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Aim Of the Study: Inflammatory cytokines have been implicated in the pathophysiology of post cardiac arrest syndrome, including myocardial dysfunction and hypotension, often leading to multi-organ system dysfunction and death. We hypothesized that administration of infliximab after return of spontaneous circulation (ROSC) would ameliorate hypotension and myocardial dysfunction and prolong survival.Methods: Domestic swine were anesthetized and instrumented. Balloon occlusion of the LAD coronary artery just distal to the first septal perforator was performed and VF followed spontaneously in all animals. After 7 min, chest compressions, defibrillation, and standard ACLS resuscitation was performed. Animals achieving ROSC (N=32) were randomized to receive infliximab (5 mg/kg, n=16) or vehicle (250 mL normal saline, n=16) immediately post-ROSC and survival and hemodynamics were monitored for 3 h.Results: There were no differences in prearrest hemodynamic variables, TNF-α levels, or resuscitation variables between groups. Both groups demonstrated a time dependent decline in mean arterial pressure (MAP) and stroke work (SW) post-ROSC with a nadir at 1 h followed by recovery over hours 2 and 3. This decline was blunted in infliximab-treated swine (1-h between group difference in MAP 21 mm Hg, 95% CI 3-38 mm Hg and SW 6.7 gm-m, 95% CI 0.4-13 at 1 h). Left ventricular systolic dp/dt fell in the vehicle group (-437 mm Hg/s, 95% CI -183 to -690) but did not in the infliximab group. Tau rose only in the vehicle group (44 ms, 95% CI 1-87). Short-term survival was higher in the infliximab group (Kaplan-Meier p=0.022).Conclusions: Blockade of TNF-α in the immediate post-ROSC period improved survival and hemodynamic parameters in this swine model of ischemic VF. [ABSTRACT FROM AUTHOR]

STUDY OBJECTIVES: We compare laryngoscopic quality and time to highest-grade view between a face-to-face approach with the GlideScope and traditional flexible fiber-optic laryngoscopy in awake, upright volunteers. METHODS: This was a prospective, randomized, crossover study in which we performed awake laryngoscopy under local anesthesia on 23 healthy volunteers, using both a GlideScope video laryngoscopy face-to-face technique with the blade held upside down and flexible fiber-optic laryngoscopy. Operator reports of Cormack-Lehane laryngoscopic views and video-reviewed time to highest-grade view, as well as number of attempts, were recorded. RESULTS: Ten women and 13 men participated. A grade II or better view was obtained with GlideScope video laryngoscopy in 22 of 23 (95.6%) participants and in 23 of 23 (100%) participants with flexible fiber-optic laryngoscopy (relative risk GlideScope video laryngoscopy versus flexible fiber-optic laryngoscopy 0.96; 95% confidence interval 0.88 to 1.04). Median time to highest-grade view for GlideScope video laryngoscopy was 16 seconds (interquartile range 9 to 34) versus 51 seconds (interquartile range 35 to 96) for flexible fiber-optic laryngoscopy. A distribution of interindividual differences demonstrated that GlideScope video laryngoscopy was, on average, 39 seconds faster than flexible fiber-optic laryngoscopy (95% confidence interval 0.2 to 76.9 seconds). CONCLUSION: GlideScope video laryngoscopy can be used to obtain a Cormack-Lehane grade II or better view in the majority of awake, healthy volunteers when an upright face-to-face approach is used and was slightly faster than traditional flexible fiber-optic laryngoscopy. However, flexible fiber-optic laryngoscopy may be more reliable at obtaining high-grade views of the larynx. Awake, face-to-face GlideScope use may offer an alternative approach to the difficulty airway, particularly among providers uncomfortable with flexible fiber-optic laryngoscopy. [ABSTRACT FROM AUTHOR]

Objective: This study sought to externally validate and compare proposed methods for stratifying sepsis risk at emergency department (ED) triage., Methods: This nested case/control study enrolled ED patients from four hospitals in Utah and evaluated the performance of previously-published sepsis risk scores amenable to use at ED triage based on their area under the precision-recall curve (AUPRC, which balances positive predictive value and sensitivity) and area under the receiver operator characteristic curve (AUROC, which balances sensitivity and specificity). Score performance for predicting whether patients met Sepsis-3 criteria in the ED was compared to patients' assigned ED triage score (Canadian Triage Acuity Score [CTAS]) with adjustment for multiple comparisons., Results: Among 2000 case/control patients, 981 met Sepsis-3 criteria on final adjudication. The best performing sepsis risk scores were the Predict Sepsis version #3 (AUPRC 0.183, 95 % CI 0.148-0.256; AUROC 0.859, 95 % CI 0.843-0.875) and Borelli scores (AUPRC 0.127, 95 % CI 0.107-0.160, AUROC 0.845, 95 % CI 0.829-0.862), which significantly outperformed CTAS (AUPRC 0.038, 95 % CI 0.035-0.042, AUROC 0.650, 95 % CI 0.628-0.671, p < 0.001 for all AUPRC and AUROC comparisons). The Predict Sepsis and Borelli scores exhibited sensitivity of 0.670 and 0.678 and specificity of 0.902 and 0.834, respectively, at their recommended cutoff values and outperformed Systemic Inflammatory Response Syndrome (SIRS) criteria (AUPRC 0.083, 95 % CI 0.070-0.102, p = 0.052 and p = 0.078, respectively; AUROC 0.775, 95 % CI 0.756-0.795, p < 0.001 for both scores)., Conclusions: The Predict Sepsis and Borelli scores exhibited improved performance including increased specificity and positive predictive values for sepsis identification at ED triage compared to CTAS and SIRS criteria., Competing Interests: Declaration of competing interest Outside the present work, KR reports issued patent, IDP reports grant funding from Janssen Pharmaceuticals and payments to his institution for study enrollments from Regeneron and Bluejay Diagnostics, SMB reports royalties on a patent from ReddyPort. STY reports industry grant from CoLabs, and JRB reports payment from JAJ LLC medical consulting. Other authors report no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: Transport destination decisions by prehospital personnel depend on a combination of protocols, judgment, patient acuity, and patient preference. Non-protocolized transport outside the service area may result in unnecessary time out of service and inappropriate resource utilization. Scant research exists regarding clinician rationale for destination decisions., Methods: We retrospectively reviewed one year of scene transports by a single rural, hospital-based emergency medical services (EMS) system. We collected dispatch, patient demographic, primary impression, and transport data from prehospital records and matched them to emergency department (ED) data. We characterized rationale for transport decisions and compared rates of hospital admission and specialist consultation in the ED as surrogates for decision appropriateness., Results: We reviewed 2,223 patient transports, 281 of which were transported out of the service area. The most common reasons for out-of-area transport were patient preference NOT related to prior medical care (40%) and clinician judgment (24%). Admit rates were highest for per protocol (85%) and patient preference related to prior medical care (67%) groups and lowest for no explanation (41%) and clinician judgment (47%) groups. Rates of in person specialist consultation in the ED were highest in per protocol (69%) and clinician judgment (47%) groups and lowest in no explanation (23%) and patient preference NOT related to prior medical care (30%) groups. Clinician judgment was less predictive of admission and specialist consultation for non-trauma and pediatric patients than for all patients. Median time out of service was more than twice as long for out-of-area transports (140 min) compared to patients transported to the nearest facility (62 min). For out-of-area transports discharged from the ED without specialty consultation ( n  = 104), ambulances traveled an additional 52 miles/patient compared to theoretical transport to nearest facility., Conclusions: Unit out of service time more than doubled for non-protocolized transports outside of the service area and rationale for destination decisions variably predicted admission and specialist consultation rates. Patient preference NOT related to prior medical care and, in pediatric and non-trauma populations, clinician judgment, were less predictive of admission and specialist consultation. Transport guidelines should balance rationale for transport destination and patient characteristics with resource preservation, especially in low-resource systems.

