T2D) but their efficacy and safety in older or frail individuals remains unclear. Methods We searched PubMed, Scopus, Web of Science, Cochrane CENTRA and Google Scholar and selected randomised controlled trials and observational studies comparing SGLT2Is versus placebo/other glucose-lowering agent for people with frailty or older individuals (>65 years) with T2D and heart failure (HF). Extracted data on the change in HbA1c % and safety outcomes were pooled in a random-effects meta-analysis model. Results We included data from 20 studies (22 reports; N  = 77,083 patients). SGLT2Is did not significantly reduce HbA1c level (mean difference −0.13, 95%CI: −0.41 to 0.14). SGLT2Is were associated with a significant reduction in the risk of all-cause mortality (risk ratio (RR) 0.81, 95%CI: −0.69 to 0.95), cardiac death (RR 0.80, 95%CI: −0.94 to 0.69) and hospitalisation for heart failure (HHF) (RR 0.69, 95%CI: 0.59–0.81). However, SGLT2Is did not demonstrate significant effect in reducing in the risk of macrovascular events (acute coronary syndrome or cerebral vascular occlusion), renal progression/composite renal endpoint, acute kidney injury, worsening HF, atrial fibrillation or diabetic ketoacidosis. Conclusions In older or frail patients with T2D and HF, SGLT2Is are consistently linked with a decrease in total mortality and the overall burden of cardiovascular (CV) events, including HHF events and cardiac death, but not protective for macrovascular death or renal events. Adverse events were more difficult to quantify but the risk of diabetic ketoacidosis or acute kidney injury was not significantly increase. [ABSTRACT FROM AUTHOR]

Summary: Thrombolysis with prolonged cardiopulmonary resuscitation may be required for the successful resuscitation of patients presenting with massive pulmonary embolism leading to cardiac arrest. A rare, recognised complication of cardiopulmonary resuscitation is traumatic hepatic and splenic laceration. The incidence of complications is believed to be increased in those who receive automated mechanical cardiopulmonary resuscitation, compared to those who receive standard chest compressions. We present a case of a patient with massive pulmonary embolism leading to cardiac arrest which was successfully treated with thrombolysis and mechanical automated cardiopulmonary resuscitation. The patient suffered hepatic and splenic lacerations resulting in major haemorrhage. This required emergency resuscitation with blood products and splenic embolisation. This case highlights the importance of continual re‐assessment of patients, the early recognition of complications and an awareness of the potential complications of treatments we deliver. [ABSTRACT FROM AUTHOR]

Summary: The Royal College of Anaesthetists' 7th National Audit Project baseline survey assessed knowledge, attitudes, practices and experiences of peri‐operative cardiac arrests among UK anaesthetists and Anaesthesia Associates. We received 10,746 responses, representing a 71% response rate. In‐date training in adult and paediatric advanced life support was reported by 9646 (90%) and 7125 (66%) anaesthetists, respectively. There were 8994 (84%) respondents who were confident in leading a peri‐operative cardiac arrest, with males more confident than females, but only 5985 (56%) were confident in leading a debrief and 7340 (68%) communicating with next of kin. In the previous two years, 4806 (46%) respondents had managed at least one peri‐operative cardiac arrest, of which 321 (7%) and 189 (4%) of these events involved a child or an obstetric patient, respectively. Respondents estimated the most common causes of peri‐operative cardiac arrest to be hypovolaemia, hypoxaemia and cardiac ischaemia, with haemorrhage coming fifth. However, the most common reported causes for the most recently attended peri‐operative cardiac arrest were haemorrhage; (927, 20%); anaphylaxis (474, 10%); and cardiac ischaemia (397, 9%). Operating lists or shifts were paused or stopped after 1330 (39%) cardiac arrests and 1693 (38%) respondents attended a debrief, with 'hot' debriefs most common. Informal wellbeing support was relatively common (2458, 56%) and formal support was uncommon (472, 11%). An impact on future care delivery was reported by 196 (4%) anaesthetists, most commonly a negative psychological impact. Management of a peri‐operative cardiac arrest during their career was reported by 8654 (85%) respondents. The overall impact on professional life was more often judged positive (2630, 30%) than negative (1961, 23%), but impact on personal life was more often negative. [ABSTRACT FROM AUTHOR]

Summary: We report the results of the Royal College of Anaesthetists' 7th National Audit Project organisational baseline survey sent to every NHS anaesthetic department in the UK to assess preparedness for treating peri‐operative cardiac arrest. We received 199 responses from 277 UK anaesthetic departments, representing a 72% response rate. Adult and paediatric anaesthetic care was provided by 188 (95%) and 165 (84%) hospitals, respectively. There was no paediatric intensive care unit on‐site in 144 (87%) hospitals caring for children, meaning transfer of critically ill children is required. Remote site anaesthesia is provided in 182 (92%) departments. There was a departmental resuscitation lead in 113 (58%) departments, wellbeing lead in 106 (54%) and departmental staff wellbeing policy in 81 (42%). A defibrillator was present in every operating theatre suite and in all paediatric anaesthesia locations in 193 (99%) and 149 (97%) departments, respectively. Advanced airway equipment was not available in: every theatre suite in 13 (7%) departments; all remote locations in 103 (57%) departments; and all paediatric anaesthesia locations in 23 (15%) departments. Anaesthetic rooms were the default location for induction of anaesthesia in adults and children in 148 (79%) and 121 (79%) departments, respectively. Annual updates in chest compressions and in defibrillation were available in 149 (76%) and 130 (67%) departments, respectively. Following a peri‐operative cardiac arrest, debriefing and peer support programmes were available in 154 (79%) and 57 (29%) departments, respectively. While it is likely many UK hospitals are very well prepared to treat anaesthetic emergencies including cardiac arrest, the survey suggests this is not universal. [ABSTRACT FROM AUTHOR]

