Out-of-Hospital Resuscitation: Have We Gone Too Far?

2006 ◽  
Vol 21 (6) ◽  
pp. 445-450 ◽  
Author(s):  
Corita Grudzen
Keyword(s):  
Cardiac Arrest ◽  
Prehospital Care ◽  
Sudden Cardiac Arrest ◽  
Hospital Setting ◽  
The United States ◽  
Spontaneous Circulation ◽  
Emergency Medical ◽  
Clinical Scenarios ◽  
Life Sustaining Treatment ◽  
Future Policy

AbstractAmericans are living longer and are more likely to be chronically or terminally ill at the time of death. Although surveys indicate that most people prefer to die at home, the majority of people in the United States die in acute care hospitals. Each year, approximately 400,000 persons suffer sudden cardiac arrest in the US, the majority occurring in the out-of-hospital setting. Mortality rates are high and reach almost 100% when prehospital care has failed to restore spontaneous circulation. Nonetheless, patients who receive little benefit or may wish to forgo life-sustaining treatment often are resuscitated. Risk versus harm of resuscitation efforts can be differentiated by various factors, including cardiac rhythm. Emergency medical services policy regarding resuscitation should consider its utility in various clinical scenarios. Patients, family members, emergency medical providers, and physicians all are important stakeholders to consider in decisions about out-of-hospital cardiac arrest. Ideally, future policy will place greater emphasis on patient preferences and quality of life by including all of these viewpoints.

Abstract 246: Therapeutic Hypothermia Mimicking Peptide Administration During Cardiopulmonary Resuscitation Improved Cardiac Arrest Survival in Swine

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_4) ◽  
Author(s):  
Matt Oberdier ◽  
Jing Li ◽  
Dan Ambinder ◽  
Xiangdong Zhu ◽  
Sarah Fink ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Therapeutic Hypothermia ◽  
Venous Blood ◽  
Plasma Concentrations ◽  
Sudden Cardiac Arrest ◽  
The United States ◽  
Rapid Onset ◽  
Spontaneous Circulation ◽  
Control Group ◽  
Swine Model

Background: Out-of-hospital sudden cardiac arrest is a leading cause of death in the United States, affecting over 350,000 people per year with an overall survival rate around 10%. CPR, defibrillation, and therapeutic hypothermia are common resuscitation strategies, but hypothermia is difficult to implement timely to achieve survival benefit. A cell-permeable peptide TAT-PHLPP9c has been shown to alter metabolic pathways similar to hypothermia, and decreases the release of two biomarkers, taurine and glutamate, during the high osmotic stress of heart stunning and brain injury in a mouse arrest model. Hypothesis: TAT-PHLPP9c, given during CPR, enhances 24-hour survival in a swine ventricular fibrillation (VF) model. Methods: In 14 (8 controls and 6 treated) sedated, intubated, and mechanically ventilated swine, after 5 min of VF, ACLS with vest CPR and periodic defibrillations was performed. Venous blood samples were collected at baseline, after 2 min of CPR, and at 2 and 30 min after return of spontaneous circulation (ROSC). The animals were survived up to 24 hrs and plasma samples were analyzed for glutamate and taurine in 2 controls and 1 animal given peptide. Results: Three of the control animals had ROSC, but none survived for 24 hrs, while 4 of 6 treated animals achieved neurologically intact survival at 24 hrs (p < 0.02). Compared to baseline, both taurine and glutamate plasma concentrations increased in the control group, but the increase was reduced substantially by the peptide treatment at 30 min after ROSC (Figure). Conclusion: The use of the cooling mimicking peptide TAT-PHLPP9c administered during CPR significantly improved 24-hour survival in this swine model of cardiac arrest. It reduced the increase of cerebral and myocardial metabolic biomarkers, which encourages utilizing a strategy of cell-permeable peptides for intravenous administration for more rapid onset of hypothermia-like salutary effects than are possible with current CPR cooling devices.

Neuroprognostication after Cardiac Arrest: Who Recovers? Who Progresses to Brain Death?

2021 ◽  
Vol 41 (05) ◽  
pp. 606-618
Author(s):  
Elizabeth Carroll ◽  
Ariane Lewis
Keyword(s):  
Cardiac Arrest ◽  
Brain Death ◽  
Survival Rates ◽  
Sudden Cardiac Arrest ◽  
Spontaneous Circulation ◽  
Temperature Management ◽  
Neurologic Recovery ◽  
Life Sustaining Treatment ◽  
Developed Nations ◽  
Overall Survival Rates