Aim: Cardiac arrest afflicts over 600,000 people annually in the United States. Rates of survival from cardiac arrest have remained stagnant for decades. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is most commonly used in the management of severe hemorrhagic shock, primarily for non-compressible thoracoabdominal trauma. A growing body of evidence suggests it may serve a role in augmenting cardiac and cerebral perfusion in non-traumatic, refractory cardiac arrest. Typically, REBOA is deployed by interventional radiologists under real-time fluoroscopy. Limited data exist to demonstrate the feasibility or logistics of successful REBOA deployment in emergency departments by emergency medicine physicians., Methods: We describe an emergency medicine-driven training program and treatment protocol developed to deploy REBOA in the emergency department for patients experiencing refractory out-of-hospital cardiac arrest and deemed ineligible for ECPR. We detail the training, certification processes, and clinical outcomes from our first eight cases., Results: Five emergency medicine physicians underwent training for REBOA placement through a didactic curriculum and hands-on training with mannequin and live tissue porcine models. Since protocol implementation, eight patients have undergone REBOA catheterization by emergency medicine physicians: 5 males and 3 females, age range 25-79. The first pass success was 8/8 (100 %), and all 3 commercially available catheters in the United States were successfully used. ROSC was achieved in 3/8 (37.5 %) patients, although no patients survived to hospital discharge. No REBOA catheter-associated complications were identified., Conclusions: This series demonstrates feasibility of emergency physician placed REBOA for non-traumatic, refractory cardiac arrest a novel resuscitative technique. Through a combination of focused education, innovative technology use, robust large animal model-based training, and strategic procedural integration, we showcase the potential for emergency departments to spearhead the adoption of this potentially life-saving intervention., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Austin Johnson is a co-founder, board member, consultant, and stockholder in Certus Critical Care. Dr. Austin Johnson is a board member of TitinKM Biomedical.

Background: Early administration of adrenaline is associated with improved survival after out-of-hospital cardiac arrest (OHCA). Delays in vascular access may impact the timely delivery of adrenaline. Novel methods for administering adrenaline before vascular access may enhance survival. The objective of this study was to determine whether an initial intramuscular (IM) adrenaline dose followed by standard IV/IO adrenaline is associated with improved survival after OHCA., Methods Study Design: We conducted a before-and-after study of the implementation of an early, first-dose IM adrenaline EMS protocol for adult OHCAs. The pre-intervention period took place between January 2010 and October 2019. The post-intervention period was between November 2019 and May 2024., Setting: Single-center urban, two-tiered EMS agency., Participants: Adult, nontraumatic OHCA meeting criteria for adrenaline use., Intervention: Single dose (5 mg) IM adrenaline. All other care, including subsequent IV or IO adrenaline, followed international guidelines., Main Outcomes and Measures: The primary outcome was survival to hospital discharge. Secondary outcomes were time from EMS arrival to the first dose of adrenaline, survival to hospital admission, and favorable neurologic function at discharge., Results: Among 1405 OHCAs, 420 (29.9%) received IM adrenaline and 985 (70.1%) received usual care. Fifty-two patients received the first dose of adrenaline through the IV or IO route within the post-intervention period and were included in the standard care group analysis. Age was younger and bystander CPR was higher in the IM adrenaline group. All other characteristics were similar between IM and standard care cohorts. Time to adrenaline administration was faster for the IM cohort [(median 4.3 min (IQR 3.0-6.0) vs. 7.8 min (IQR 5.8-10.4)]. Compared with standard care, IM adrenaline was associated with improved survival to hospital admission (37.1% vs. 31.6%; aOR 1.37, 95% CI 1.06-1.77), hospital survival (11.0% vs 7.0%; aOR 1.73, 95% CI 1.10-2.71) and favorable neurologic status at hospital discharge (9.8% vs 6.2%; aOR 1.72, 95% CI 1.07-2.76)., Conclusion: In this single-center before-and-after implementation study, an initial IM dose of adrenaline as an adjunct to standard care was associated with improved survival to hospital admission, survival to hospital discharge, and functional survival. A randomized controlled trial is needed to fully assess the potential benefit of IM adrenaline delivery in OHCA., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Objective: Optimal timing for subsequent defibrillation attempts for Out-of-hospital cardiac arrest (OHCA) patients with recurrent VF/pVT is uncertain. We investigated the relationship between VF/pVT duration and return of spontaneous circulation (ROSC) in OHCA patients with recurrent shockable rhythms., Methods: We analyzed data from the Salt Lake City Fire Department (SLCFD) spanning from 2012 to 2023. The implementation of rhythm-filtering technology since 2011 enabled real-time rhythm interpretation during CPR, with local protocols allowing early defibrillation for recurrent/refractory VF/pVT cases. We included patients experiencing four or five episodes of VF and pVT rhythms and employed generalized estimating equation (GEE) regression analysis to examine the association between VF/pVT durations preceding recurrent defibrillation and return of spontaneous circulation (ROSC)., Results: Analysis of 622 appropriate shocks showed that patients achieving ROSC had significantly shorter median VF/pVT duration than those who did not achieve ROSC (0.83 minutes vs. 1.2 minutes, p = 0.004). Adjusted analysis of those with 4 VF/pVT episodes (N = 142) revealed that longer VF/pVT durations were associated with lower odds of achieving ROSC (odds ratio: 0.81, 95% CI: 0.72-0.93, p = 0.005). Every one-minute delay in intra-arrest defibrillation is predicted to decrease the likelihood of achieving ROSC by 19%., Conclusion: Every one-minute increase in intra-arrest VF/pVT duration was associated with a statistically significant 19% decrease in the chance of achieving ROSC. This highlights the importance of reducing time to shock in managing recurrent VF/pVT. The findings suggest reevaluating the current recommendations of two minutes intervals for rhythm check and shock delivery., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier B.V.)

Objectives: This study assesses the feasibility, inter-rater reliability, and accuracy of using OpenAI's ChatGPT-4 and Google's Gemini Ultra large language models (LLMs), for Emergency Medical Services (EMS) quality assurance. The implementation of these LLMs for EMS quality assurance has the potential to significantly reduce the workload on medical directors and quality assurance staff by automating aspects of the processing and review of patient care reports. This offers the potential for more efficient and accurate identification of areas requiring improvement, thereby potentially enhancing patient care outcomes., Methods: Two expert human reviewers, ChatGPT GPT-4, and Gemini Ultra assessed and rated 150 consecutively sampled and anonymized prehospital records from 2 large urban EMS agencies for adherence to 2020 National Association of State EMS metrics for cardiac care. We evaluated the accuracy of scoring, inter-rater reliability, and review efficiency. The inter-rater reliability for the dichotomous outcome of each EMS metric was measured using the kappa statistic., Results: Human reviewers showed high interrater reliability, with 91.2% agreement and a kappa coefficient 0.782 (0.654-0.910). ChatGPT-4 achieved substantial agreement with human reviewers in EKG documentation and aspirin administration (76.2% agreement, kappa coefficient 0.401 (0.334-0.468), but performance varied across other metrics. Gemini Ultra's evaluation was discontinued due to poor performance. No significant differences were observed in median review times: 01:28 min (IQR 1:12 - 1:51 min) per human chart review, 01:24 min (IQR 01:09 - 01:53 min) per ChatGPT-4 chart review ( p  = 0.46), and 01:50 min (IQR 01:10-03:34 min) per Gemini Ultra review ( p  = 0.06)., Conclusions: Large language models demonstrate potential in supporting quality assurance by effectively and objectively extracting data elements. However, their accuracy in interpreting non-standardized and time-sensitive details remains inferior to human evaluators. Our findings suggest that current LLMs may best offer supplemental support to the human review processes, but their current value remains limited. Enhancements in LLM training and integration are recommended for improved and more reliable performance in the quality assurance processes.