Introduction: Innovative large language model (LLM)-powered chatbots, which are extremely popular nowadays, represent potential sources of information on resuscitation for the general public. For instance, the chatbot-generated advice could be used for purposes of community resuscitation education or for just-in-time informational support of untrained lay rescuers in a real-life emergency. Study Objective: This study focused on assessing performance of two prominent LLM-based chatbots, particularly in terms of quality of the chatbot-generated advice on how to give help to a non-breathing victim. Methods: In May 2023, the new Bing (Microsoft Corporation, USA) and Bard (Google LLC, USA) chatbots were inquired (n = 20 each): "What to do if someone is not breathing?" Content of the chatbots' responses was evaluated for compliance with the 2021 Resuscitation Council United Kingdom guidelines using a pre-developed checklist. Results: Both chatbots provided context-dependent textual responses to the query. However, coverage of the guideline-consistent instructions on help to a non-breathing victim within the responses was poor: mean percentage of the responses completely satisfying the checklist criteria was 9.5% for Bing and 11.4% for Bard (P >.05). Essential elements of the bystander action, including early start and uninterrupted performance of chest compressions with adequate depth, rate, and chest recoil, as well as request for and use of an automated external defibrillator (AED), were missing as a rule. Moreover, 55.0% of Bard's responses contained plausible sounding, but nonsensical guidance, called artificial hallucinations, that create risk for inadequate care and harm to a victim. Conclusion: The LLM-powered chatbots' advice on help to a non-breathing victim omits essential details of resuscitation technique and occasionally contains deceptive, potentially harmful directives. Further research and regulatory measures are required to mitigate risks related to the chatbot-generated misinformation of public on resuscitation. [ABSTRACT FROM AUTHOR]

Background: Patient activated rapid response (PARR) services allow patients and family members to escalate care in hospital without agreement by their primary care team. Methods: This paper explores the evidence base for PARR and examines the experience of a sample of patients to identify barriers and opportunities for PARR. These are then used to develop a framework for the measurement of PARR that can be applied to quantify clinical impact and develop new research. Results: The observed number of escalation events by patients and family members is small. Interviews with patients suggested concerns of patients in undermining staff and difficulties to recall the mechanics of escalation during periods of acute illness. The Quadruple aim could be used as a framework to quantify impact: In a functioning PARR system earlier recognition of illness can be facilitated by patients and this should lead to 1. a reduction in cardiac arrests and preventable deaths, 2. timely admission to critical care with shorter (cheaper) length of stay, 3. better patient engagement and Patient Reported Experience measures and 4. flatter hierarchies with higher staff satisfaction. Conclusion: PARR services are in the early stages of implementation. We present a framework to measure improvement of services and research. [ABSTRACT FROM AUTHOR]

Summary: Aotearoa New Zealand uses a single early warning score (EWS) across all public and private hospitals to detect adult inpatient physiological deterioration. This combines the aggregate weighted scoring of the UK National Early Warning Score with single parameter activation from Australian medical emergency team systems. We conducted a retrospective analysis of a large vital sign dataset to validate the predictive performance of the New Zealand EWS in discriminating between patients at risk of serious adverse events and compared this with the UK EWS. We also compared predictive performance for patients admitted under medical vs. surgical specialties. A total of 1,738,787 aggregate scores (13,910,296 individual vital signs) were obtained from 102,394 hospital admissions to six hospitals within the Canterbury District Health Board of New Zealand's South Island. Predictive performance of each scoring system was determined using area under the receiver operating characteristic curve. Analysis showed that the New Zealand EWS is equivalent to the UK EWS in predicting patients at risk of serious adverse events (cardiac arrest, death and/or unanticipated ICU admission). Area under the receiver operating characteristic curve for both EWSs for any adverse outcome was 0.874 (95%CI 0.871–0.878) and 0.874 (95%CI 0.870–0.877), respectively. Both EWSs showed superior predictive value for cardiac arrest and/or death in patients admitted under surgical rather than medical specialties. Our study is the first validation of the New Zealand EWS in predicting serious adverse events in a broad dataset and supports previous work showing the UK EWS has superior predictive performance in surgical rather than medical patients. [ABSTRACT FROM AUTHOR]

Synthetic cannabinoid receptor agonists (SCRAs) are one of the fastest growing classes of recreational drugs. Despite their growth in use, their vast chemical diversity and rapidly changing landscape of structures make understanding their effects challenging. In particular, the side effects for SCRA use are extremely diverse, but notably include severe outcomes such as cardiac arrest. These side effects appear at odds with the main putative mode of action, as full agonists of cannabinoid receptors. We have hypothesized that SCRAs may act as MAO inhibitors, owing to their structural similarity to known monoamine oxidase inhibitors (MAOI's) as well as matching clinical outcomes (hypertensive crisis) of 'monoaminergic toxicity' for users of MAOIs and some SCRA use. We have studied the potential for SCRA‐mediated inhibition of MAO‐A and MAO‐B via a range of SCRAs used commonly in the UK, as well as structural analogues to prove the atomistic determinants of inhibition. By combining in silico and experimental kinetic studies we demonstrate that SCRAs are MAO‐A‐specific inhibitors and their affinity can vary significantly between SCRAs, most notably affected by the nature of the SCRA 'head' group. Our data allow us to posit a putative mechanism of inhibition. Crucially our data demonstrate that SCRA activity is not limited to just cannabinoid receptor agonism and that alternative interactions might account for some of the diversity of the observed side effects and that these effects can be SCRA‐specific. [ABSTRACT FROM AUTHOR]

