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Background Airway management in patients with out of hospital cardiac arrest (OHCA) is important and several methods are used. The establishment of a supraglottic airway device (SAD) is a common technique used during OHCA. Two types of SAD are routinely used in Norway; the Kings LTS-D™ and the I-gel®. The aim of this study was to compare the clinical performance of these two devices in terms of difficulty, number of attempts before successful insertion and overall success rate of insertion. Methods All adult patients with OHCA, in whom ambulance personnel used a SAD over a one-year period in the ambulance services of Central Norway, were included. After the event, a questionnaire was completed and the personnel responsible for the airway management were interviewed. Primary outcomes were number of attempts until successful insertion, by either same or different ambulance personnel, and the difficulty of insertion graded by easy, medium or hard. Secondary outcomes were reported complications with inserting the SAD’s. Results Two hundred and fifty patients were included, of whom 191 received I-gel and 59 received LTS-D. Overall success rate was significantly higher in I-gel (86%) compared to LTS-D (75%, p = 0.043). The rates of successful placements were higher when using I-gel compared to LTS-D, and there was a significant increased risk that the insertion of the LTS-D was unsuccessful compared to the I-gel (risk ratio 1.8, p = 0.04). I-gel was assessed to be easy to insert in 80% of the patients, as opposed to LTS-D which was easy to insert in 51% of the patients. Conclusions Overall success rate was significantly higher and the difficulty in insertion was significantly lower in the I-gel group compared to the LTS-D in patients with OHCA.

All information on injuries should be collected in a national injury registry devised for research. This will pave the way for a new strategy for injury prevention.

Background To provide age- and sex-specific incidence and case fatality rates for non-traumatic aneurysmal subarachnoid hemorrhage (aSAH) in Norway. We also studied time trends in incidence and case fatality, as well as predictors of death following aSAH. Methods A nationwide study using discharge data for patients admitted with aSAH between 2008 and 2014. Results A total of 1732 patients with aSAH were included. The mean age was 60 years (SD 14) and 63% were females. Crude annual incidence was 5.7 per 100,000 person-years (95% CI 5.4–6.0) and was higher in females (6.3 per 100,000, 95% CI 5.9–6.7) compared with males (4.9 per 100,000, 95% CI 4.5–5.3). The annual decline in aSAH incidence was 3.2% per year (p = 0.007). The cumulative proportions of fatalities at days 30, 90, and 1 year were 22%, 25%, and 37%, respectively. The 30-day mortality rate did not change during the study period. Age (HR 0.7–2.2) and aneurysms in the posterior circulation (HR 1.7, 95% CI 1.3–2.3, p = 0.001) were associated with higher 30-day case fatality following aSAH, while aneurysm repair (HR 0.2, 95% CI 0.2–0.3, p Conclusions The incidence of aSAH declined in Norway between 2008 and 2014. Case fatality following aSAH continues to be high, and the 30-day mortality during the study period was unchanged. Increasing age and aneurysms in the posterior circulation were associated with increased risk of death within 30 days following aSAH.

Background Endotracheal suctioning (ETS) is required in critically ill patients but may lead to adverse physiologic effects. The aim of this study was to investigate risk factors associated with adverse respiratory and circulatory effects of ETS, in post-cardiac arrest patients receiving controlled ventilation. Methods Patients with return of spontaneous circulation after out-of-hospital cardiac arrest were followed the first five days in the intensive care unit (ICU). For each ETS procedure performed, data were extracted from the electronic ICU records 10 min before and until 30 min after the procedure. Adverse events were defined as heart rate > 120 beats/min, systolic blood pressure > 200 or < 80 mmHg or SpO2 < 85%. Multivariate logistic regression was applied with SpO2 < 85% and systolic blood pressure < 80 mmHg as primary outcomes. Results For the 36 patients included in the study, the median number of ETS-procedures per patient was 13 (range 1–33). Oxygen desaturation occurred in 10.3% of procedures and severe hypotension in 6.6% of procedures. In the multivariate analysis, dose of noradrenaline, light sedation and oxygen desaturation prior to suctioning were associated with increased risk of oxygen desaturation. Doses of noradrenaline, suction with manual ventilation, suction in combination with patient repositioning, and first day of treatment in the ICU were significantly associated with severe hypotension. Conclusions The risk of circulatory and respiratory deterioration during ETS in post-cardiac arrest patients is increased the first day of ICU care, and related to sedation, dose of noradrenaline and pre-procedure hypoxemia.

Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be an adjunct treatment to cardiopulmonary resuscitation (CPR). Aortic occlusion may increase aortic pressure and increase the coronary perfusion pressure and the cerebral blood flow. Peripheral arterial blood pressure is often measured during or after CPR, however, changes in peripheral blood pressure after aortic occlusion is insufficiently described. This study aimed to assess changes in peripheral arterial blood pressure after REBOA in patients with out of hospital cardiac arrest. Methods A prospective observational study performed at the helicopter emergency medical service in Trondheim (Norway). Eligible patients received REBOA as adjunct treatment to advanced cardiac life support. Peripheral invasive arterial blood pressure and end-tidal CO2 (EtCO2) was measured before and after aortic occlusion. Differences in arterial blood pressures and EtCO2 before and after occlusion was analysed with Wilcoxon Signed Rank test. Results Five patients were included to the study. The median REBOA procedural time was 11 min and median time from dispatch to aortic occlusion was 50 min. Two patients achieved return of spontaneous circulation. EtCO2 increased significantly 60 s after occlusion, by a mean of 1.16 kPa (p = 0.043). Before occlusion the arterial pressure in the compression phase were 43.2 (range 12–112) mmHg, the mean pressure 18.6 (range 4–27) mmHg and pressure in the relaxation phase 7.8 (range − 7 – 22) mmHg. After aortic occlusion the corresponding pressures were 114.8 (range 23–241) mmHg, 44.6 (range 15–87) mmHg and 14.8 (range 0–29) mmHg. The arterial pressures were significant different in the compression phase and as mean pressure (p = 0.043 and p = 0.043, respectively) and not significant in the relaxation phase (p = 0.223). Conclusion This study is, to our knowledge, the first to assess the peripheral invasive arterial blood pressure response to aortic occlusion during CPR in the pre-hospital setting. REBOA application during CPR is associated with a significantly increase in peripheral artery pressures. This likely indicates improved central aortic blood pressure and warrants studies with simultaneous peripheral and central blood pressure measurement during aortic occlusion. Trial registration The study is registered in ClinicalTrials.gov (NCT03534011).

Background: Pulseless Electrical Activity (PEA) is common during in-hospital cardiac arrest. We investigated the development of four types of PEA: PEA as presenting clinical state (primary) and PEA secondary to transient return of spontaneous circulation (ROSC), ventricular fibrillation/tachycardia (VF/VT), or asystole (ASY). Methods: We analyzed 660 episodes of cardiac arrest at one Norwegian and three U.S. hospitals. ECG, chest compressions and ventilations were recorded by defibrillators during CPR. Clinical states were annotated using a graphical application. We quantified the transition intensities from PEA to ROSC (i.e. the immediate probability of a transition), and the observed half-lives for the four types of PEA (i.e. how quickly PEA develops into another clinical state), using Aalen’s additive model for time-to-event data. Results: The transition intensities to ROSC from primary PEA (n=386) and secondary PEA after ASY (n=226) were about 0.08 per minute, peaking at 6 and 9 min, respectively (figure, left). Thus, an average patient in these types of PEA has about 8% chance to achieve ROSC in one minute. Much higher transition intensities to ROSC of about 0.20 per min were observed for secondary PEA after transient ROSC (n=209) or VF/VT (n=225), peaking at 10 and 5 min, respectively. Half-live times for the four types of PEA (figure, right) were 8.5 min, 6.8 min, 4.6 min and 1.6 min, for primary PEA, and secondary PEA after ASY, transient ROSC and VF/VT, respectively. Discussion: The observed clinical development of PEA in terms of intensity, peak intensity and half-lives during resuscitation differs substantially between the four types of PEA. The chance of obtaining ROSC is considerably lower in primary PEA or PEA after ASY, compared to PEA following transient ROSC or after VF/VT. This may increase understanding of the nature of PEA and the process leading to ROSC; and allow for simple prognostic assessments during a resuscitation attempt.

Cardiac arrest in toddlers is rare, but accidental electrocution may induce arrhythmias.A previously healthy one-year-old child suffered electrocution from an old shoe-warmer and went into cardiac arrest. Her mother started cardiopulmonary resuscitation (CPR) and the ambulance arrived after seven minutes. The first registered rhythm was ventricular tachycardia and the child was defibrillated with an energy dose of 50 joules. One minute after the shock, the child regained spontaneous breathing and was transported to the nearby hospital. The child was unconscious on arrival, intubated and sedated. The first capillary blood gas showed a pH of 7.20, a pCO2 of 5.2 kPa and lactate of 8.4 mmol/l. The child was extubated five hours later. Apart from burn injuries to both hands that necessitated skin transplants, the child survived without sequelae.Healthcare providers must be prepared to apply a defibrillator in cases of paediatric cardiac arrest.

Background Survival after out-of-hospital cardiac arrest (OHCA) is poor and dependent on high-quality cardiopulmonary resuscitation. Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be advantageous in non-traumatic OHCA due to the potential benefit of redistributing the cardiac output to organs proximal to the aortic occlusion. This theory is supported by data from both preclinical studies and human case reports. Methods This multicentre trial will enrol 200 adult patients, who will be randomised in a 1:1 ratio to either a control group that receives advanced cardiovascular life support (ACLS) or an intervention group that receives ACLS and REBOA. The primary endpoint will be the proportion of patients who achieve return of spontaneous circulation with a duration of at least 20 min. The secondary objectives of this trial are to measure the proportion of patients surviving to 30 days with good neurological status, to describe the haemodynamic physiology of aortic occlusion during ACLS, and to document adverse events. Discussion Results from this study will assess the efficacy and safety of REBOA as an adjunctive treatment for non-traumatic OHCA. This novel use of REBOA may contribute to improve treatment for this patient cohort. Trial registration The trial is approved by the Regional Committee for Medical and Health Research Ethics in Norway (reference 152504) and is registered at ClinicalTrials.gov (reference NCT04596514) and as Universal Trial Number WHO: U1111-1253-0322.