AbstractApproximately 15% of deaths in developed nations are due to sudden cardiac arrest, making it the most common cause of death worldwide. Though high-quality cardiopulmonary resuscitation has improved overall survival rates, the majority of survivors remain comatose after return of spontaneous circulation secondary to hypoxic ischemic injury. Since the advent of targeted temperature management, neurologic recovery has improved substantially, but the majority of patients are left with neurologic deficits ranging from minor cognitive impairment to persistent coma. Of those who survive cardiac arrest, but die during their hospitalization, some progress to brain death and others die after withdrawal of life-sustaining treatment due to anticipated poor neurologic prognosis. Here, we discuss considerations neurologists must make when asked, “Given their recent cardiac arrest, how much neurologic improvement do we expect for this patient?”

scholarly journals SUDDEN CARDIAC ARREST IN PATIENTS OVER 60 YEARS OF AGE IN THE OPERATION AREA OF EMERGENCY MEDICAL SERVICE IN SIEDLCE IN 2013-2017

2020 ◽  
Vol 7 (3) ◽  
pp. 170-177
Author(s):  
Agnieszka Hawrylewicz-Łuka ◽  
Robert Gałązkowski ◽  
Daniel Celiński ◽  
Krzysztof Mitura ◽  
Leszek Szpakowski ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Emergency Medical Service ◽  
Medical Service ◽  
Human Life ◽  
Sudden Cardiac Arrest ◽  
Spontaneous Circulation ◽  
Time Range ◽  
Emergency Medical ◽  
Qualitative Variables ◽  
The Mean

Introduction: Sudden cardiac arrest is an integral part of the end of every human life. The aim: To analyze and determine the characteristics of the geriatric patients with sudden cardiac arrest. Material and methods: This was a retrospective study covering the operation area of the Emergency Medical Service in Siedlce. Time range: from January 1, 2013 to December 31, 2017. The Chi2 test was used to assess the significant differences between the analyzed qualitative variables. The level of significance was 0.05. Results: Out of 182,584 emergency medical records collected over 5 years, 5682 cases were manually selected as interventions for a patient with sudden cardiac arrest. This represented 3.11% of all medical services provided, from which a group of n = 3840 patients over 60 years of age was selected. The patient had usually between 75 and 90 years of age. The mean age was 75.55 years. The mean arrival time to such a patient was 10.28 min. The most common ECG rhythm was asystole, followed by return of spontaneous circulation (ROSC) in 12.71% of cases (n = 67). No mechanical chest compression equipment was used. Most often adrenaline and fluid therapy were administered after obtaining intravenous access. Mostly, the witness of the event did not undertake rescue activities. The mean resuscitation time was 48.11 min in the case of ROSC, and 36.98 minutes, if there was no ROSC. Conclusions: In the studied group of patients over 60 years, the chances of ROSC clearly decreased with age.

scholarly journals P058: Morbid obesity association with return of spontaneous circulation from sudden cardiac arrest treated in a large, urban EMS system in the United States

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S97-S98
Author(s):  
J.M. Goodloe ◽  
L.D. Vinson ◽  
M.L. Cox ◽  
B.D. Burns
Keyword(s):  
United States ◽  
Morbid Obesity ◽  
Cardiac Arrest ◽  
Adult Population ◽  
Sudden Cardiac Arrest ◽  
The United States ◽  
Spontaneous Circulation ◽  
Contributing Factors ◽  
Return Of Spontaneous Circulation ◽  
Specific Analysis

Introduction: Patient co-morbidities contribute to survivability from out-of-hospital sudden cardiac arrest. Many studies have been conducted regarding contributing factors to sudden cardiac arrest survival, though very few studies have been published detailing specific analysis of morbid obesity association with return of spontaneous circulation (ROSC) in adults treated by paramedics. Methods: Adults in sudden cardiac arrest with resuscitation initiated, including at least one defibrillation, between July 1, 2016 and December 1, 2016 were enrolled. Due to an increasing prevalence of morbid obesity in the United States adult population, a novel defibrillation strategy, involving weight-based joule settings and double sequential external defibrillation (DSED) was initiated in June 2016. As exact body weight is logistically difficult to obtain in the EMS care environment, a paramedic-estimated weight at the time of resuscitation to be 100 kg or greater was deemed representative of “morbid obesity” for this analysis. All resuscitations were reviewed from electronic medical records (EMRs) completed by treating paramedics, alongside telemetry and defibrillation events recorded, transmitted, and analyzed in proprietary software (CODE-STAT, Physio-Control Corporation, Redmond, WA). ROSC was determined from both paramedic and hospital clinician EMRs reviewed by a paramedic researcher. Results: During the 5 month study period, paramedics involved treated 133 adults in sudden cardiac arrest involving perceived ventricular fibrillation that was treated with at least one defibrillation. 49/90 (54.4%) with weight &lt;100 kg as estimated by paramedics at the time of resuscitative care achieved at least transient ROSC. Only 17/43 (39.5%) with estimated weight ≥100 kg achieved any ROSC, despite paramedics authorized to perform defibrillations at higher joule energy settings for such weight. The OR for ROSC if &lt;100 kg estimated weight is 1.83 (95% CI 0.87-3.83), though given limited sample size p=0.11. Conclusion: While survival from out-of-hospital sudden cardiac arrest in adults is multi-factorial, the presence of morbid obesity, defined as estimated weight ≥100 kg, trends towards less ROSC. Continued community health efforts to decrease the prevalence of morbid obesity in the adult population may confer improved ability to survive out-of-hospital sudden cardiac arrest.