Aims: Sudden cardiac death (SCD) is defined as natural unexpected death in witnessed cases occurring < 1 h and in unwitnessed cases as last seen alive < 24 h. SCD due to ischaemic heart disease (IHD) is frequent in older age groups; in younger people genetic cardiac causes, including channelopathies and cardiomyopathies, are more frequent. This study aimed to present the causes of SCD from a large specialist pathology registry. Methods and results: Cases were examined macroscopically and microscopically by two expert cardiac pathologists. The hearts from 7214 SCD cases were examined between 1994 and 2021. Sudden arrhythmic death syndrome (SADS), a morphologically normal heart, which can be underlaid by cardiac channelopathies, is most common (3821, 53%) followed by the cardiomyopathies (1558, 22%), then IHD (670, 9%), valve disease (225, 3%), congenital heart disease (213, 3%) and myocarditis/sarcoidosis (206, 3%). Hypertensive heart disease (185, 3%), aortic disease (129, 2%), vascular disease (97, 1%) and conduction disease (40, 1%) occur in smaller proportions. Discussion: To our knowledge, this is the largest SCD cohort with autopsy findings ever reported from one country. SADS and cardiomyopathies predominate. This study highlights the importance of the autopsy in SCD, which is a significant public health concern in all age groups. Knowing the true incidence in our population will improve risk stratification and develop preventative strategies for family members. There is now a national pilot study integrating molecular autopsy and family screening into the assessment of SCD victims. [ABSTRACT FROM AUTHOR]

Introduction : Simulation training offers an authentic team-based learning opportunity without risk to real patients. The Educational Corner at the annual congress of the European Branch of Extracorporeal Life Support Organisation (EuroELSO) provided an opportunity for multiple simulation training sessions facilitated by experts from all over the world. Aim : We aimed to review the educational impact of EuroELSO Educational Corner and whether it provides a quality ECLS training to a wide spectrum of multidisciplinary international attendees utilising high and low fidelity simulation, workshops and hands on sessions. Methods : During the congress, 43 sessions were conducted dedicated to ECLS education with identified educational objectives. The sessions focused on management of adults and children on V-V or V-A ECMO. Adult sessions covered emergencies on mechanical circulatory support with management of LVAD and Impella, managing refractory hypoxemia on V-V ECMO, emergencies on ECMO, renal replacement therapy on ECMO, V-V ECMO, ECPR cannulation and performing perfect simulation. Paediatric sessions covered ECPR neck and central cannulation, renal replacement on ECMO, troubleshooting, cannulation workshop, V-V recirculation, ECMO for single ventricle, PIMS-TS and CDH, ECMO transport and neurological injury. Results : The Educational Corner was attended by more than 400 participants over the two congress days. Majority of responders (88%) reported that training sessions met the set educational goals and objectives and that this would change their current practice. Almost all (94%) reported that they received useful information and 95% would recommend the session to their colleagues. Conclusion : The Educational Corner, as an integral component of the annual EuroELSO congress, achieved the set educational goals and provided quality education based on the recipient survey. Structured multidisciplinary ECLS education with standardised curriculum and feedback is an important key step in delivering quality training to an international audience. Standardisation of European ECLS education remains an important focus of the EuroELSO. [ABSTRACT FROM AUTHOR]

This article outlines the current guidelines and recommendations for pre- and post-discharge care and rehabilitation of survivors of out-of-hospital cardiac arrest (OHCA) and their families. Although many OHCA survivors make an overall good physical and neurological recovery, many others experience a combination of cognitive decline, emotional problems, fatigue and difficulties in reintegrating in the community and in the workplace. Current pathways of care in the UK are not well suited in identifying and addressing these issues. Neuropsychologists, in particular, are rarely involved in the care of these often-complex patients who fall on the boundaries of neurology, cardiology and critical care. In this article we summarise the current best practice in the development of a pathway of care and rehabilitation for OHCA survivors in the UK. The role of Neuropsychology is discussed, and clinics are invited to collaborate in the development and evaluation of this pathway of care. [ABSTRACT FROM AUTHOR]

Causes and precipitating factors of sudden cardiac death (SCD) in adolescents are poorly understood. The authors sought to investigate the etiologies of SCD and their association with physical activity in a large cohort of adolescents. Between 1994 and June 2022, 7,675 cases of SCD were consecutively referred to our national cardiac pathology center; 756 (10%) were adolescents. All cases underwent detailed autopsy evaluation by expert cardiac pathologists. Clinical information was obtained from referring coroners. A structurally normal heart, indicative of sudden arrhythmic death syndrome was the most common autopsy finding (n = 474; 63%). Myocardial diseases were detected in 163 cases (22%), including arrhythmogenic cardiomyopathy (n = 36; 5%), hypertrophic cardiomyopathy (n = 31; 4%), idiopathic left ventricular hypertrophy (n = 31; 4%), and myocarditis (n = 30; 4%). Coronary artery anomalies were identified in 17 cases (2%). Decedents were competitive athletes in 128 cases (17%), and 159 decedents (21%) died during exercise. Arrhythmogenic cardiomyopathy was diagnosed in 8% of athletes compared with 4% of nonathletes (P = 0.05); coronary artery anomalies were significantly more common in athletes (9% vs 1%; P < 0.001), as well as commotio cordis (5% compared with 1% in nonathletes; P = 0.001). The 3 main comorbidities were asthma (n = 58; 8%), epilepsy (n = 44; 6%), and obesity (n = 40; 5%). Sudden arrhythmic death syndrome and myocardial diseases are the most common conditions diagnosed at autopsy in adolescent victims of SCD. Among causes of SCD, arrhythmogenic cardiomyopathy, coronary artery anomalies, and commotio cordis are more common in young athletes than in similar age sedentary individuals. [Display omitted] [ABSTRACT FROM AUTHOR]