Purpose Patients transferred from an intensive care unit (ICU) to a general ward are at risk for clinical deterioration. The aim of the study was to determine if an increase in National Early Warning Score (NEWS) value predicted worse outcomes in surgical ward patients previously treated in the ICU. Patients and methods A retrospective observational study was conducted in a cohort of gastrointestinal surgery patients after transfer from an ICU/high dependency unit (HDU). NEWS values were collected throughout the ward admission. Clinical deterioration was defined by ICU readmission or death. The ability of NEWS to predict clinical deterioration was determined using a linear mixed effect model. Results We included 124 patients, age 65.9±14.5, 60% males with an ICU Simplified Acute Physiology Score II 33.8±12.7. No patients died unexpectedly at the ward and 20 were readmitted to an ICU/HDU. The NEWS values increased by a mean of 0.15 points per hour (intercept 3.7, P

Background Whole body ischemia and reperfusion injury after cardiac arrest leads to the massive inflammation clinically manifested in the post-cardiac arrest syndrome. Previous studies on the inflammatory effect on circulatory failure after cardiac arrest have either investigated a selected patient group or a limited part of the inflammatory mechanisms. We examined the association between cardiac arrest characteristics and inflammatory biomarkers, and between inflammatory biomarkers and circulatory failure after cardiac arrest, in an unselected patient cohort. Methods This was a prospective study of 50 consecutive patients with out-of-hospital cardiac arrest. Circulation was invasively monitored from admission until day five, whereas inflammatory biomarkers, i.e. complement activation, cytokines and endothelial injury, were measured daily. We identified predictors for an increased inflammatory response, and associations between the inflammatory response and circulatory failure. Results We found a marked and broad inflammatory response in patients after cardiac arrest, which was associated with clinical outcome. Long time to return of spontaneous circulation and high lactate level at admission were associated with increased complement activation (TCC and C3bc), pro-inflammatory cytokines (IL-6, IL-8) and endothelial injury (syndecan-1) at admission. These biomarkers were in turn significantly associated with lower mean arterial blood pressure, lower cardiac output and lower systemic vascular resistance, and increased need of circulatory support in the initial phase. High levels of TCC and IL-6 at admission were significantly associated with increased 30-days mortality. Conclusion Inflammatory biomarkers, including complement activation, cytokines and endothelial injury, were associated with increased circulatory failure in the initial period after cardiac arrest.

Background Cardiac arrest in toddlers is rare, but accidental electrocution may induce arrhythmias. Case presentation A previously healthy one-year-old child suffered electrocution from an old shoe-warmer and went into cardiac arrest. Her mother started cardiopulmonary resuscitation (CPR) and the ambulance arrived after seven minutes. The first registered rhythm was ventricular tachycardia and the child was defibrillated with an energy dose of 50 joules. One minute after the shock, the child regained spontaneous breathing and was transported to the nearby hospital. The child was unconscious on arrival, intubated and sedated. The first capillary blood gas showed a pH of 7.20, a pCO2 of 5.2 kPa and lactate of 8.4 mmol/l. The child was extubated five hours later. Apart from burn injuries to both hands that necessitated skin transplants, the child survived without sequelae. Interpretation Healthcare providers must be prepared to apply a defibrillator in cases of paediatric cardiac arrest.

IntroductionTraumatic injuries constitute a major cause of mortality and morbidity. Still, the public health burden of trauma in Norway has not been characterised using nationwide registry data. More knowledge is warranted on trauma risk factors and the long-term outcomes following trauma. The Injury Prevention and long-term Outcomes following Trauma project will establish a comprehensive research database. The Norwegian National Trauma Registry (NTR) will be merged with several data sources to pursue the following three main research topics: (1) the public health burden of trauma to society (eg, excess mortality and disability-adjusted life-years (DALYs)), (2) trauma aetiology (eg, socioeconomic factors, comorbidity and drug use) and (3) trauma survivorship (eg, survival, drug use, use of welfare benefits, work ability, education and income).Methods and analysisThe NTR (n≈27 000 trauma patients, 2015–2018) will be coupled with the data from Statistics Norway, the Norwegian Patient Registry, the Cause of Death Registry, the Registry of Primary Health Care and the Norwegian Prescription Database. To quantify the public health burden, DALYs will be calculated from the NTR. To address trauma aetiology, we will conduct nested case–control studies with 10 trauma-free controls (drawn from the National Population Register) matched to each trauma case on birth year, sex and index date. Conditional logistic regression models will be used to estimate trauma risk according to relevant exposures. To address trauma survivorship, we will use cohort and matched cohort designs and time-to-event analyses to examine various post-trauma outcomes.Ethics and disseminationThe project is approved by the Regional Committee for Medical Research Ethics. The project’s data protection impact assessment is approved by the data protection officer. Results will be disseminated to patients, in peer-reviewed journals, at conferences and in the media.