Abstract 11269: Recombinant Soluble Thrombomodulin in Prolonged Porcine Cardiac Arrest

Circulation ◽  
2021 ◽  
Vol 144 (Suppl_2) ◽  
Author(s):  
Boya Zhang ◽  
Brendan McCracken ◽  
Danielle Leander ◽  
Carmen Colmenero ◽  
Nicholas Greer ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Sudden Cardiac Arrest ◽  
The United States ◽  
Hypercoagulable State ◽  
Soluble Thrombomodulin ◽  
Consumptive Coagulopathy ◽  
Antithrombotic Effects ◽  
Potential Contributor ◽  
Ca Model ◽  
Coagulation And Fibrinolysis

Introduction: Sudden Cardiac Arrest (CA) affects more than 400,000 people per year in the United States. Although a third of these patients survive to hospital admission, another 60-70% go on to die due to failed recovery of vital organ function. Microvascular thrombosis has been suggested as a potential contributor to prolonged organ dysfunction, but no antithrombotic therapies have been shown to be beneficial and coagulofibrinolytic abnormalities in prolonged CA remain poorly understood. Objectives: To establish key biomarkers of porcine coagulation and fibrinolysis in the setting of prolonged CA and cardiopulmonary resuscitation (CPR) and test the ability of ART-123 (recombinant human thrombomodulin alpha) to reverse these abnormalities. Methods: 15 pigs (n=5 per group) underwent 8 minutes of no-flow CA followed by 50 minutes of mechanical CPR. Animals were randomized to receive saline or ART-123 (~1mg/kg) pre-arrest (5 minutes prior to ventricular fibrillation) or post-arrest (2 minutes after initiation of CPR). Results: Robust and ongoing activation of coagulation and fibrinolysis were detected throughout the resuscitation. After 50 minutes of CPR, plasma tests suggested consumptive coagulopathy, while whole blood testing (thromboelastography) indicated a persistent hypercoagulable state. ART-123 had a clear anticoagulant effect irrespective of timing (TAT complexes 381±25 vs. 238±18 vs. 226±12, p<0.01, and d-dimer 4.86±0.54 vs. 2.39±0.2 vs. 2.46±0.21 for vehicle, pre-arrest, post-arrest, p = 0.05). A pro-fibrinolytic effect was also observed, but only when the drug was given before no-flow, with a significant increase in levels of free endogenous tPA (1.2±0.12 vs. 3.29±0.29 vs. 1.72±0.3, p < 0.001) and corresponding suppression of free PAI-1 (0.59±0.15 vs. 0.14±0.01 vs. 0.41±0.09, p < 0.001). Conclusion: Our porcine CA model provides an excellent platform for evaluating antithrombotic interventions. Plasma testing after prolonged CA/CPR suggests consumptive coagulopathy, although TEG indicates a persistent hypercoagulable state. ART-123 given before no-flow or just after CPR demonstrates antithrombotic effects, although the specific modes of action depending on the timing of administration.

Abstract 127: Machine Learning Techniques to Predict Cardiac Re-Arrest in Out-Of-Hospital Setting

Circulation ◽  
2019 ◽  
Vol 140 (Suppl_2) ◽  
Author(s):  
Andoni Elola ◽  
Elisabete Aramendi ◽  
Unai Irusta ◽  
Naroa Amezaga ◽  
Jon Urteaga ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Prediction Model ◽  
Prehospital Care ◽  
Hospital Setting ◽  
Area Under The Curve ◽  
Interquartile Range ◽  
Machine Learning Techniques ◽  
Survival Prediction ◽  
Poincaré Plot ◽  
Rr Intervals