Introduction: Hypothermia is an uncommon cause of cardiac arrest in the United Kingdom, and more commonly occurs in countries experiencing avalanches and significant winter climates; however, this case demonstrates that the presentation can occur in the United Kingdom. This case adds to a body of evidence that prolonged resuscitation can be successful in patients suffering a cardiac arrest secondary to hypothermia, leading to a good neurological outcome. Case presentation: The patient suffered a witnessed out-of-hospital cardiac arrest following rescue from a free-flowing river, and underwent prolonged resuscitation. The patient presented in persistent ventricular fibrillation, unresponsive to defibrillation attempts. An oesophageal probe recorded the patient's temperature as 24°C. Rescuers were guided by the Resuscitation Council UK advanced life support algorithm to withhold drug therapy and limit defibrillation attempts to three, until the patient had been rewarmed to above 30°C. Appropriate triage of the patient to an extracorporeal life support (ECLS) capable centre allowed specialised treatment to be initiated, and culminated in successful resuscitation once normothermia was restored. After a short stay in intensive care, the patient was discharged for rehabilitation due to a hypoxic spinal cord injury before discharge home. Conclusion: This case highlights that hypothermia is a reversible cause of cardiac arrest, which needs to be recognised and acted upon appropriately to provide the best possible chance for a positive outcome. Low-reading thermometers capable of identifying the temperature thresholds stated in the Resuscitation Council UK guidelines are required, to allow clinicians to adapt their practice according to the presenting situation. Tympanic thermometers are often limited to their lowest recordable temperature, and invasive monitoring such as oesophageal or rectal probes are not common in UK ambulance service practice. With the necessary equipment, patients can be triaged to an ECLS-capable centre, allowing them to receive the specialist rewarming that they require. [ABSTRACT FROM AUTHOR]

Background: Community first responders (CFRs) work voluntarily to support UK ambulance services by responding to emergencies. They are dispatched via the local 999 call centre and details of incidents in their local area are sent to their mobile phone. They have emergency equipment with them, including a defibrillator and oxygen, and attend a range of incidents, including cardiac arrests. Previous research has looked at the impact the CFR role has had on patient survival, but there is no previous research looking at the experiences of the CFRs while working in a UK ambulance service. Method: This study involved 10 semi-structured interviews, which took place in November and December 2018. One researcher interviewed all the CFRs using a pre-defined interview schedule. The findings of the study were analysed using thematic analysis. Results: The main themes from the study are 'relationships' and 'systems'. The sub-themes of relationships are the relationship between CFRs; the relationship between CFRs and ambulance service staff; and the relationship between CFRs and patients. The sub-themes of systems are call allocation; technology; and reflection and support. Conclusions: CFRs support one another and are encouraging with new starting members. Their relationships with ambulance service staff have improved since CFRs first became active, but there is still room for improvement. The calls that CFRs attend are not always within their scope of practice, but the rate of this occurring is unclear. CFRs are frustrated with the level of technology involved in their role and feel it impacts them attending incidents quickly. CFRs reported attending cardiac arrests on a regular basis and the support that they receive afterwards. Further research should use a survey approach to further explore the experiences of the CFRs based on the themes raised in this study. Using this methodology would identify if these themes are unique to the one ambulance service where this was conducted, or if they are relevant to all UK CFRs. [ABSTRACT FROM AUTHOR]

An editorial is presented that focuses on the under-recognition and misdiagnosis of cardiac symptoms in women, particularly concerning heart valve diseases like aortic stenosis and mitral regurgitation. It highlights disparities in symptom recognition, diagnosis delays, and treatment referrals compared to men, despite similar presentation of cardiac conditions.

Introduction: Revised guidelines for the management of cardiac arrest have placed greater emphasis on early defibrillation and closed chest compressions; subsequently there has been a significant rise in the number of patients gaining a return of spontaneous circulation (ROSC). As a consequence, emergency medical services have realised the importance of therapies delivered during this phase of care. In some Trusts this includes the use of inotropic agents to augment the cardiovascular system and maintain adequate cerebral and coronary perfusion pressures to mitigate the effects of post-cardiac arrest syndrome. Currently, limited evidence exists with regards to the efficacy of such treatments in the pre-hospital phase. Methods: Retrospective observational analysis of out-of-hospital cardiac arrest patients who received an adrenaline infusion by critical care paramedics. Infusion rates, time of call (ToC) to ROSC and 30-day mortality were compared. Results: Over a 2-year period, 202 patients were recorded as having an adrenaline infusion commenced. Of these, 25 were excluded as they did not meet criteria or had incomplete data and 22 were excluded as the infusion was stopped at scene; 155 patients were admitted to hospital. There were no survivors in the non-shockable group and three survivors in the shockable group at 30 days. A rare events analysis found no relationship between infusion rate, ToC to ROSC and 30-day mortality (Wald chi2, 1.37). Conclusion: Commencement of adrenaline infusions in post-ROSC was associated with significant 30-day mortality, especially in non-shockable rhythms. Further research is needed to elucidate whether this intervention has any benefit in the post-ROSC patient. [ABSTRACT FROM AUTHOR]

Background: Following the emergence of COVID-19, there have been local and national changes in the way emergency medical service (EMS) staff respond to and treat patients in out-of-hospital cardiac arrest (OHCA). The views of EMS staff on the impact of COVID-19 and management of OHCA have not previously been explored. This study aimed to explore the views of staff, with a specific focus on communication during resuscitation, resuscitation procedures and the perception of risk. Methods: A qualitative phenomenological enquiry was conducted. A purposive sample of n = 20 participants of various clinical grades was selected from NHS EMS providers in the United Kingdom. Data were collected using semi-structured interviews, transcribed verbatim and inductive thematic analysis was applied. Results: Three main themes emerged which varied according to clinical grade, location and guidelines. Decision making: Staff generally felt supported to make best-interest termination of resuscitation decisions. Staff made informed decisions to compromise on recommended levels of personal protective equipment (PPE), since it felt impractical in the pre-hospital context, to improve communication or to reduce delays to care. Service pressures: Availability of operational staff and in-hospital capacity were reduced. Staff felt pressure and disconnect from the continuous updates to clinical guidelines which resulted in organisational change fatigue. Moral injury: The emotional impacts of prolonged and frequent exposure to failed resuscitation attempts and patient death caused many staff to take time away from work to recover. Conclusion: This qualitative study is the first known to explore staff views on the impacts of COVID-19 on OHCA resuscitation, which found positive outcomes but also negative impacts important to inform EMS systems. Staff felt that COVID-19 created delays to the delivery of resuscitation, which were multi-faceted. Staff developed new ways of working to overcome the barriers of impractical PPE. There was little impact on resuscitation procedures. Moving forwards, EMS should consider how to limit organisational change and better support the ongoing emotional impacts on staff. [ABSTRACT FROM AUTHOR]