Cardiopulmonary resuscitation quality (CPRQ) parameters can be derived from electric signals obtained during resuscitation. We propose to model a probabilistic relationship between CPRQ parameters and the physiological response as judged by ECG-features, to guide therapy in a clinical context. A total of 821 compression sequences were extracted from 394 out-of-hospital resuscitation episodes. Sequences were categorized as effective if the post sequence cardiac rhythm had better prognosis than the pre-sequence rhythm by a positive difference, otherwise as non effective if the difference was negative. CPRQ parameters related to depth and rate were calculated. Three alternative approaches were designed for the binary classifier based on the CPRQ parameters: quadratic discriminant analysis (QDA), logistic regression (LR) and artificial neural networks (ANN). The positive class discriminant function defined the probability of effective compressions (Pec). The classification accuracies were around 0.6 for all three models. The highest probability estimates of effective chest compressions corresponded to the depth (5–6 cm) and rate (100–120 min −1 ) currently recommended in the CPR guidelines. We have proposed a novel method to relate the quality of chest compressions to the physiologic response to CPR.

Background: Airway management in patients with out of hospital cardiac arrest (OHCA) is important and several methods are used. The establishment of a supraglottic airway device (SAD) is a common technique used during OHCA. Two types of SAD are routinely used in Norway; the Kings LTS-D™ and the I-gel®. The aim of this study was to compare the clinical performance of these two devices in terms of difficulty and number of attempts before successful insertion.Methods: All adult patients with OHCA, in whom ambulance personnel used a SAD over a one-year period in the ambulance services of Central Norway, were included. After the event, a questionnaire was completed and the personnel responsible for the airway management were interviewed. Primary outcomes were number of attempts until successful placement of SAD and graded difficulty of insertion. Secondary outcomes were specified challenges with the SAD at insertion. Intergroup differences were compared using Chi-square test for multiple groups.Results: Two hundred and fifty patients were included, of whom 191 received I-gel and 59 received LTS-D. Overall success rate was significantly higher in I-gel (86 %) compared to LTS-D (75%, p = 0,043). The difficulties of insertion were significantly lower among patients receiving I-gel (easy 80 %, medium 13 % and difficult 7 %) compared to LTS-D (easy 51 %, medium 22 % and difficult 27 %, p < 0,001). Conclusions: Overall success rate was significantly higher and the difficulty in insertion was significantly lower in the I-gel group compared to the LTS-D in patients with OHCA.

Background: Cardiac arrest presents with one of three clinical states; Cardiac standstill (asystole), Pulseless Electrical Activity (PEA), or ventricular fibrillation/tachycardia (VF/VT). PEA results from multiple etiologies and accounts for most in-hospital cardiac arrests. We quantified the dynamic nature of transitions in and out of PEA, in terms of hospital sites and presumed etiology. Methods: We analyzed 538 episodes of cardiac arrest at one Norwegian hospital and three U.S. hospitals. ECG, chest compressions and ventilations were recorded by defibrillators during CPR. Each event was assessed using a graphical application. We quantified the transition intensity, i.e. the immediate probability of a transition given the current state, between PEA and ROSC using Aalen’s additive model for time-to-event data. Results: The overall transition intensity from PEA to ROSC was about 0.10 min -1 , so an average patient in PEA has about 10 % chance to gain ROSC the following 1 minute. The intensity peaked at 7 minutes of CPR (Figure), with some heterogeneity between hospitals (0.07 to 0.11 min -1 ). The reverse transition intensity from ROSC to PEA was rather constant at 0.10 min -1 (range 0.05-0.11). Information regarding assumed cardiac or non-cardiac etiology was available in 208 episodes (123 cardiac). Patients with a cardiac etiology had a marginally smaller (-0.03 min -1 ) chance of making the transition from PEA to ROSC (p=0.049), but etiology did not impact on the ROSC to PEA transition (p=0.39). Discussion: For transitions between PEA and ROSC we observed an overall intensity of 0.1 min -1 , with some hospital heterogeneity. This may be due to heterogeneity in the underlying patient populations. We found the probability of transitioning from PEA to ROSC to increase from the start event recording until an average peak intensity at 7 minutes. This information may increase the clinicians’ understanding of the process from PEA to ROSC.

A woman in her forties who was hospitalised after a three-week history of respiratory tract infection, developed severe acute respiratory distress syndrome. Nasopharyngeal swabs taken on days 1 and 3 after admission were negative for the SARS-CoV-2 virus, while bronchoalveolar lavage tested positive. We assume this is because the patient had stopped viral shedding in the upper respiratory tract because of the long time between symptom onset and testing.