Aims: Previous research has reported racial disparities in out-of-hospital cardiac arrest (OHCA) interventions, including bystander CPR and AED use. However, studies on other prehospital interventions are limited. The primary objective of this study was to investigate race/ethnic disparities in out-of-hospital cardiac arrest (OHCA) interventions: EMS response times, medication administration, and decisions for intra-arrest transport. The secondary objective was to evaluate differences in the provision of Bystander CPR (CPR) and application of AED., Methods: We retrospectively analyzed data from the Salt Lake City Fire Department (2010-2023). We included adults 18 years or older with EMS-treated OHCA. Race/ethnicity was categorized as White people, Asian people, Black people, Hispanic people, and others. We employed multivariable regression analysis to evaluate the association between race/ethnicity and the outcomes of interest., Results: Unadjusted analyses revealed no significant differences across ethnic groups in EMS response, medication administration, bystander CPR, or intra-arrest transport decisions. However, significant ethnic disparities were observed in Automated External Defibrillator (AED) utilization, Black people having the lowest rate (6.5%) and Asian people the highest (21.8%). The adjusted analysis found no significant association between race/ethnicity and all OHCA intervention measures, nor between race/ethnicity and survival outcomes., Conclusions: Our multivariable analysis found no statistically significant association between race/ethnicity and EMS response time, epinephrine administration, antiarrhythmic medication use, bystander CPR, AED intervention, or intra-arrest transport. These results imply regional variations in ethnic disparities in OHCA may not be consistent across all areas, warranting further research into disparities in other regions and additional influential factors like neighborhood conditions and socioeconomic status., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

ischemia-reperfusion injury (IRI) after hemorrhage is potentiated by aortic occlusion or resuscitative endovascular balloon occlusion of the aorta (REBOA). Given the central role of mitochondrial injury in shock, we hypothesized that Elamipretide, a peptide that protects mitochondria, would mitigate IRI after hemorrhagic shock and REBOA. Twelve pigs were subjected to hemorrhagic shock and 45 min of REBOA. After 25 min of REBOA, animals received either saline or Elamipretide. Animals were transfused with autologous blood during balloon deflation, and pigs were resuscitated with isotonic crystalloids and norepinephrine for 4.25 h. Elamipretide-treated animals required less crystalloids than the controls (62.5 [50-90] and 25 [5-30] mL/kg, respectively), but similar amounts of norepinephrine (24.7 [8.6-39.3] and 9.7 [2.1-12.5] mcg/kg, respectively). Treatment animals had a significant reduction in serum creatinine (control: 2.7 [2.6-2.8]; Elamipretide: 2.4 [2.4-2.5] mg/dL; p = 0.04), troponin (control: 3.20 [2.14-5.47] ng/mL, Elamipretide: 0.22 [0.1-1.91] ng/mL; p = 0.03), and interleukin-6 concentrations at the end of the study. There were no differences in final plasma lactate concentration. Elamipretide reduced fluid requirements and protected the kidney and heart after profound IRI. Further understanding the subcellular consequences of REBOA and mitochondrial rescue will open new therapeutic avenues for patients suffering from IRI after hemorrhage., (© 2023. The Author(s).)

It is not know if hospital-level extracorporeal cardiopulmonary resuscitation (ECPR) case volume, or postcannulation clinical management associate with survival outcomes., Objectives: To describe variation in postresuscitation management practices, and annual hospital-level case volume, for patients who receive ECPR and to determine associations between these management practices and hospital survival., Design: Observational cohort study using case-mix adjusted survival analysis., Setting and Participants: Adult patients greater than or equal to 18 years old who received ECPR from the Extracorporeal Life Support Organization Registry from 2008 to 2019., Main Outcomes and Measures: Generalized estimating equation logistic regression was used to determine factors associated with hospital survival, accounting for clustering by center. Factors analyzed included specific clinical management interventions after starting extracorporeal membrane oxygenation (ECMO) including coronary angiography, mechanical unloading of the left ventricle on ECMO (with additional placement of a peripheral ventricular assist device, intra-aortic balloon pump, or surgical vent), placement of an arterial perfusion catheter distal to the arterial return cannula (to mitigate leg ischemia); potentially modifiable on-ECMO hemodynamics (arterial pulsatility, mean arterial pressure, ECMO flow); plus hospital-level annual case volume for adult ECPR., Results: Case-mix adjusted patient-level management practices varied widely across individual hospitals. We analyzed 7,488 adults (29% survival); median age 55 (interquartile range, 44-64), 68% of whom were male. Adjusted hospital survival on ECMO was associated with mechanical unloading of the left ventricle (odds ratio [OR], 1.3; 95% CI, 1.08-1.55; p = 0.005), performance of coronary angiography (OR, 1.34; 95% CI, 1.11- 1.61; p = 0.002), and placement of an arterial perfusion catheter distal to the return cannula (OR, 1.39; 95% CI, 1.05-1.84; p = 0.022). Survival varied by 44% across hospitals after case-mix adjustment and was higher at centers that perform more than 12 ECPR cases/yr (OR, 1.23; 95% CI, 1.04-1.45; p = 0.015) versus medium- and low-volume centers., Conclusions and Relevance: Modifiable ECMO management strategies and annual case volume vary across hospitals, appear to be associated with survival and should be the focus of future research to test if these hypothesis-generating associations are causal in nature., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Background: Large animal studies are an important step in the translation pathway, but single laboratory experiments do not replicate the variability in patient populations. Our objective was to demonstrate the feasibility of performing a multicenter, preclinical, randomized, double-blinded, placebo-controlled cardiac arrest trial. We evaluated the effect of epinephrine on coronary perfusion pressure (CPP) as previous single laboratory studies have reported mixed results., Methods: Forty-five swine from 5 different laboratories (Ann Arbor, MI; Baltimore, MD; Los Angeles, CA; Pittsburgh, PA; Toronto, ON) using a standard treatment protocol. Ventricular fibrillation was induced and left untreated for 6 min before starting continuous cardiopulmonary resuscitation (CPR). After 2 min of CPR, 9 animals from each lab were randomized to 1 of 3 interventions given over 12 minutes: (1) Continuous IV epinephrine infusion (0.00375 mg/kg/min) with placebo IV normal saline (NS) boluses every 4 min, (2) Continuous placebo IV NS infusion with IV epinephrine boluses (0.015 mg/kg) every 4 min or (3) Placebo IV NS for both infusion and boluses. The primary outcome was mean CPP during the 12 mins of drug therapy., Results: There were no significant differences in mean CPP between the three groups: 14.4 ± 6.8 mmHg (epinephrine Infusion), 16.9 ± 5.9 mmHg (epinephrine bolus), and 14.4 ± 5.5 mmHg (placebo) (p = NS). Sensitivity analysis demonstrated inter-laboratory variability in the magnitude of the treatment effect (p = 0.004)., Conclusion: This study demonstrated the feasibility of performing a multicenter, preclinical, randomized, double-blinded cardiac arrest trials. Standard dose epinephrine by bolus or continuous infusion did not increase coronary perfusion pressure during CPR when compared to placebo., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Objectives: Endovascular aortic occlusion as an adjunct to cardiopulmonary resuscitation (CPR) for non-traumatic cardiac arrest is gaining interest. In a recent clinical trial, return of spontaneous circulation (ROSC) was achieved despite prolonged no-flow times. However, 66% of patients re-arrested upon balloon deflation. We aimed to determine if automated titration of endovascular balloon volume following ROSC can augment diastolic blood pressure (DBP) to prevent re-arrest., Methods: Twenty swine were anesthetized and placed into ventricular fibrillation (VF). Following 7 minutes of no-flow VF and 5 minutes of mechanical CPR, animals were subjected to complete aortic occlusion to adjunct CPR. Upon ROSC, the balloon was either deflated steadily over 5 minutes (control) or underwent automated, dynamic adjustments to maintain a DBP of 60 mmHg (Endovascular Variable Aortic Control, EVAC)., Results: ROSC was obtained in ten animals (5 EVAC, 5 REBOA). Sixty percent (3/5) of control animals rearrested while none of the EVAC animals rearrested ( p  = 0.038). Animals in the EVAC group spent a significantly higher proportion of the post-ROSC period with a DBP > 60 mmHg [median (IQR)] [control 79.7 (72.5-86.0)%; EVAC 97.7 (90.8-99.7)%, p  = 0.047]. The EVAC group had a statistically significant reduction in arterial lactate concentration [7.98 (7.4-8.16) mmol/L] compared to control [9.93 (8.86-10.45) mmol/L, p  = 0.047]. There were no statistical differences between the two groups in the amount of adrenaline (epinephrine) required., Conclusion: In our swine model of cardiac arrest, automated aortic endovascular balloon titration improved DBP and prevented re-arrest in the first 20 minutes after ROSC., (© 2022 The Author(s).)