Introduction: Some experts recommend that ambulant hypothermic patients should be rewarmed, fed, and not permitted to exercise for 30 min because of concerns that afterdrop can cause cardiac instability. We investigated the outcome of ambulant hypothermic patients in a case series from mountain rescue teams in Great Britain., Methods: A questionnaire was used to collect information on a series of adult patients with a clinical diagnosis of mild hypothermia. All patients were alert on the AVPU scale and evacuated by walking from the mountain. The outcome measures were survival or a change in management because of medical deterioration during evacuation., Results: A series of 108 eligible cases were reported over a 5-year period. When rescuers arrived on the scene, 98 (91%) patients were stationary, and 10 (9%) were still mobile. Thirty-eight (39%) of the stationary cases were walked immediately off the mountain without any on-scene delay. In the remaining 60 (61%) stationary cases, the decision was taken to delay evacuation to provide food, drinks, and additional clothing. In 3 cases, the use of heat packs indicated an intention to actively rewarm. In cases where the on-scene time was reported, 27 (79%) were known to be mobile again within 20 min. All patients survived, and no adverse medical events occurred in all 108 cases., Conclusions: In this study, no adverse events occurred because of immediate mobilization, suggesting that in these cases, there appears to be minimal risk of early activity., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Paramedics are responsible for critical resuscitation decisions when attending Out of Hospital Cardiac Arrests (OHCA). Existing research indicates that a range of clinical and non-clinical factors moderate their decision-making. Within the United Kingdom (UK), there is little evidence on how and why paramedics make their decisions at actual OHCA events., Methods: We explored the experiences of UK paramedics using individually recalled OHCA events as catalysts for discussion. Pen portraits developed from semi-structured interviews with 31 paramedics across two UK ambulance services were thematically analysed, enabling cross-participant comparisons whilst retaining depth and context., Results: We identified four themes: uncertainties encountered in resuscitation guidelines, influences on decision-making, holistic perspectives, and indirect moderators. We found that paramedics experienced uncertainty at all stages of the resuscitation process. Uncertainties arose from indeterminate, ambiguous or complex information and were described as having both clinical and ethical dimensions. Whilst guidelines drove paramedics' decisions, non-clinical personal, practical and relational factors moderated their assessments of survivability and decision-making, with attitudes to interactions between patient age, frailty and quality of life playing a substantial role. Coping strategies such as uncertainty reduction, assumption-based reasoning and weighing pros and cons were evident from interviews., Conclusions: The complexity of interactions between clinical and non-clinical factors points to an element of variability in paramedics' responses to uncertainty. Exploring UK paramedics' uncertainties and decision-making during specific OHCA events can help acknowledge and address uncertainties in resuscitation guidelines and paramedic training, providing paramedics with the tools to manage uncertainty in a consistent and transparent way., (© 2024. Crown.)

Frailty increases peri-operative risk, but details of its burden, clinical features and the risk of, and outcomes following, peri-operative cardiac arrest are lacking. As a preplanned analysis of the 7th National Audit Project of the Royal College of Anaesthetists, we described the characteristics of older patients living with frailty undergoing anaesthesia and surgery, and those reported to the peri-operative cardiac arrest case registry. In the activity survey, 1676 (26%) of 6466 patients aged > 65 y were reported as frail (Clinical Frailty Scale score ≥ 5). Increasing age and frailty were both associated with increasing comorbidities and the proportion of surgery undertaken as an emergency. Except in patients who were terminally ill (Clinical Frailty Scale score 9), increasing frailty was associated with an increased proportion of complex or major surgery. The rate of use of invasive arterial blood pressure monitoring was associated with frailty only until Clinical Frailty Scale score 5, and then plateaued or fell. Of 881 cardiac arrests reported to the 7th National Audit Project, 156 (18%) were in patients aged > 65 y and living with frailty, with an estimated incidence of 1 in 1204 (95%CI 1 in 1027-1412) and a mortality rate of 1 in 2020 (95%CI 1 in 1642-2488), approximately 2.6-fold higher than in adults who were not frail. Hip fracture, emergency laparotomy, emergency vascular surgery and urological surgery were the most common surgical procedures in older patients living with frailty who had a cardiac arrest. We report a high burden of frailty within the surgical population, requiring complex, urgent surgery, and the extent of poorer outcomes of peri-operative cardiac arrest compared with patients of the same age not living with frailty., (© 2024 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.)

Background: Sudden arrhythmic death syndrome (SADS), defined as sudden cardiac death (SCD) with a morphologically normal heart, is an important cause of sudden death. Hypoperfusion due to cardiac arrest followed by successful cardiopulmonary resuscitation (CPR) may induce histologic changes that mimic pathologic conditions. Detailed characterisation of such features and whether they could confound SADS diagnosis are not described.Methods: Retrospective observational study analysing all consecutive cases of sudden death prospectively referred to a UK national cardiac pathology centre between 2017 and 2021. Cases showing hypoperfusion features were identified after review of clinical information and examination by expert cardiac pathologists.Results: Out of 2,568 SCD cases, 126 (4.9%) were identified with hypoperfusion changes. Macroscopically, the commonest finding was left ventricular focal or diffuse subendocardial haemorrhage (13.5%). Microscopically, haemorrhage and contraction band necrosis (n = 50, 37.7%), subendocardial acute infarction (n = 44, 34.1%), interstitial mixed inflammatory cell infiltrates (n = 31, 24.9%), healing granulation tissue (n = 9, 7.1%) and subendocardial fibrosis (n = 1, 0.7%) were observed. These changes correlated to duration of survival following resuscitation. In a subcohort of 41 cases, autopsy pathologists misinterpreted such changes as ischaemic myocardial infarction (n = 7; 17%), myocarditis (n = 5; 12.1%), or other pathologies (n = 2; 4.8%) in 14 SADS cases.Conclusion: We provide a comprehensive characterisation of hypoperfusion-related changes in the heart following successful CPR with survival, which are time related. These features can lead to diagnostic confusion among pathologists but knowledge of history of resuscitation with survival should help with general and expert pathology assessment and improve SADS diagnostic yield, prompting genetic screening of decedents' relatives. [ABSTRACT FROM AUTHOR]