En kvinne i 40-årene som ble innlagt etter tre ukers sykehistorie med luftveisinfeksjon, utviklet alvorlig akutt lungesviktsyndrom. Nasofarynksprøver tatt dag 1 og 3 etter innleggelse var negative for sars-CoV-2-viruset, mens bronkoalveolær skylling var positiv. Vi antar dette skyldes at pasienten hadde sluttet å frigjøre virus i øvre luftveier grunnet lang tid fra symptomdebut til testing.

Background: Although in-hospital pediatric cardiac arrests and cardiopulmonary resuscitation occur >15,000/year in the US, few studies have assessed which factors affect the course of resuscitation in these patients. We investigated transitions from Pulseless Electrical Activity (PEA) to Ventricular Fibrillation/pulseless Ventricular Tachycardia (VF/pVT), Return of Spontaneous Circulation (ROSC) and recurrences from ROSC to PEA in children and adolescents with in-hospital cardiac arrest. Methods: Episodes of cardiac arrest at the Children's Hospital of Philadelphia were prospectively registered. Defibrillators that recorded chest compression depth/rate and ventilation rate were applied. CPR variables, patient characteristics and etiology, and dynamic factors (e.g. the proportion of time spent in PEA or ROSC) were entered as time-varying covariates for the transition intensities under study. Results: In 67 episodes of CPR in 59 patients (median age 15 years) with cardiac arrest, there were 52 transitions from PEA to ROSC, 22 transitions from PEA to VF/pVT, and 23 recurrences of PEA from ROSC. Except for a nearly significant effect of mean compression depth beyond a threshold of 5.7 cm, only dynamic factors that evolved during CPR favored a transition from PEA to ROSC. The latter included a lower proportion of PEA over the last 5 min and a higher proportion of ROSC over the last 5 min. Factors associated with PEA to VF/pVT development were age, weight, the proportion spent in VF/pVT or PEA the last 5 min, and the general transition intensity, while PEA recurrence from ROSC only depended on the general transition intensity. Conclusion: The clinical course during pediatric cardiac arrest was mainly influenced by dynamic factors associated with time in PEA and ROSC. Transitions from PEA to ROSC seemed to be favored by deeper compressions. /© 2020 TheAuthor(s). Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/ by/4.0/).This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)

Background Pulseless electrical activity (PEA) is a frequent initial rhythm in cardiac arrest, and ECG characteristics have been linked to prognosis. The aim of this study was to examine the development of ECG characteristics during advanced life support (ALS) and cardiopulmonary resuscitation (CPR) in cardiac arrest with initial PEA, and to assess any association with survival. Methods Patients with in-hospital cardiac arrest with initial PEA at St. Olav Hospital (Trondheim, Norway) over a three-year period were included. A total of 2187 combined observations of QRS complex rate (heart rate) and QRS complex width for the duration of ALS were determined from defibrillator recordings from 74 episodes of cardiac arrest. Results Increasing heart rate and decreasing QRS complex width during ALS was significantly more prevalent in patients who obtained return of spontaneous circulation compared to patients who were declared dead. Conclusion Changes in ECG characteristics during ALS in cardiac arrest presenting as PEA are related to prognosis. An increase in heart rate was observed in the last 3–6 min before ROSC was obtained.

Introduction: The proportion of patients surviving to hospital discharge after out of hospital cardiac arrest (OHCA) is low and any measure that may improve circulation to vital organs during cardiopulmonary resuscitation (CPR) is beneficial. The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) will redistribute cardiac output to the organs proximal to the occlusion. Animal studies supports that aortic occlusion during CPR might benefit patients suffering from OHCA, but human data are scarce. Methods: We performed an observational study at the helicopter emergency medical service in Trondheim (Norway) to assess the feasibility and safety of establishing REBOA in OHCA patients. The femoral artery was identified by ultrasound and a REBOA catheter was placed in the thoracic aorta. All patients received advanced cardiac life support (ACLS) during the procedure. REBOA eligibility, procedural success and time intervals were registered. A safety monitoring program was conducted to ensure that the procedure did not interfere with the quality of ACLS. Results: REBOA was initiated in ten of 98 OHCA patients. The mean age was 63 years (55-71) and 7 were male. The REBOA procedure was successful in all cases (100%), with 80% success rate on first cannulation attempt. Mean REBOA procedural time was 11,7 minutes (8-16, SD 3,2). End-tidal CO2 (EtCO2) increased by a mean of 1.9 kPa at 60 seconds after inflation compared to baseline (p < 0.001). Six of 10 patients (60%) achieved return of spontaneous circulation, 3 (30%) was admitted to hospital. 30-day survival was 10%. The mean width of the femoral artery and vein during CPR was 5,9 mm (3,6 - 7,4, SD 1,2) and 9,4 mm (5,0 - 12,9, SD 2,9), respectively. The safety monitoring group identified no negative influence on the ACLS quality. Conclusions: This is the first study to assess the pre-hospital use of REBOA in patients with non-traumatic cardiac arrest. The REBOA procedure does not interfere with the quality of the ACLS. REBOA is a feasible adjunct treatment in OHCA. The significant increase in EtCO2 after occlusion suggests improved organ circulation during CPR.