Research Question: Given the relative independence of ventilator settings from gas exchange and plasticity of blood gas values during extracorporeal cardiopulmonary resuscitation (ECPR), do mechanical ventilation parameters and blood gas values influence survival?, Methods: Observational cohort study of 7488 adult patients with ECPR from the Extracorporeal Life Support Organization (ELSO) Registry. We performed case-mix adjustment for severity of illness and patient type using generalized estimating equation logistic regression to determine factors associated with hospital survival accounting for clustering by center, standardizing variables by 1 standard deviation (SD) of their values. We examined non-linear relationships between ventilatory and blood gas values with hospital survival., Results: Hospital survival was decreased with higher PaO 2 on ECMO (OR 0.69, per 1SD increase [95% CI 0.64, 0.74]; p < 0.001) and with any relative changes in PaCO 2 (pre-arrest to on-ECMO) in a non-linear fashion. Survival was worsened with any peak inspiratory pressure >20 cmH 2 0 (OR 0.69, per 1SD [0.64, 0.75]; p < 0.001) and above 40% fraction of inspired oxygen (OR 0.75, per 1SD [0.69, 0.82]; p < 0.001), and with higher dynamic driving pressure (OR 0.72, per 1 SD increase [0.65, 0.79]; <0.001). Ventilation settings and blood gas values varied widely across hospitals, but were not associated with annual hospital ECPR case volume., Conclusion: Lower ventilatory pressures, avoidance of hyperoxia, and relatively unchanged CO 2 (pre- to on-ECMO) were all associated with survival in patients after ECPR, yet varied across hospitals. Our findings represent potential targets for prospective trials for this rapidly growing therapy to test if these associations have causality., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Early recognition and rapid defibrillation of shockable rhythms is strongly associated with survival in out of hospital cardiac arrest (OHCA). Little is known about the accuracy of paramedic rhythm interpretation and its impact on survival. We hypothesized that inaccurate paramedic interpretation of initial rhythm would be associated with worse survival., Methods: This is a retrospective cohort analysis of prospectively collected OHCA data over a nine-year period within a single, urban, fire-based EMS system that utilizes manual defibrillators equipped with rhythm-filtering technology. We compared paramedic-documented initial rhythm with a reference standard of post-event physician interpretation to estimate sensitivity and specificity of paramedic identification of and shock delivery to shockable rhythms. We assessed the association between misclassification of initial rhythm and neurologically intact survival to hospital discharge using multivariable logistic regression., Results: A total of 863 OHCA cases were available for analysis with 1,756 shocks delivered during 542 (63%) resuscitation attempts. Eleven percent of shocks were delivered to pulseless electrical activity (PEA). Sensitivity and specificity for paramedic initial rhythm interpretation were 176/197 (0.89, 95% CI 0.84-0.93) and 463/504 (0.92, 95% CI 0.89-0.94) respectively. No patient survived to hospital discharge when paramedics misclassified the initial rhythm., Conclusions: Paramedics achieved high sensitivity for shock delivery to shockable rhythms, but with an 11% shock delivery rate to PEA. Misclassification of initial rhythm was associated with poor survival. Technologies that assist in rhythm identification during CPR, rapid shock delivery, and minimal hands-off time may improve outcomes., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Joseph E. Tonna was supported by a career development award (K23HL141596) from the National Heart, Lung, And Blood Institute (NHLBI) of the National Institutes of Health (NIH). M. Austin Johnson is a founder and stockholder of Certus Critical Care, Inc. Stavros Drakos is supported by funding from the AHA Heart Failure Strategically Focused Research Network (16SFRN29020000), the National Heart, Lung, And Blood Institute (NHLBI R01 HL135121-01 and NHLBI R01 HL132067-01A1), a Merit Review Award (I01 CX002291) through the U.S. Dpt of Veterans Affairs, and the Nora Eccles Treadwell Foundation. Scott Youngquist reports grant support from the NIH SIREN Collaborative (1U01NS099046-01A1, 1OT2HL156812-01, UH3HL145269), Collabs, Inc., and The ZOLL Foundation. All other authors report no conflicts of interest., (Copyright © 2021 Elsevier B.V. All rights reserved.)

ST-segment elevation myocardial infarction is a medical emergency with significant health care delivery challenges to ensure rapid triage and treatment. Several developments over the past decades have led to improved care delivery, decreased time to reperfusion, and decreased mortality. Still, significant challenges remain to further optimize the delivery of care for this patient population., Competing Interests: Disclosure R.U. Shah reports grant support from the National Heart, Lung, and Blood Institute (NHLBI) (5K08HL136850) and additional research support from Women As One and the Doris Duke Foundation. All other authors have no disclosures to report., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Early adrenaline administration is associated with return of spontaneous circulation (ROSC) and survival in out-of-hospital cardiac arrest (OHCA). Animal data demonstrate a similar rate of ROSC when early intramuscular (IM) adrenaline is given compared to early intravenous (IV) adrenaline., Aim: To evaluate the feasibility of protocolized first-dose IM adrenaline in OHCA and it's effect on time from Public Safety Access Point (PSAP) call receipt to adrenaline administration when compared to IO and IV administration., Methods: This is a before-and-after feasibility study of adult OHCAs in a single EMS service following adoption of a protocol for first-dose IM adrenaline. Time from PSAP call to administration and outcomes were compared to 674 historical controls (from January 1, 2013-February 8, 2021) who received at least one dose of adrenaline by IV or IO routes., Results: During the study period, first-dose IM adrenaline was administered to 99 patients (December 1, 2019-February 8, 2021). IM adrenaline was given a median of 12.2 min (95% CI 11.4-13.1 min) after the PSAP call receipt compared to 15.3 min for the IV route (95% CI 14.6-16.0 min) and 15.3 min for the IO route (95% CI 14.9-15.7 min) with a time savings of 3 min (95% CI 2-4 min). Rates of survival to hospital discharge appeared similar between groups: 10% for IM, 8% for IV and 7% for IO. However, results related to survival were underpowered for statistical comparison., Conclusions: Within the limitations of a small sample size and before-and-after design, first-dose IM adrenaline was feasible and reduced the time to adrenaline administration., (© 2021 The Author(s).)