Aims: To compare in-hospital cardiac arrest (IHCA) rates and patient outcomes during the first COVID-19 wave in the United Kingdom (UK) in 2020 with the same period in previous years.Methods: A retrospective, multicentre cohort study of 154 UK hospitals that participate in the National Cardiac Arrest Audit and have intensive care units participating in the Case Mix Programme national audit of intensive care. Hospital burden of COVID-19 was defined by the number of patients with confirmed SARS-CoV2 infection admitted to critical care per 10,000 hospital admissions.Results: 16,474 patients with IHCA where a resuscitation team attended were included. Patients admitted to hospital during 2020 were younger, more often male, and of non-white ethnicity compared with 2016-2019. A decreasing trend in IHCA rates between 2016 and 2019 was reversed in 2020. Hospitals with higher burden of COVID-19 had the greatest difference in IHCA rates (21.8 per 10,000 admissions in April 2020 vs 14.9 per 10,000 in April 2019). The proportions of patients achieving ROSC ≥ 20 min and surviving to hospital discharge were lower in 2020 compared with 2016-19 (46.2% vs 51.2%; and 21.9% vs 22.9%, respectively). Among patients with IHCA, higher hospital burden of COVID-19 was associated with reduced survival to hospital discharge (OR = 0.95; 95% CI 0.93 to 0.98; p < 0.001).Conclusions: In comparison with 2016-2019, the first COVID-19 wave in 2020 was associated with a higher rate of IHCA and decreased survival among patients attended by resuscitation teams. These changes were greatest in hospitals with the highest COVID-19 burden. [ABSTRACT FROM AUTHOR]

Objective: To determine the incidence, clinical correlates and exposure risk of medical encounters during community-based physical activity events in the UK.Methods: An analysis of medical data from weekly, community-based physical activity events (parkrun) at 702 UK locations over a 6-year period (29 476 294 participations between 2014 and 2019) was conducted in order to define the incidence and clinical correlates of serious life-threatening, non-life-threatening and fatal medical encounters.Results: 84 serious life-threatening encounters (overall incidence rate=0.26/100 000 participations) occurred including 18 fatalities (0.056/100 000 participations). Statistical modelling revealed that the probabilities of serious life-threatening encounters were exceptionally low, however, male sex, increasing age, slower personal best parkrun time and less prior running engagement/experience (average number of runs per year and number of years as a parkrun participant) were associated with increased probability of serious life-threatening encounters. These were largely accounted for by cardiac arrest (48/84, 57%) and acute coronary syndromes (20/84, 24%). Non-life-threatening medical encounters were mainly attributed to tripping or falling, with a reported incidence of 39.2/100 000 participations.Conclusions: Serious life-threatening and fatal medical encounters associated with parkrun participation are extremely rare. In the context of a global public health crisis due to inactivity, this finding underscores the safety and corollary public health value of community running/walking events as a strategy to promote physical activity. [ABSTRACT FROM AUTHOR]

Background: Drug-free tracheal intubation has been a common intervention in the context of out-of-hospital cardiac arrest for many years, however its use by paramedics has recently been the subject of much debate. Recent international guidance has recommended that only those achieving high tracheal intubation success should continue to use it.Methods: We conducted a retrospective service evaluation of all drug-free tracheal intubation attempts by specialist paramedics (critical care) from South East Coast Ambulance Service NHS Foundation Trust between 1st January and 31st December 2019. Our primary outcome was first-pass success rate, and secondary outcomes were success within two attempts, overall success, Cormack-Lehane grade of view, and use of bougie.Results: There were 663 drug-free tracheal intubations and following screening, 605 were reviewed. There was a first-pass success rate of 81.5%, success within two attempts of 96.7%, and an overall success rate of 98.35%. There were ten unsuccessful attempts (1.65%). Bougie use was documented in 83.4% on the first attempt, 93.5% on the second attempt and 100% on the third attempt, CONCLUSION: Specialist paramedics (critical care) are able to deliver drug-free tracheal intubation with good first-pass success and high overall success and are therefore both safe and competent at this intervention. [ABSTRACT FROM AUTHOR]

Background: Drones are increasingly used in healthcare, and feasibility studies of deployment of Automated External Defibrillators (AED) in Out-of-hospital cardiac arrest (OHCA) have been conducted. Despite the potential contribution of drones to healthcare, regulatory barriers exist, including limits on flights beyond visual line-of-sight (BVLOS). The aim of this project was to deliver an AED BVLOS in Wales. Methods: We developed of a Concept of Operations (CONOPS) to identify requirements, constraints, organisation and roles and responsibilities associated with deploying a drone to deliver an AED BVLOS. We equipped a Penguin B drone with satellite-enabled technology to enhance situational awareness and safety for the remote pilot. A BVLOS Operating Safety Case and three-week flight test programme was conducted with an AED attached directly to parachute for deployment to simulated OHCA. Results: We completed six flights totalling 92km, 1:02.5 hours of flight time and four successful parachute payload drops. We conducted a successful end-to-end flight demonstration of an AED delivered via BVLOS by drone to a simulated OHCA and resuscitation by lay responder's in a remote location; the final delivery of 4.5km was completed in 2:50 minutes. Conclusion: We have delivered an AED by parachute, from fixed wing drone BVLOS in the UK in simulated OHCA. This project adds to the body of knowledge required for regulatory assurance on drone use BVLOS. Further research is needed before routine use of this technology. [ABSTRACT FROM AUTHOR]

