Abstract 238: In-Hospital Cardiac Arrest: The Dynamic Clinical Course During Advanced Cardiac Life Support

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.

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Abstract 110: The Dynamic Clinical Course of Resuscitation in Children With Cardiac Arrest

Circulation ◽

10.1161/circ.138.suppl_2.110 ◽

2018 ◽

Vol 138 (Suppl_2) ◽

Author(s):

Trond Nordseth ◽

Dana Niles ◽

Trygve Eftestøl ◽

Vinay Nadkarni ◽

Robert Sutton ◽

...

Keyword(s):

Cardiac Arrest ◽

Clinical Course ◽

Pulseless Electrical Activity ◽

Spontaneous Circulation ◽

Clinical State ◽

State Transitions ◽

Temporary Increase ◽

Older Children ◽

Chest Compressions ◽

Hospital Cardiac Arrest

Background: During cardiac arrest, a child may be in one of five clinical states (“rhythms”): 1) Bradycardia with poor perfusion; 2) Pulseless Electrical Activity (PEA); 3) Ventricular Fibrillation or Pulseless Ventricular Tachycardia (VF/VT); 4) Asystole; or 5) Spontaneous Circulation (ROSC). The aim of study was to investigate and quantify the dynamic characteristics of this process. Methods: We prospectively acquired data on rhythm and clinical states using recording defibrillators during active CPR. Recordings were analyzed as a multi-state statistical model, focusing on transitions between PEA (including bradycardia with poor perfusion), VF/VT, Asystole, and ROSC (defined as an organized electrical rhythm without chest compressions >= 1 minute). Instantaneous transition rates were obtained by smoothing the Nelson-Aalen estimator of cumulative intensities. Results: In 74 Cardiac Arrest events with evaluable data, median patient age was 15 years [range 1.75 to 22.9; IQR 11 to 17]. Fifty percent had a respiratory etiology and 51 % were female. PEA was the most frequent presenting cardiac arrest rhythm (38 %); followed by VF/VT (24 %), bradycardia (22 %), and asystole (16 %). Starting from time of defibrillator attachment (median 3 minutes into the event) as shown in the figure that shows 45 minutes of CPR, the prevalence of sustained ROSC reached an asymptotic value of 30 % at 20 minutes. We observed a temporary surge of PEA at about 12 minutes, resulting from a doubling (from 0.1 to 0.2 transitions/min) of the instantaneous transition rate of ROSC to PEA during this period. Conclusion: We provide a quantitative overview of the dynamic process of clinical state transitions during in-hospital cardiac arrest and resuscitation in older children and adolescents. A notable feature was a temporary increase in the prevalence of PEA at 12 minutes.

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Clinical state transitions during advanced life support (ALS) in in-hospital cardiac arrest

Resuscitation ◽

10.1016/j.resuscitation.2013.04.010 ◽

2013 ◽

Vol 84 (9) ◽

pp. 1238-1244 ◽

Cited By ~ 21

Author(s):

Trond Nordseth ◽

Daniel Bergum ◽

Dana P. Edelson ◽

Theresa M. Olasveengen ◽

Trygve Eftestøl ◽

...

Keyword(s):

Cardiac Arrest ◽

Life Support ◽

Advanced Life Support ◽

Clinical State ◽

State Transitions ◽

Hospital Cardiac Arrest

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Hot Off the Press: Prehospital Advanced Cardiac Life Support for Out-of-hospital Cardiac Arrest

Academic Emergency Medicine ◽

10.1111/acem.13334 ◽

2017 ◽

Vol 25 (4) ◽

pp. 453-455

Author(s):

Justin Morgenstern ◽

Corey Heitz ◽

William K. Milne

Keyword(s):

Cardiac Arrest ◽

Life Support ◽

Advanced Cardiac Life Support ◽

The Press ◽

Hospital Cardiac Arrest

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Abstract 150: Impact of Epinephrine on ECG Changes During Resuscitation From Out-of-Hospital Cardiac Arrest With Initial Pulseless Electrical Activity

Circulation ◽

10.1161/circ.138.suppl_2.150 ◽

2018 ◽

Vol 138 (Suppl_2) ◽

Author(s):

Gunnar W Skjeflo ◽

Eirik Skogvoll ◽

Jan Pål Loennechen ◽

Theresa M Olasveengen ◽

Lars Wik ◽

...