Disclaimer: Veno-arterial extracorporeal membrane oxygenation (ECMO) is increasingly being deployed for selected patients in cardiac arrest who do not attain a native circulation with conventional CPR (ECPR). This ELSO guideline is intended to be a practical guide to implementing ECPR and the early management following establishment of ECMO support. Where a paucity of high-quality evidence exists, a consensus has been reached amongst the authors to provide guidance to the clinician. This guideline will be updated as further evidence in this field becomes available., Competing Interests: Disclosure: Dr. Tonna was supported by a career development award (K23HL141596) from the National Heart, Lung, And Blood Institute (NHLBI) of the National Institutes of Health (NIH). Dr. Tonna received speakers’ fees from LivaNova related to cardiac arrest. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The other authors have no conflicts of interest to report., (Copyright © ELSO 2021.)

Objectives: To construct a highly detailed yet practical, attainable roadmap for enhancing the likelihood of neurologically intact survival following sudden cardiac arrest., Design Setting and Patients: Population-based outcomes following out-of-hospital cardiac arrest were collated for 10 U.S. counties in Alaska, California, Florida, Ohio, Minnesota, Utah, and Washington. The 10 identified emergency medical services systems were those that had recently reported significant improvements in neurologically intact survival after introducing a more comprehensive approach involving citizens, hospitals, and evolving strategies for incorporating technology-based, highly choreographed care and training. Detailed inventories of in-common elements were collated from the ten 9-1-1 agencies and assimilated. For reference, combined averaged outcomes for out-of-hospital cardiac arrest occurring January 1, 2017, to February 28, 2018, were compared with concurrent U.S. outcomes reported by the well-established Cardiac Arrest Registry to Enhance Survival., Interventions: Most commonly, interventions and components from the ten 9-1-1 systems consistently included extensive public cardiopulmonary resuscitation training, 9-1-1 system-connected smart phone applications, expedited dispatcher procedures, cardiopulmonary resuscitation quality monitoring, mechanical cardiopulmonary resuscitation, devices for enhancing negative intrathoracic pressure regulation, extracorporeal membrane oxygenation protocols, body temperature management procedures, rapid cardiac angiography, and intensive involvement of medical directors, operational and quality assurance officers, and training staff., Measurements and Main Results: Compared with Cardiac Arrest Registry to Enhance Survival ( n = 78,704), the cohorts from the 10 emergency medical services agencies examined ( n = 2,911) demonstrated significantly increased likelihoods of return of spontaneous circulation (mean 37.4% vs 31.5%; p < 0.001) and neurologically favorable hospital discharge, particularly after witnessed collapses involving bystander cardiopulmonary resuscitation and shockable cardiac rhythms (mean 10.7% vs 8.4%; p < 0.001; and 41.6% vs 29.2%; p < 0.001, respectively)., Conclusions: The likelihood of neurologically favorable survival following out-of-hospital cardiac arrest can improve substantially in communities that conscientiously and meticulously introduce a well-sequenced, highly choreographed, system-wide portfolio of both traditional and nonconventional approaches to training, technologies, and physiologic management. The commonalities found in the analyzed systems create a compelling case that other communities can also improve out-of-hospital cardiac arrest outcomes significantly by conscientiously exploring and adopting similar bundles of system organization and care., Competing Interests: Dr. Lurie who is a coinventor of multiple CPR devices and founder of Advanced CPR Solutions LLC, that develops novel resuscitation technologies. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

The use of extracorporeal cardiopulmonary resuscitation (ECPR) to resuscitate patients with refractory out-of-hospital cardiac arrest is increasing in the United States and the developed world. This approach to treatment is appealing, because it can restore prearrest levels of perfusion to the brain and vital organs while the cause of the arrest is addressed. In this article, the authors highlight current ECPR program development and discuss controversies., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Ventricular unloading is associated with myocardial recovery. We sought to evaluate the association of extracorporeal cardiopulmonary resuscitation (ECPR) on myocardial function after cardiac arrest. We conducted a retrospective exploratory analysis, comparing ejection fraction (EF) after adult cardiac arrest, between ECPR and conventional CPR., Results: Among 1119 cases of cardiac arrest, 116 had an echocardiogram post-return of spontaneous circulation (ROSC) and were included. Thirty-eight patients had ≥ 2 echocardiograms. ECPR patients had differences in age, hypertension and chronic heart failure. ECPR patients had a lower EF post-ROSC (24% vs 45%; p < 0.01) and were more likely to undergo percutaneous coronary intervention (25% vs 3%; p < 0.01). In multivariate analysis, only ECPR use (β-coeff: 10.4 [95% CI 3.68-17.13]; p < 0.01) independently predicted improved myocardial function. In this exploratory study, EF after cardiac arrest may be more likely to improve among ECPR patients than CCPR patients. Our methodology should be replicated to confirm or refute the validity of our findings.

Aim of the Study: Negative intrathoracic pressure (ITP) during the decompression phase of cardiopulmonary resuscitation (CPR) is essential to refill the heart, increase cardiac output, maintain cerebral and coronary perfusion pressures, and improve survival. In order to generate negative ITP, an airway seal is necessary. We tested the hypothesis that some supraglottic airway (SGA) devices do not seal the airway as well the standard endotracheal tube (ETT)., Methods: Airway pressures (AP) were measured as a surrogate for ITP in seven recently deceased human cadavers of varying body habitus. Conventional manual, automated, and active compression-decompression CPR were performed with and without an impedance threshold device (ITD) in supine and Head Up positions. Positive pressure ventilation was delivered by an ETT and 5 SGA devices tested in a randomized order in this prospective cross-over designed study. The primary outcome was comparisons of decompression AP between all groups., Results: An ITD was required to generate significantly lower negative ITP during the decompression phase of all methods of CPR. SGAs varied in their ability to support negative ITP., Conclusion: In a human cadaver model, the ability to generate negative intrathoracic pressures varied with different SGAs and an ITD regardless of the body position or CPR method. Differences in SGAs devices should be strongly considered when trying to optimize cardiac arrest outcomes, as some SGAs do not consistently develop a seal or negative intrathoracic pressure with multiple different CPR methods and devices., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Study Objective: Point-of-care ultrasonography provides diagnostic information in addition to visual pulse checks during cardiopulmonary resuscitation (CPR). The most commonly used modality, transthoracic echocardiography, has unfortunately been repeatedly associated with prolonged pauses in chest compressions, which correlate with worsened neurologic outcomes. Unlike transthoracic echocardiography, transesophageal echocardiography does not require cessation of compressions for adequate imaging and provides the diagnostic benefit of point-of-care ultrasonography. To assess a benefit of transesophageal echocardiography, we compare the duration of chest compression pauses between transesophageal echocardiography, transthoracic echocardiography, and manual pulse checks on video recordings of cardiac arrest resuscitations., Methods: We analyzed 139 pulse check CPR pauses among 25 patients during cardiac arrest., Results: Transesophageal echocardiography provided the shortest mean pulse check duration (9 seconds [95% confidence interval {CI} 5 to 12 seconds]). Mean pulse check duration with transthoracic echocardiography was 19 seconds (95% CI 16 to 22 seconds), and it was 11 seconds (95% CI 8 to 14 seconds) with manual checks. Intraclass correlation coefficient between abstractors for a portion of individual and average times was 0.99 and 0.99, respectively (P<.001 for both)., Conclusion: Our study suggests that pulse check times with transesophageal echocardiography are shorter versus with transthoracic echocardiography for ED point-of-care ultrasonography during cardiac arrest resuscitations, and further emphasizes the need for careful attention to compression pause duration when using transthoracic echocardiography for point-of-care ultrasonography during ED cardiac arrest resuscitations., (Copyright © 2019 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Survival for out-of-hospital cardiac arrest (OHCA) is, on average, approximately 10% but considerable variability exists among emergency medical services (EMS) systems across the United States. The medical director of an EMS system has considerable control and influence over outcomes in a system by developing evidence-based protocols and overseeing a robust system of quality assurance. A vision for system-level oversight of care that includes continuous data collection and assessment, personally delivered and constructive feedback to providers, and a constant drive for improvement can result in improvements in both processes and patient-centered outcomes., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To assess interruptions in chest compressions associated with advanced airway placement during cardiopulmonary resuscitation (CPR) of out-of-hospital cardiac arrest (OHCA) victims., Methods: The method used was observational analysis of prospectively collected clinical and defibrillator data from 339 adult OHCA victims, excluding victims with <5 minutes of CPR. Interruptions in CPR, summarized by chest compression fraction (CCF), longest pause, and the number of pauses greater than 10 seconds, were compared between patients receiving bag valve mask (BVM), supraglottic airway (SGA), endotracheal intubation (ETI) via direct laryngoscopy (DL), and ETI via video laryngoscopy (VL). Secondary outcomes included first pass success and the effect of multiple airway attempts on CPR interruptions., Results: During the study period, paramedics managed 23 cases with BVM, 43 cases with SGA, 148 with DL, and 125 with VL. There were no statistically significant differences between the airway groups with regard to longest compression pause (BVM 18 sec [IQR 11-33], SGA 29 sec [IQR 15-65], DL 26 sec [IQR 12-59], VL 22 sec [IQR 14-41]), median number of pauses greater than 10 seconds (BVM 2 [IQR 1-3], SGA 2 [IQR 1-3], DL 2 [IQR 1-4], VL 2 [IQR 1-3]), or CCF (0.92 for all groups). However, each additional attempt following failed initial DL was associated with an increase in the risk of additional chest compression pauses (relative risk 1.29, 95% confidence interval 1.02-1.64). Such an association was not observed with additional attempts using VL or SGA. First pass success was highest with SGA (77%), followed by between DL (68%) and VL (67%); these differences were not statistically significant., Conclusions: While summary measures of chest compression delivery did not differ significantly between airway classes in this observational study, repeated attempts following failed initial DL during cardiopulmonary resuscitation were associated with an increase in the number of pauses in chest compression delivery observed.