Background: Re-arrest occurs when a cardiac arrest patient being treated by the emergency medical services experiences another cardiac arrest after return of spontaneous circulation (ROSC).The incidence of re-arrest is high, close to 40% in out-of-hospital cardiac arrest (OHCA), and it is associated with lower survival. Prediction of re-arrest could improve prehospital care. The aim of this study was to develop a re-arrest prediction model based on heart rate variability (HRV) features. Materials and methods: OHCA cases treated by Dallas-FortWorth Center of Resuscitation Research were analyzed. Patients with at least two minutes of ROSC were included. Re-arrest was ascertained by the presence of life-threatening ECG and/or presence of chest compressions within 12 minutes after ROSC. Eighteen HRV characteristics for 1 min and 2 min intervals after ROSC were computed. Features were fed into a Random Forest (RF) classifier with 100 trees to predict re-arrest cases. Ten-fold cross-validation with 30 repetitions was applied to train the model and assess the performance in terms of area under the curve (AUC). Results: Inclusion criteria were met by 98 patients, 41 of which suffered re-arrest. The median time (interquartile range) to re-arrest from ROSC onset was 5 (3-7) min. The re-arrest prediction model showed a median AUC of 0.71 and 0.75 for 1 and 2 min post ROSC intervals, respectively. The most important HRV features in the RF predictor were the SD1/SD2 ratio (where SD1 and SD2 are the dispersions of points both perpendicular and parallel to the line-of-identity in the Poincaré plot), SD2, the interquartile range of the RR intervals, peak frequency in the high frequency band (0.15-0.4 Hz) and coefficient of variation of RR intervals (the ratio between the mean and standard deviation of RR intervals). Conclusions: HRV metrics predict re-arrest in OHCA. Further studies with larger datasets are needed to better understand re-arrest dynamics and confirm conclusions.

Abstract 147: Rapid Responder Operating Times for Out-of-hospital Cardiac Arrest Using Three Automated External Defibrillator Models

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_4) ◽  
Author(s):  
Mengqi Gao ◽  
Chenguang Liu ◽  
Dawn Jorgenson
Keyword(s):  
Cardiac Arrest ◽  
Life Support ◽  
Operating Time ◽  
Sudden Cardiac Arrest ◽  
The United States ◽  
Automated External Defibrillator ◽  
Simulation Studies ◽  
Time Intervals ◽  
Shock Delivery ◽  
External Defibrillator

Background: Early defibrillation with an automated external defibrillator (AED) is crucial for improving the survival rate in out-of-hospital resuscitation from sudden cardiac arrest (SCA). Chance of survival decreases by 7% to 10% for every minute that defibrillation is delayed. While simulation studies have been used to assess AED usability factors, our objective was to report the actual operating time for three Philips AED models used in SCA responses. Methods: A convenience dataset recorded by Philips AEDs (HS1, FRx, or FR3) was obtained from Europe and the United States from 2007 - 2018. The HS1 is intended for minimally trained or untrained individuals, the FRx is for Basic Life Support (BLS), and the FR3 is for both BLS and Advanced Life Support (ALS) responders. A retrospective analysis was conducted to report the operating time intervals for cases where a shock was delivered after initial rhythm analysis. The study analyzed 90 HS1, 46 FRx and 32 FR3 cases. Results: Compared with HS1, both FRx (p < 0.001) and FR3 (p = 0.001) responders spent less time in placing pads on the patient after powering on the AED (Figure 1) as expected. Similarly, time intervals from the start of shock advised prompt to first shock delivery for FRx (p = 0.02) and FR3 (p < 0.01) are shorter than for HS1. Time from AED power-on to first shock was within 90 seconds in 74.4% (67 of 90) HS1 cases, 97.8% (45 of 46) FRx cases, and 100% (32 of 32) FR3 cases. On average, the FR3 and FRx responders were able to deliver the first shock within 48 seconds. Conclusions: The analysis shows that responders were able to quickly apply the AEDs and respond to the shock advisory prompt for all three AED models despite different training levels. This real-world performance is better than most reported simulation studies, however, this analysis cannot convey variety of activities that account for the differences in timing (e.g. pads applied before power-on, or compressions began before applying pads, etc.).

Post–Cardiac Arrest Syndrome

2020 ◽  
Vol 31 (4) ◽  
pp. 383-393
Author(s):  
Linda Dalessio
Keyword(s):  
Cardiac Arrest ◽  
Myocardial Dysfunction ◽  
The United States ◽  
Spontaneous Circulation ◽  
Clinical State ◽  
Precipitating Factors ◽  
Patient Health ◽  
Global Brain ◽  
The Brain ◽  
Post Cardiac Arrest Syndrome

More than 356 000 out-of-hospital cardiac arrests occur in the United States annually. Complications involving post–cardiac arrest syndrome occur because of ischemic-reperfusion injury to the brain, lungs, heart, and kidneys. Post–cardiac arrest syndrome is a clinical state that involves global brain injury, myocardial dysfunction, macrocirculatory dysfunction, increased vulnerability to infection, and persistent precipitating pathology (ie, the cause of the arrest). The severity of outcomes varies and depends on precipitating factors, patient health before cardiac arrest, duration of time to return of spontaneous circulation, and underlying comorbidities. In this article, the pathophysiology and treatment of post–cardiac arrest syndrome are reviewed and potential novel therapies are described.

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