Training in first aid has a long tradition in Norway. We believe that survival after time-critical events outside hospital can be further improved through systematic training.

Training in first aid has a long tradition in Norway. We believe that survival after time-critical events outside hospital can be further improved through systematic training.

Introduction Pulseless electrical activity (PEA) is an increasingly common presentation in cardiac arrest. The aim of this study was to investigate possible associations between early ECG patterns in PEA and the underlying causes and survival of in-hospital cardiac arrest (IHCA). Methods Prospectively observed episodes of IHCA presenting as PEA between January 2009 and august 2013, with a reliable cause of arrest and corresponding defibrillator ECG recordings, were analysed. QRS width, QT interval, Bazett's corrected QT interval, presence of P waves and heart rate (HR) was determined. QRS width and HR were considered to be normal below 120 ms and within 60–100 cardiac cycles per minute, respectively. Results Fifty-one episodes fulfilled the inclusion criteria. The defibrillator was attached after a median of one minute (75th percentile; 3 min) after the onset of arrest. Ninety percent (46/51) had widened QRS complexes, 63% (32/51) were defined as ‘wide-slow’ due to QRS-widened bradycardia, and only 6% (3/51) episodes were categorized as normal. No unique cause-specific ECG pattern could be identified. Further 7 episodes with a corresponding defibrillator file, but without a reliable cause, were included in analysis of survival. Abnormal ECG patterns were seen in all survivors. None of the patients with ‘normal’ PEA survived. Conclusion Abnormal ECG patterns were frequent at the early stage of in-hospital PEA. No unique patterns were associated with the underlying causes or survival.

Introduction: Presence of electrocardiographic rhythm, documented by the electrocardiogram (ECG), in the absence of palpable pulses defines pulseless electrical activity (PEA). Our aims were to examine the development of ECG characteristics during advanced life support (ALS) from Out-of-Hospital-Cardiac-Arrest (OHCA) with initial PEA, and to explore the effects of epinephrine on these characteristics. Methods: Patients with OHCA and initial PEA in a randomized controlled trial of ALS with or without intravenous access and medications were included. QRS widths and heart-rates were measured in recorded ECG signals during pauses in compressions. Statistical analysis was carried out by multivariate regression (MANOVA). Results: Defibrillator recordings from 170 episodes of cardiac arrest were analyzed, 4840 combined measurements of QRS complex width and heart rate were made. By the multivariate regression model both whether epinephrine was administered and whether return of spontaneous circulation (ROSC) was obtained were significantly associated with changes in QRS width and heart rate. For both control and epinephrine groups, ROSC was preceded by decreasing QRS width and increasing rate, but in the epinephrine group an increase in rate without a decrease in QRS width was associated with poor outcome (fig). Conclusion: The QRS complex characteristics are affected by epinephrine administration during ALS, but still yields valuable prognostic information.

Introduction: Pulseless electrical activity (PEA) is a frequent initial rhythm in in-hospital cardiac arrest. ECG changes during cardiopulmonary resuscitation (CPR) have been linked to prognosis; QRS complex narrowing and increase in QRS-rate/heart rate was observed before return of spontaneous circulation (ROSC). Our hypothesis was that ECG changes during CPR of patients with cardiac arrest with initial PEA could also be different depending on etiology of arrest. Methods: Patients with cardiac arrest with initial PEA at St. Olav University Hospital (Trondheim, Norway) between January 2009 and January 2012 were prospectively included. QRS duration and heart rate were measured at all pauses in chest compressions. Etiologies were categorized as ‘Cardiac’ or ‘Other’. Trends in the material were inspected using additive mixed effects models for the last 18 minutes before ROSC or end of CPR and development of QRS width was analyzed using linear mixed effects models based on these trends. Results: A total of 63 patients for whom a reliable cause of arrest could be identified retrospectively were included. 1844 combined measurements of QRS width and heart rate were made. According to the additive mixed effects model the development in heart rate was similar in both etiology groups. The change in QRS width differed in patients who obtained ROSC, with the Cardiac group narrowing more than the other group, and both groups ending at essentially the same QRS widths at ROSC (figure). By the linear mixed effects model this difference in change was statistically significant (p=0.04). In patients who did not have ROSC, the cardiac group had significantly (p=0.001, linear mixed effects model) wider QRS complexes, but the change towards ROSC was the same in both groups. Conclusion: During the last 18 minutes before ROSC ECG characteristics differed depending on etiology, with cardiac etiologies having wider QRS complexes in the no-ROSC groups and narrowing more towards ROSC in the ROSC groups.