Keyword(s):

Heart Rate ◽

Cardiac Arrest ◽

Electrical Activity ◽

Multivariate Regression ◽

Life Support ◽

Controlled Trial ◽

Pulseless Electrical Activity ◽

Qrs Complex ◽

Epinephrine Administration ◽

Hospital Cardiac Arrest

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.

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Abstract 2003: More Chest Compressions and Fewer Shocks Are Given During Out-of-Hospital Cardiac Arrest Resuscitation With the 2005 AHA Guidelines

Circulation ◽

10.1161/circ.116.suppl_16.ii_433-a ◽

2007 ◽

Vol 116 (suppl_16) ◽

Author(s):

Lynn J White ◽

Sarah A Cantrell ◽

Robert Cronin ◽

Shawn Koser ◽

David Keseg ◽

...

Keyword(s):

Cardiac Arrest ◽

Life Support ◽

Survival Rates ◽

Automated Analysis ◽

Spontaneous Circulation ◽

Chest Compressions ◽

Convenience Sample ◽

Care Protocol ◽

Before And After ◽

Hospital Cardiac Arrest

Introduction Long pauses without chest compressions (CC) have been identified in CPR provided by EMS professionals for out-of-hospital cardiac arrest (OOHCA). The 2005 AHA ECC CPR guidelines emphasize CC. The 2005 AHA Basic Life Support (BLS) for Healthcare Professionals (HCP) course introduced a training method with more CPR skills practice during the DVD based course. The purpose of this before/after study was to determine whether CC rates increased after introduction of the 2005 course. Methods This urban EMS system has 400 cardiac etiology OOHCA events annually. A convenience sample of 49 continuous electronic ECG recordings of VF patients was analyzed with the impedance channel of the LIFEPAK 12 (Physio-Control, Redmond WA) and proprietary software. A trained researcher verified the automated analysis. Each CC during the resuscitation attempt and pauses in CC before and after the first defibrillation shock were noted. The time of return of spontaneous circulation (ROSC) was determined by medical record review and onset of regular electrical activity without CC. Medical records were reviewed for outcome to hospital discharge. The EMS patient care protocol for VF was changed on July 1, 2006 to comply with the 2005 AHA ECC guidelines. Cases were grouped by the OOHCA date: 9/2004 to 12/31/2006 (pre) and 7/1/2006 to 4/21/2007 (post). EMS personnel began taking the 2005 BLS for HCP course during spring 2006. Monthly courses over 3 years will recertify 1500 personnel. Results 29 cases were analyzed from the pre group and 20 from the post group. Compressions per minute increased from a mean (±SD) of 47 ± 16 pre to 75 ± 33 post (P < 0.01). The mean count of shocks given per victim decreased from 4.5 ± 4.0 pre to 2.8 ± 1.8 post (P < 0.04). The CC pause before the first shock was unchanged (23.6 ± 18.4 seconds to 22.1 ± 17.9). but the CC pause following that shock decreased significantly from 48.7 ± 63.2 to 11.8 ± 22.5 (p=0.008). Rates of ROSC (55% pre, 50% post) and survival to discharge (15% pre, 13% post) were similar. Conclusion Following introduction of the 2005 BLS for HCP course and the EMS protocol change, the quality of CPR delivered to victims of OOHCA improved significantly compared with pre-2006 CPR. The sample size was too small to detect differences in survival rates.

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Abstract 18: Analyzing Heart Rhythm During Chest Compressions in Out-of-Hospital Cardiac Arrest Patients Using New Algorithm for Automated External Defibrillators

Circulation ◽

10.1161/circ.138.suppl_2.18 ◽

2018 ◽

Vol 138 (Suppl_2) ◽

Author(s):

Corina de Graaf ◽

Stefanie G Beesems ◽

Ronald E Stickney ◽

Paula Lank ◽

Fred W Chapman ◽

...