Aim: Optimal airway management during out-of-hospital cardiac arrest (OHCA) is uncertain. Complications from tracheal intubation (TI) may be avoided with supraglottic airway (SGA) devices. The AIRWAYS-2 cluster randomised controlled trial (ISRCTN08256118) compared the i-gel SGA with TI as the initial advanced airway management (AAM) strategy by paramedics treating adults with non-traumatic OHCA. This paper reports the trial cost-effectiveness analysis.Methods: A within-trial cost-effectiveness analysis of the i-gel compared with TI was conducted, with a six-month time horizon, from the perspective of the UK National Health Service (NHS) and personal social services. The primary outcome measure was quality-adjusted life years (QALYs), estimated using the EQ-5D-5L questionnaire. Multilevel linear regression modelling was used to account for clustering by paramedic when combining costs and outcomes.Results: 9296 eligible patients were attended by 1382 trial paramedics and enrolled in the AIRWAYS-2 trial (4410 TI, 4886 i-gel). Mean QALYs to six months were 0.03 in both groups (i-gel minus TI difference -0.0015, 95% CI -0.0059 to 0.0028). Total costs per participant up to six months post-OHCA were £3570 and £3413 in the i-gel and TI groups respectively (mean difference £157, 95% CI -£270 to £583). Based on mean difference point estimates, TI was more effective and less costly than i-gel; however differences were small and there was great uncertainty around these results.Conclusion: The small differences between groups in QALYs and costs shows no difference in the cost-effectiveness of the i-gel and TI when used as the initial AAM strategy in adults with non-traumatic OHCA. [ABSTRACT FROM AUTHOR]

New Resuscitation guidelines have been published this year by Resuscitation Council UK (RCUK). Its the commentary and comparison of changes to the previous guidelines of BLS, ALS, PLS and PALS The new topics are also added in new guidelines and details are in full text [ABSTRACT FROM AUTHOR]

Aim: To investigate how the publication of the targeted temperature management (TTM) trial in December 2013 affected the trends in temperature management and outcome following admission to UK intensive care units (ICUs) after out-of-hospital cardiac arrest (OHCA).Methods: We used a national ICU database of 1,181,405 consecutive admissions to 235 adult ICUs. OHCA admissions mechanically ventilated in the first 24 h in the ICU were divided into a pre-TTM trial cohort of patients admitted before publication of the TTM trial (January 2010-December 2013) and post-TTM cohort of patients admitted after TTM trial publication (January 2014-December 2017). The primary outcome variables were lowest temperature in the first 24 h in ICU and survival to hospital discharge.Results: The lowest temperature recorded in the first-24 h of admission was significantly higher in the post-TTM cohort (n = 18,106) than in the pre-TTM cohort (n = 12,162) (mean 34.7 (±1.6) versus 33.6 °C (±1.8); absolute difference 1.12 °C (95% CI 1.08-1.16). The post-TTM cohort had a greater prevalence of fever (>38.0 °C) (24.8% vs 14.7%; (odds ratio (OR) 1.91 (95% CI 1.80-2.03); p < 0.001)) and higher unadjusted in-hospital mortality (63.7% vs 61.6%). In a multilevel model, accounting for time trend and including site as a random effect, neither the step change in acute hospital mortality following publication of the TTM trial result (OR 1.04, 95% CI 0.95-1.15; p = 0.37), nor the change in slope (from OR 1.00 per year, 95% CI 0.97-1.04, to 1.04 per year, 95% CI 1.02-1.07; p = 0.059), was statistically significant. Adjusted analyses were limited by the models' dependence on temperature and temperature-related variables.Conclusions: The lowest temperature recorded in the first-24 h of admission in OHCA patients was higher in the post-TTM cohort compared with the pre-TTM cohort. There has been an increase in the proportion of patients with fever (>38 °C) in the first 24 h. Although crude mortality was slightly higher in the post-TTM cohort, an analysis accounting for time trend and variation between critical care units, found no significant change associated with the TTM publication. [ABSTRACT FROM AUTHOR]

Cardiac arrest leaves witnesses, survivors, and their relatives with a multitude of questions. When a young or a public figure is affected, interest around cardiac arrest and cardiopulmonary resuscitation (CPR) increases. ChatGPT allows everyone to obtain human-like responses on any topic. Due to the risks of accessing incorrect information, we assessed ChatGPT accuracy in answering laypeople questions about cardiac arrest and CPR. We co-produced a list of 40 questions with members of Sudden Cardiac Arrest UK covering all aspects of cardiac arrest and CPR. Answers provided by ChatGPT to each question were evaluated by professionals for their accuracy, by professionals and laypeople for their relevance, clarity, comprehensiveness, and overall value on a scale from 1 (poor) to 5 (excellent), and for readability. ChatGPT answers received an overall positive evaluation (4.3 ± 0.7) by 14 professionals and 16 laypeople. Also, clarity (4.4 ± 0.6), relevance (4.3 ± 0.6), accuracy (4.0 ± 0.6), and comprehensiveness (4.2 ± 0.7) of answers was rated high. Professionals, however, rated overall value (4.0 ± 0.5 vs 4.6 ± 0.7; p = 0.02) and comprehensiveness (3.9 ± 0.6 vs 4.5 ± 0.7; p = 0.02) lower compared to laypeople. CPR-related answers consistently received a lower score across all parameters by professionals and laypeople. Readability was 'difficult' (median Flesch reading ease score of 34 [IQR 26–42]). ChatGPT provided largely accurate, relevant, and comprehensive answers to questions about cardiac arrest commonly asked by survivors, their relatives, and lay rescuers, except CPR-related answers that received the lowest scores. Large language model will play a significant role in the future and healthcare-related content generated should be monitored. [ABSTRACT FROM AUTHOR]