Background: Pediatric cardiac arrests are relatively rare outside specialist centres, and may differ in several ways from adults. The aim of this study was to investigate factors that may impact on the transition from Pulseless electrical activity (PEA) to Return of spontaneous circulation (ROSC), or recurrence of PEA from ROSC, in children and adolescents. Methods: We prospectively registered resuscitation episodes in a pediatric hospital over a period of 3 years, using defibrillators that can register CPR variables like chest compression depth and rate, and ventilation rate. ROSC was defined as an organized electrical rhythm without chest compressions >= 1 minute. CPR variables, patient characteristics and etiology, and dynamic covariates (e.g. the proportion of time spent in PEA or ROSC) were entered as univariate predictors of the transition intensity between PEA and ROSC or the reverse. Statistical anlysis was done with using Aalen’s additive regression model, a variant of survival analysis. Results: In 64 cardiac arrest patients (median age 15, range 2-22 years), there were 49 transitions from PEA to ROSC, and 25 recurrences of PEA from ROSC. Identified factors favoring a transition from PEA to ROSC include greater mean compression depth (p=0.010), higher weight (p=0.006), and lower proportion of PEA for the last 5 minutes (p=0.001). PEA recurrence from ROSC was also associated with greater mean compression depth (p=0.006) and higher weight (p=0.021). However, respiratory etiology was negatively associated with PEA recurrence (p=0.007). Immediate effects (i.e. the last 1-minute average) were more pronounced than 3-minute average effects. Dynamic covariates, which capture the course of the individual patient (e.g. cumulative time in PEA or in ROSC, number of transitions), were strongly associated with the transitions. Conclusion: Some event variables (compression depth, patient weight) were associated with transitions between PEA and ROSC in both directions, and a respiratory etiology appears to protect against PEA recurrence. Dynamic covariates impact on the likelihood of transitioning from PEA to ROSC or PEA recurrence.

Background: Sudden cardiac arrest may present with one of three clinical states (rhythms): Ventricular fibrillation/tachycardia (VF/VT), Pulseless Electrical Activity (PEA), or Asystole (ASY). During Advanced Cardiac Life Support (ACLS), the patient may also transition between the other states or reach temporary ROSC (defined as an organized electrical rhythm without chest compressions >= 1 min). Finally, either sustained ROSC or death will ensue. The aim of study was to investigate and quantify the dynamic characteristics of this process and compare with previous studies. Methods: As part of a CPR quality assessment initiative, we prospectively registered the development of clinical states using defibrillators that records the ECG as well as ongoing chest compressions. These recordings were analyzed in a multi-state statistical framework. Instantaneous transition rates were obtained by smoothing the Nelson-Aalen estimator of cumulative intensities. Results: We analyzed 201 episodes in 168 patients between 2008 and 2009 at the Hospital of the University of Pennsylvania (51% women; median age 60, IQR 49-73 years). Most episodes (62%) took place in the Medical ICU, and represented multiple etiologies. PEA was the most frequent presenting rhythm (69%); VF/VT and ASY contributed with 15 % each. In the 191 episodes with complete information about the clinical course, the transition rate from PEA to ROSC was 0.11 episodes/min (approximately 11%), the rate of PEA recurring from temporary ROSC was 0.12/min. These transition rates are both about 40 % higher than observed earlier. The prevalence of sustained ROSC was 0.6 (60%) at about 25 min (figure: 0 to 45 min of CPR). Conclusion: We provide quantitative overview of the dynamic process of clinical state transitions during in-hospital cardiac arrest in adults. Compared to earlier studies from American and Norwegian Hospitals, we found higher transition rates between PEA to ROSC, and a high prevalence of sustained ROSC.

During paediatric cardiopulmonary resuscitation (CPR), patients may transition between pulseless electrical activity (PEA), asystole, ventricular fibrillation/tachycardia (VF/VT), and return of spontaneous circulation (ROSC). The aim of this study was to quantify the dynamic characteristics of this process. Methods ECG recordings were collected in patients who received CPR at the Children’s Hospital of Philadelphia (CHOP) between 2006 and 2013. Transitions between PEA (including bradycardia with poor perfusion), VF/VT, asystole, and ROSC were quantified by applying a multi-state statistical model with competing risks, and by smoothing the Nelson-Aalen estimator of cumulative hazard. Results Seventy-four episodes of cardiac arrest were included. Median age of patients was 15 years [IQR 11–17], 50% were female and 62% had a respiratory aetiology of arrest. Presenting cardiac arrest rhythms were PEA (60%), VF/VT (24%) and asystole (16%). A temporary surge of PEA was observed between 10 and 15 min due to a doubling of the transition rate from ROSC to PEA (i.e. ‘re-arrests’). The prevalence of sustained ROSC reached an asymptotic value of 30% at 20 min. Simulation suggests that doubling the transition rate from PEA to ROSC and halving the relapse rate might increase the prevalence of sustained ROSC to 50%. Conclusion Children and adolescents who received CPR were prone to re-arrest between 10 and 15 min after start of CPR efforts. If the rate of PEA to ROSC transition could be increased and the rate of re-arrests reduced, the overall survival rate may improve.