Despite advances in the medical and surgical management of cardiovascular disease, greater than 350,000 patients experience out-of-hospital cardiac arrest in the United States annually, with only a 12% neurologically favorable survival rate. Of these patients, 23% have an initial shockable rhythm of ventricular fibrillation/pulseless ventricular tachycardia (VF/VT), a marker of high probability of acute coronary ischemia (80%) as the precipitating factor. However, few patients (22%) will experience return of spontaneous circulation and sufficient hemodynamic stability to undergo cardiac catheterization and revascularization. Previous case series and observational studies have demonstrated the successful application of intra-arrest extracorporeal life support, including to out-of-hospital cardiac arrest victims, with a neurologically favorable survival rate of up to 53%. For patients with refractory cardiac arrest, strategies are needed to bridge them from out-of-hospital cardiac arrest to the catheterization laboratory and revascularization. To address this gap, we expanded our ICU and perioperative extracorporeal membrane oxygenation (ECMO) program to the emergency department (ED) to reach this cohort of patients to improve survival. In this report, we illustrate our process and initial experience of developing a multidisciplinary team for rapid deployment of ED ECMO as a template for institutions interested in building their own ED ECMO programs., (Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: To discuss the increasing value of technological tools to assess and augment the quality of cardiopulmonary resuscitation (CPR) and, in turn, improve chances of surviving out-of-hospital cardiac arrest (OHCA)., Recent Findings: After decades of disappointing survival rates, various emergency medical services systems worldwide are now seeing a steady rise in OHCA survival rates guided by newly identified 'sweet spots' for chest compression rate and chest compression depth, aided by monitoring for unnecessary pauses in chest compressions as well as methods to better ensure full-chest recoil after compressions. Quality-assurance programs facilitated by new technologies that monitor chest compression rate, chest compression depth, and/or frequent pauses have been shown to improve the quality of CPR. Further aided by other technologies that enhance flow or better identify the best location for hand placement, the future outlook for better survival is even more promising, particularly with the potential use of another technology - extracorporeal membrane oxygenation for OHCA., Summary: After 5 decades of focus on manual chest compressions for CPR, new technologies for monitoring, guiding, and enhancing CPR performance may enhance outcomes from OHCA significantly in the coming years.

Most resuscitated victims of out-of-hospital cardiac arrest who survive to hospital expire due to the postresuscitation syndrome. This syndrome is characterized by a sepsis-like proinflammatory state. The objective of this investigation was to determine whether a relationship exists between the rise of tumor necrosis factor (TNF), a proinflammatory cytokine, following return of spontaneous circulation (ROSC), and early postarrest survival in a clinically relevant animal model of spontaneous ventricular fibrillation (VF). Mixed-breed Yorkshire swine (n = 20), weighing 39 ± 5 kg, were anesthetized and catheters placed in the right atrium and left ventricle/ascending aorta for continuous pressure monitoring. VF was induced by occluding the left anterior descending coronary artery with an angioplasty balloon. After 7 min of untreated VF, advanced life support resuscitation attempts were made for up to 20 min. Animals achieving ROSC were monitored for 3 h and fluid and pressor support was administered as needed. TNF levels were measured before VF and at 0, 15, and 30 min after ROSC using quantitative sandwich enzyme-linked immunosorbent assay. Twelve (60%) animals experienced early death, expiring during the 3 hour postarrest period (9 pulseless electrical activity, 2 VF, and 1 asystole). The TNF level at 15 min post-ROSC was significantly associated with death within the first 3 h post-ROSC with a univariate odds ratio of 1.4 [95% confidence interval (CI) 1.05-2.2, P = 0.01]. Using a cutoff TNF level of 525 pg/mL at 15 min post-ROSC had 100% negative predictive value (95% CI 0%-37%) and 67% positive predictive value (95% CI 35%-90%) for early death with a hazard ratio of 6.6 (95% CI 1.9-23.5). TNF increases shortly after ROSC and is predictive of early death. Early identification of resuscitated victims at greatest risk for hemodynamic collapse and recurrent arrest might facilitate the use of early hospital-based interventions to decrease the likelihood of a poor outcome., Competing Interests: Author Disclosure Statement No competing financial interests exist.