Background: In the United Kingdom (UK) there were 6507 deaths by suicide in 2018, with hanging being the most common method. Hanging will normally result in emergency medical services (EMS) being called and may result in resuscitation being attempted. Trauma audits conducted by North East Ambulance Service NHS Foundation Trust have identified an increased trend in hanging cases, which were also reported in national data. The aim of this scoping review was to explore the literature around EMS attendance at hangings to inform further research and clinical practice. Methods: A five-stage scoping review method was used. Relevant studies were identified by searching MEDLINE, CINAHL, EMBASE and EMCARE with the help of the Library and Knowledge Service for NHS Ambulance Services in England. Grey literature and reference lists were also searched. Studies were included based on relevance to hangings attended by EMS. Data were tabulated and narratively synthesised. Results: Sixteen papers were included in the review. Australia was the most frequent source of studies (n = 5, 31%). Most studies (n = 11, 69%) were published in the past 10 years. The median sample size was 53 (IQR 41–988, range 10–3981). All papers included varying levels of patient characteristics, EMS input and patient outcomes. Conclusion: Hanging is a highly lethal method of suicide that is increasingly used in the UK. This scoping review found that there is scarce literature focused on hangings attended by EMS. Treatment of the hanging patient in cardiac arrest is described in many of the papers included. Hanging patients may benefit from the presence of specialist resources who can deliver interventions such as sedation and advanced airway management. The psychological impact of attending, or witnessing, hanging patients is an area that needs further consideration. Further research is needed to describe and improve EMS treatment of hangings. [ABSTRACT FROM AUTHOR]

Introduction: Consciousness may occur during cardiopulmonary resuscitation despite the absence of a palpable pulse. This phenomenon, known as CPR-Induced Consciousness (CPR-IC), was first described over three decades ago and there has been an increase in case reports describing it. However, there remains limited evidence in relation to the incidence of CPR-IC and to practitioners' experiences of it. Methods: A mixed-methods, cross-sectional survey of paramedics who were registered with the Health and Care Professions Council (HCPC) and working in the United Kingdom (UK) at the time of the survey. Participants who had experienced CPR-IC were asked to provide details about the number of episodes, a description of how consciousness was manifested and whether or not it interfered with resuscitation. Results: 293 eligible participants completed the study and 167 (57%) said that they had witnessed CPR-IC. Of those, over 56% reported that they had experienced it on at least two occasions. CPR-IC was deemed to interfere with resuscitation in nearly 50% of first experiences but this fell to around 31% by the third experience. The most common reasons for CPR-IC to interfere with resuscitation were: patient resisting clinical interventions, increased rhythm and pulse checks, distress, confusion and reluctance to perform CPR. Conclusions: The prevalence of CPR-IC in our study was similar to that in earlier studies; however, unlike the other studies, we did not define what constituted interfering CPR-IC. Our findings suggest that interference may be related as much to the exposure of the clinician to CPR-IC as to any specific characteristic of the phenomenon itself. [ABSTRACT FROM AUTHOR]

Over 30,000 adult cardiac operations are carried out in the UK annually. A small number of these patients need to return to theatre in the first few days after the initial surgery, but the exact proportion is unknown. The majority of these resternotomies are for bleeding or cardiac tamponade. The Association of Cardiothoracic Anaesthesia and Critical Care carried out a 1-year national audit of resternotomy in 2018. Twenty-three of the 35 centres that were eligible participated. The overall resternotomy rate (95%CI) within the period of admission for the initial operation in these centres was 3.6% (3.37-3.85). The rate varied between centres from 0.69% to 7.6%. Of the 849 patients who required resternotomy, 127 subsequently died, giving a mortality rate (95%CI) of 15.0% (12.7-17.5). In patients who underwent resternotomy, the median (IQR [range]) length of stay on ICU was 5 (2-10 [0-335]) days, and time to tracheal extubation was 20 (12-48 [0-2880]) hours. A total of 89.3% of patients who underwent resternotomy were transfused red cells, with a median (IQR [range]) of 4 (2-7 [1-1144]) units of red blood cells. The rate (95%CI) of needing renal replacement therapy was 23.4% (20.6-26.5). This UK-wide audit has demonstrated that resternotomy after cardiac surgery is associated with prolonged intensive care stay, high rates of blood transfusion, renal replacement therapy and very high mortality. Further research into this area is required to try to improve patient care and outcomes in patients who require resternotomy in the first 24 h after cardiac surgery. [ABSTRACT FROM AUTHOR]

Background: Mechanical chest compression devices deliver high-quality chest compressions. Early data suggests that mechanical devices may be superior to manual chest compressions in adults following an in-hospital cardiac arrest patients. To determine the feasibility of undertaking an effectiveness trial in this population, we undertook a feasibility randomised controlled trial.Methods: We undertook a multi-centre parallel group feasibility randomised controlled trial (COMPRESS-RCT). Adult in-hospital cardiac arrest patients that were in a non-shockable rhythm were randomised in a 3:1 ratio to receive mechanical CPR (Jolfe AB/Stryker, Lund, Sweden) or ongoing manual CPR. Recruitment was led by the clinical cardiac arrest team. The primary study outcome was the proportion of eligible participants randomised in the study during site operational recruitment hours. Patients were enrolled under a model of deferred consent. We report data using descriptive statistics, point estimates and 95% confidence intervals.Results: Over a two-year period, we recruited 127 patients across five UK hospitals. We recruited 55.2% (95% CI 48.5%-61.8%) of eligible study participants in site operational recruitment hours. Most participants were male (n = 76, 59.8%) with a mean age of 72 (95% CI: 69.9-74.9) years. Median arrest duration was 18 (IQR 13-29) minutes. In patients randomised to mech-CPR, median time from CPR start to device deployment was 11 (IQR 7-15) minutes. ROSC was achieved in 27.6% (n = 35) participants and 4.7% (n = 6) were alive at 30-days.Conclusion: COMPRESS-RCT identified important factors that preclude progression to an effectiveness trial of mechanical CPR in the hospital setting in the UK. Findings will inform the design of future in-hospital intra-arrest intervention trials. ISRCTN38139840, date of registration 9th January 2017. [ABSTRACT FROM AUTHOR]