BackgroundThe proportion of avoidable hospital deaths is challenging to estimate, but has great implications for quality improvement and health policy. Many studies and monitoring tools are based on selected high-risk populations, which may overestimate the proportion. Mandatory reporting systems, however, under-report. We hypothesise that a review of an unselected sample of hospital deaths will provide an estimate of avoidability in-between the estimates from these methods.MethodsA retrospective case record review of an unselected population of 1000 consecutive non-psychiatric hospital deaths in a Norwegian hospital trust was conducted. Reviewers evaluated to what degree each death could have been avoided, and identified problems in care.ResultsWe found 42 (4.2%) of deaths to be at least probably avoidable (more than 50% chance of avoidability). Life expectancy was shortened by at least 1 year among 34 of the 42 patients with an avoidable death. Patients whose death was found to be avoidable were less functionally dependent compared with patients in the non-avoidable death group. The surgical department had the greatest proportion of such deaths. Very few of the avoidable deaths were reported to the hospital’s report system.ConclusionsAvoidable hospital deaths occur less frequently than estimated by the national monitoring tool, but much more frequently than reported through mandatory reporting systems. Regular reviews of an unselected sample of hospital deaths are likely to provide a better estimate of the proportion of avoidable deaths than the current methods.

Aim To propose a method which analyses the electrocardiogram (ECG) waveform of any cardiac rhythm occurring during resuscitation and computes the probability of that rhythm converting into another with better prognosis ( P des ). Methods Rhythm transitions occurring spontaneously or due to defibrillation were analyzed. For each possible rhythm, ventricular fibrillation/ventricular tachycardia (VF/VT), pulseless electrical activity (PEA), pulse-generating rhythm (PR) and asystole (AS), the desired and undesired transitions were defined. ECG segments corresponding to the last 3s of rhythms prior to transition were used to extract waveform features. For each rhythm type, waveform features were combined into a logistic regression model to develop a rhythm specific classifier of desired transitions. This model was the monitoring function for the P des . The capacity of each rhythm specific classifier to discriminate between desired and undesired transitions was evaluated in terms of area under the curve (AUC). P des was integrated into a state sequence representation, which structures the information of cardiac arrest episodes, to analyze the effect of therapy on patient. As a case study, the effect of optimal/suboptimal cardiopulmonary resuscitation (CPR) on P des was analyzed. The mean P des was computed for the pre- and post-CPR intervals which presented the same underlying rhythm. The relationship between the optimal/suboptimal CPR and increase/decrease of P des was analyzed. Results The AUC was 0.80, 0.79, 0.73 and 0.61 for VF/VT, PEA, PR and AS respectively. The P des quantified the probability of every rhythm of the episode developing to a better state, and the evolution of P des was coherent with the provided therapy. The case study indicated, for most rhythms, that positive trends in the dynamic behaviour could be associated with optimal CPR, whereas the opposite seemed true for negative trends. Conclusion A method for continuous ECG waveform analysis covering all cardiac rhythms during resuscitation has been proposed. This methodology can be further developed to be used in retrospective studies of CPR techniques, and, in the future, for potentially monitoring in real time the probability of survival of patients being resuscitated.

Background In advanced life support (ALS), time-cycled “loops” of chest compressions form the basis of action. However, the provider must compromise between interrupting compressions and detecting a change in cardiac rhythm. An “optimal” loop duration would best balance these choices. The current international CPR guidelines recommend 2-min loop durations. The aim of this study was to investigate the “optimal” loop duration in patients with initial asystole or pulseless electrical activity (PEA). Materials and methods Detailed defibrillator recordings from 249 in-hospital cardiac arrests at the University of Chicago Medicine (Chicago, IL) and St. Olav University Hospital (Trondheim, Norway) were analysed. The clinical states of asystole, PEA, ventricular fibrillation/-tachycardia (VF/VT) and return of spontaneous circulation (ROSC) were annotated along the time axis. PEA and asystole were combined as a single state for the analysis of state development. The probability of staying in PEA/asystole over time was estimated non-parametrically. In addition, to distinguish between initial and secondary PEA/asystole, the latter was defined by the transition from VF/VT or ROSC. Results Among patients with initial PEA ( n = 179), 25% and 50% of patients had left PEA/asystole after 4 and 9 min of ALS efforts, respectively. The corresponding time points for patients with initial asystole ( n = 70) were 7.3 and 13.3 min, respectively. The probability of transition from secondary PEA/asystole to ROSC or VF/VT varied between 10% and 20% in each 2–4 min interval. Conclusion The “optimal” first loop duration may be 4 min in initial PEA and 6–8 min in initial asystole. If secondary PEA/asystole is encountered, 2-min loop duration seems appropriate.