Purpose: To characterize the current scope and practices of centers performing extracorporeal cardiopulmonary resuscitation (eCPR) on the undifferentiated patient with cardiac arrest in the emergency department., Methods: We contacted all US centers in January 2016 that had submitted adult eCPR cases to the Extracorporeal Life Support Organization (ELSO) registry and surveyed them, querying for programs that had performed eCPR in the Emergency Department (ED ECMO). Our objective was to characterize the following domains of ED ECMO practice: program characteristics, patient selection, devices and techniques, and personnel., Results: Among 99 centers queried, 70 responded. Among these, 36 centers performed ED ECMO. Nearly 93% of programs are based at academic/teaching hospitals. 65% of programs are less than 5 years old, and 60% of programs perform ≤3 cases per year. Most programs (90%) had inpatient eCPR or salvage ECMO programs prior to starting ED ECMO programs. The majority of programs do not have formal inclusion and exclusion criteria. Most programs preferentially obtain vascular access via the percutaneous route (70%) and many (40%) use mechanical CPR during cannulation. The most commonly used console is the Maquet Rotaflow(®). Cannulation is most often performed by cardiothoracic (CT) surgery, and nearly all programs (>85%) involve CT surgeons, perfusionists, and pharmacists., Conclusions: Over a third of centers that submitted adult eCPR cases to ELSO have performed ED ECMO. These programs are largely based at academic hospitals, new, and have low volumes. They do not have many formal inclusion or exclusion criteria, and devices and techniques are variable., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objective: To compare functional survival (discharge cerebral performance category 1 or 2) among victims of out-of-hospital cardiac arrest (OHCA) who had resuscitations performed using mechanical chest compression (mech-CC) devices vs. those using manual chest compressions (man-CC)., Methods: Observational cohort of 2600 cases of OHCA from a statewide, prospectively-collected cardiac arrest registry (Utah Cardiac Arrest Registry to Enhance Survival). Comparison of functional survival among those receiving mech-CC vs man-CC was performed using a mixed-effects Poisson model with inverse probability weighted propensity scores to control for selection bias., Results: Overall, mech-CC was utilized in 405/2600 (16%) of the total arrests in Utah during this period. 371/405 (92%) were of the load-distributing band type (AutoPulse(®)) and 22/405 (5%) were mechanical piston devices (LUCAS™), while 12/405 (3%) employed other devices. The relative risk (RR) for functional survival comparing mech-CC to man-CC after propensity score adjustment was 0.41 (95% CI 0.24-0.70, p=0.001)., Conclusions: Mechanical chest compression device use was associated with lower rates of functional survival in this propensity score analysis, controlling for Utstein variables and early return of spontaneous circulation., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Introduction: Survival from out-of-hospital cardiac arrest (OHCA) varies by community and emergency medical services (EMS) system. We hypothesized that the adoption of multiple best practices to focus EMS crews on high-quality, minimally interrupted cardiopulmonary resuscitation (CPR) would improve survival of OHCA patients in Salt Lake City., Methods and Results: In September 2011, Salt Lake City Fire Department EMS providers underwent a systemwide restructuring of care for OHCA patients that focused on the adoption of high-quality CPR with minimal interruptions and offline medical review of defibrillator data and feedback on CPR metrics. Victims were directed to ST-elevation myocardial infarction receiving centers. Prospectively collected data on patient survival and neurological outcome for all OHCAs were compared. In the postintervention period, there were 407 cardiac arrests with 65 neurologically intact survivors (16%), compared with 330 cardiac arrests with 25 neurologically intact survivors (8%) in the preintervention period. Among patients who survived to hospital admission, a higher proportion in the postintervention period survived to hospital discharge (71/141 [50%] versus 36/98 [37%], P=0.037) and had a favorable neurological outcome (65 [46%] versus 25 [26%], P=0.0005) compared with patients treated before the protocol changes. The univariate odds ratio or the association between neurologically intact survival (cerebral performance category 1 and 2) and protocol implementation was 2.3 (95% CI 1.4 to 3.7, P=0.001). Among discharged patients, the distribution of cerebral performance category scores was more favorable in the postintervention period (P<0.0001)., Conclusions: A multifaceted protocol, including several American Heart Assocation best practices for the resuscitation of patients with OHCA, was associated with improved survival and neurological outcome., (© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: It is unclear whether factors identified during the emergency department (ED) visit predict noncompliance with ED recommendations., Study Objective: We sought to determine predictors of adherence to medical recommendations after an ED visit., Methods: We conducted a prospective, observational study at a single urban medical center. Eligible ED patients provided baseline demographic data as well as information regarding insurance status, whether they had a primary care physician (PCP), and the impact of cost of care on their ability to follow medical recommendations. Patients were contacted at least 1 week after the ED visit and answered questions regarding adherence to medical recommendations., Results: Four hundred twenty-two patients agreed to participate in the study. At follow-up, 89.7% of patients reported that they had complied with recommendations made during the ED visit. Patients who were adherent to follow-up recommendations were more likely to have a primary care provider (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.1-6.1), have an annual income of greater than $35000 (OR, 2.9; 95% CI, 1.2-7.2), and report a non-Hispanic ethnicity or race (OR, 2.8; 95% CI, 1.1-7.1). Individuals who reported that cost "sometimes" or "always" impacts their ability to follow their physician's recommendations were significantly less likely to comply with ED recommendations (OR, 2.7; 95% CI, 1.3-5.6)., Conclusion: Individuals who reported that cost affects their ability to follow their physician's recommendations and those who did not have a PCP were less likely to follow ED recommendations. Identification of predictors of noncompliance during the ED visit may aid in ensuring compliance with ED recommendations., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: The association between acute medical illness and motor vehicle collisions (MVCs) among elderly emergency department patients is unclear. We sought to determine the prevalence of acute medical conditions that might impair driving ability among the elderly involved in MVCs and determine if there was an increased risk of the driver having an acute medical condition compared to similarly aged passengers., Methods: We reviewed charts of patients aged 65 years or older whose emergency department visit was prompted by a motor vehicle collision between 1 July 2000 and 30 June 2010 at two Level 1 trauma centres. The exposure of interest was occupancy status (driver vs. passenger), and the outcome measure was the presence of any predefined acute medical illness that might impair driving ability., Results: Final analysis included 871 drivers (cases) and 307 passengers (controls). An acute medical illness was recorded in 107 patients (9%): 97 drivers (11%) and 10 passengers (3%). Compared to passengers, drivers had significantly higher odds of presenting with acute medical illness (OR 3.7, 95% CI 1.9-7.2). After controlling for potential confounders, the adjusted odds ratio was 5.5 (95% CI 2.3-13.0)., Conclusion: Acute medical conditions are a moderately common diagnosis among elderly drivers, presenting in about one in ten patients. A difference in the risk of finding an acute medical illness when comparing elderly drivers and passengers evaluated in the emergency department after a collision suggests the need for considering additional diagnostic investigation and post-discharge surveillance in this population., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Aim of the Study: To determine the ability of readily available prehospital variables to predict acute coronary artery disease (CAD) as the cause of arrest in failed out-of hospital cardiac arrest (OHCA) resuscitations., Methods: Retrospective analysis of a prospectively collected database of all adult cases of OHCA who underwent resuscitation attempts and later post-mortem examination by the state Medical Examiner (ME) over a 6 year period. Multivariable logistic regression modeling was used to identify predictors., Results: Among the 151 cases linked to ME reports, CAD was judged to be the cause of arrest in 65/151 (43%). In multivariable modeling, CAD was more likely to be found at autopsy among older victims (Odds ratio [OR] 2.3 per decade of life, 95% confidence interval [CI] 1.6-3.4), males (OR 7.3, 95% CI 1.9-27.4), and those with an initial shockable rhythm (OR 5.3, 95% CI 2.0-14.2). The combination of these three variables correctly classified 75% of victims with an area under the ROC curve (AUC) of 0.85., Conclusion: As hospital-based salvage therapies offer opportunities to extend survival for victims of OHCA who fail prehospital treatment, an ability to predict CAD may help guide protocols for appropriate use. In this derivation analysis, a simple set of variables available on scene can be used to predict CAD with good accuracy among OHCA victims who fail prehospital resuscitation attempts. An initial shockable rhythm should still be considered the result of acute coronary artery disease until proven otherwise., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: Ischemic postconditioning (stutter CPR) and sevoflurane have been shown to mitigate the effects of reperfusion injury in cardiac tissue after 15min of ventricular fibrillation (VF) cardiac arrest. Poloxamer 188 (P188) has also proven beneficial to neuronal and cardiac tissue during reperfusion injury in human and animal models. We hypothesized that the use of stutter CPR, sevoflurane, and P188 combined with standard advanced life support would improve post-resuscitation cardiac and neurologic function after prolonged VF arrest., Methods: Following 17min of untreated VF, 20 pigs were randomized to Control treatment with active compression/decompression (ACD) CPR and impedance threshold device (ITD) (n=8) or Bundle therapy with stutter ACD CPR+ITD+sevoflurane+P188 (n=12). Epinephrine and post-resuscitation hypothermia were given in both groups per standard protocol. Animals that achieved return of spontaneous circulation (ROSC) were evaluated with echocardiography, biomarkers, and a blinded neurologic assessment with a cerebral performance category score., Results: Bundle therapy improved hemodynamics during resuscitation, reduced need for epinephrine and repeated defibrillation, reduced biomarkers of cardiac injury and end-organ dysfunction, and increased left ventricular ejection fraction compared to Controls. Bundle therapy also improved rates of ROSC (100% vs. 50%), freedom from major adverse events (50% vs. 0% at 48h), and neurologic function (42% with mild or no neurologic deficit and 17% achieving normal function at 48h)., Conclusions: Bundle therapy with a combination of stutter ACD CPR, ITD, sevoflurane, and P188 improved cardiac and neurologic function after 17min of untreated cardiac arrest in pigs. All studies were performed with approval from the Institutional Animal Care Committee of the Minneapolis Medical Research Foundation (protocol #12-11)., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objectives: The objective of this study was to determine the feasibility of telementored instruction in bedside ultrasonography (US) using Google Glass. The authors sought to examine whether first-time US users could obtain adequate parasternal long axis (PSLA) views to approximate ejection fraction (EF) using Google Glass telementoring., Methods: This was a prospective, randomized, single-blinded study. Eighteen second-year medical students were randomized into three groups and tasked with obtaining PSLA cardiac imaging. Group A received real-time telementored education through Google Glass via Google Hangout from a remotely located expert. Group B received bedside education from the same expert. Group C represented the control and received no instruction. Each subject was given 3 minutes to obtain a best PSLA cardiac imaging using a portable GE Vscan. Image clips obtained by each subject were stored. A second expert, blinded to instructional mode, evaluated images for adequacy and assigned an image quality rating on a 0 to 10 scale., Results: Group A was able to obtain adequate images six out of six times (100%) with a median image quality rating of 7.5 (interquartile range [IQR] = 6 to 10) out of 10. Group B was also able to obtain adequate views six out of six times (100%), with a median image quality rating of 8 (IQR = 7 to 9). Group C was able to obtain adequate views one out of six times (17%), with a median image quality of 0 (IQR = 0 to 2). There were no statistically significant differences between Group A and Group B in the achievement of adequate images for E-point septal separation measurement or in image quality., Conclusions: In this pilot/feasibility study, novice US users were able to obtain adequate imaging to determine a healthy patient's EF through telementored education using Google Glass. These preliminary data suggest telementoring as an adequate means of medical education in bedside US. This conclusion will need to be validated with larger, more powerful studies including evaluation of pathologic findings and varying body habitus among models., (© 2014 by the Society for Academic Emergency Medicine.)

Study Objective: We investigated emergency physician knowledge of the Centers for Medicare & Medicaid Services (CMS) reimbursement for common tests ordered and procedures performed in the emergency department (ED), determined the relative accuracy of their estimation, and reported the impact of perceived costs on physicians' ordering and prescribing behavior., Methods: We distributed an online survey to 189 emergency physicians in 11 EDs across multiple institutions. The survey asked respondents to estimate reimbursement rates for a limited set of medical tests and procedures, rate their level of current cost knowledge, and determine the effect of health expenditures on their medical decision making. We calculated relative accuracy of cost knowledge as a percent difference of participant estimation of cost from the CMS reimbursement rate., Results: Ninety-seven physicians participated in the study. Most respondents (65%) perceived their knowledge of costs as inadequate, and 39.3% indicated that beliefs about cost impacted their ordering behavior. Eighty percent of physicians surveyed were unable to estimate 25% of the costs within ±25%, and no physicians estimated at least 50% of costs within 25% of the CMS reimbursement and only 17.3% of medical services were estimated correctly within ±25% by 1 or more physicians., Conclusion: Most emergency physicians indicated they should consider cost in their decision making but have a limited knowledge of cost estimates used by CMS to calculate reimbursement rates. Interventions that are easily accessible and applicable in the ED setting are needed to educate physicians about costs, reimbursement, and charges associated with the care they deliver., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Aims: To compare the effects of two TNF-α antagonists, etanercept and infliximab, on post-cardiac arrest hemodynamics and global left ventricular function (LV) in a swine model following ventricular fibrillation (VF)., Methods: Domestic swine (n=30) were placed under general anesthesia and instrumented before VF was induced electrically. After 7 min of VF, standard ACLS resuscitation was performed. Animals achieving return of spontaneous circulation (ROSC) were randomized to immediately receive infliximab (5 mg/kg, n=10) or etanercept (0.3 mg/kg [4 mg/m(2)], n=10) or vehicle (250 mL normal saline [NS], n=10) and LV function and hemodynamics were monitored for 3 h., Results: Following ROSC, mean arterial pressure (MAP), stroke work (SW), and LV dP/dt fell from pre-arrest values in all groups. However, at the 30 min nadir, infliximab-treated animals had higher MAP than either the NS group (difference 14.4 mm Hg, 95% confidence interval [CI] 4.2-24.7) or the etanercept group (19.2 mm Hg, 95% CI 9.0-29.5), higher SW than the NS group (10.3 gm-m, 95% CI 5.1-15.5) or the etanercept group (8.9 gm-m, 95% CI 4.0-14.4) and greater LV dP/dt than the NS group (282.9 mm Hg/s, 95% CI 169.6-386.1 higher with infliximab) or the etanercep group (228.9 mm Hg/s, 95% CI 115.6-342.2 higher with infliximab)., Conclusions: Only infliximab demonstrated a beneficial effect on post cardiac arrest hemodynamics and LV function in this swine model. Etanercept was no better in this regard than saline., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

To compare the early postarrest inflammatory cytokine response between animals administered amiodarone (AMIO) and lidocaine (LIDO) intra-arrest during resuscitation from ventricular fibrillation (VF). Domestic swine (n=32) were placed under general anesthesia and instrumented before spontaneous VF was induced by balloon occlusion of the left anterior descending coronary artery. After 7 min of VF, standard ACLS resuscitation was performed and animals were randomized to either bolus AMIO (5 mg/kg, n=13) or LIDO (1 mg/kg, n=14) for recurrent or refractory VF. A non-antiarrhythmic (n=5) was also used for comparison. Following return of spontaneous circulation (ROSC), tumor necrosis factor (TNF)-α levels were drawn at 30 and 60 min. Groups were comparable with respect to prearrest hemodynamics and resuscitation variables. In the postarrest period, the LIDO and non-antiarrhythmic group demonstrated virtually identical TNF-α response trajectories. However, TNF-α levels were significantly higher in AMIO- than LIDO-treated animals at 30 min (geometric mean 539 versus 240 pg/mL, 2.2-fold higher, 95% confidence interval [CI] 1.3-3.8-fold higher, P=0.003) and at 60 min (geometric mean 570 versus 204 pg/mL, 2.8-fold higher, 95% CI 1.1-7.0-fold higher, P=0.03). Significant differences in the postarrest TNF-α levels were observed between animals treated with AMIO as compared to those treated with LIDO. Improved rates of ROSC seen with AMIO may come at the expense of a heightened proinflammatory state in the postcardiac arrest period.