Keyword(s):

Cardiac Arrest ◽

Negative Impact ◽

Pulseless Electrical Activity ◽

Heart Rhythm ◽

Chest Compressions ◽

Study Region ◽

Automated External Defibrillators ◽

Conventional Analysis ◽

Hospital Cardiac Arrest ◽

Conventional Algorithm

Purpose: Automated external defibrillators (AED) prompt the rescuer to stop cardiopulmonary resuscitation (CPR) for ECG analysis. Any interruption of CPR has a negative impact on outcome. We prospectively evaluated a new algorithm (cprINSIGHT) which can analyse the ECG while rescuers continue CPR. Methods: We analysed data from patients with attempted resuscitation from OHCA who were connected to an AED with cprINSIGHT (Stryker Physio-Control LIFEPAK CR2) between June 2017 and June 2018 in the Amsterdam Resuscitation Study region. The first analysis in the CR2 is a conventional analysis; subsequent analyses use the cprINSIGHT algorithm. This algorithm classifies the rhythm as shockable (S), non-shockable (NS), or no decision. If no decision, the AED prompts for a pause in CPR and uses its conventional algorithm. The characteristics of the first 3 cprINSIGHT analyses (analyses 2-4) were analysed. Ventricular fibrillation (VF) cases were both coarse and fine VF with a lower threshold of 0.08 mV. Results: Data from 132 consecutive OHCA cases were analysed. The initial recorded rhythm was VF or pulseless ventricular tachycardia (VT) in 35 cases (27%), pulseless electrical activity in 34 cases (25%) and asystole in 63 cases (48%). In 114 cases (86%), 1 or more cprINSIGHT analyses were done. Analyses 2-4 covered 90% of all cprINSIGHT analyses. The analyzed rhythm was VF/VT in 12-17%, organised QRS rhythm in 29-35% and asystole in 51-56% (see table). cprINSIGHT reached a S or NS decision in 65-74% of cases, with a sensitivity of 90-100% and a specificity of 100%. When it reached no decision, the rhythm was asystole in 65-79% of analyses, VF/VT in 0-9% and QRS rhythm in 18-27%; conventional analysis followed. Chest compression fraction was 85-88%, CPR fraction was 99%. Conclusion: This new algorithm analysed the ECG without need for a pause in chest compressions 65-74% of the time and had 90-100% sensitivity and 100% specificity when it made a shock or a no shock decision.

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Strengthening Links in the “Chain of Survival”: A Singapore Perspective

Hong Kong Journal of Emergency Medicine ◽

10.1177/102490790200900301 ◽

2002 ◽

Vol 9 (3) ◽

pp. 121-125 ◽

Cited By ~ 2

Author(s):

Ra Charles ◽

F Lateef ◽

V Anantharaman

Keyword(s):

Emergency Department ◽

Cardiac Arrest ◽

Life Support ◽

Advanced Cardiac Life Support ◽

Basic Cardiac Life Support ◽

Chain Of Survival ◽

Bystander Cpr ◽

Mean Time ◽

Hospital Cardiac Arrest ◽

Ambulance Crew

Introduction The concept of the chain of survival is widely accepted. The four links viz. early access, early cardiopulmonary resuscitation (CPR), early defibrillation and early Advanced Cardiac Life Support (ACLS) are related to survival after pre-hospital cardiac arrest. Owing to the dismal survival-to-discharge figures locally, we conducted this study to identify any weaknesses in the chain, looking in particular at bystander CPR rates and times to Basic Cardiac Life Support (BCLS) and ACLS. Methods and materials A retrospective cohort study was conducted in the Emergency Department of an urban tertiary 1500-bed hospital. Over a 12-month period, all cases of non-trauma out-of-hospital cardiac arrest were evaluated. Results A total of 142 cases of non-trauma out-of-hospital cardiac arrest were identified; the majority being Chinese (103/142, 72.5%) and male (71.8%) with a mean age of 64.3±7.8 years (range 23–89 yrs). Most patients (111/142, 78.2%) did not receive any form of life support until arrival of the ambulance crew. Mean time from collapse to arrival of the ambulance crew and initiation of BCLS and defibrillation was 9.2±3.5 minutes. Mean time from collapse to arrival in the Emergency Department (and thus ACLS) was 16.8±7.1 minutes. Three patients (2.11%) survived to discharge. Conclusion There is a need to (i) facilitate layperson training in bystander CPR, and (ii) enhance paramedic training to include ACLS, in order to improve the current dismal survival outcomes from out-of-hospital cardiac arrest in Singapore.

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Pupillary Light Reflex Is Not Abolished by Epinephrine and Atropine Given During Advanced Cardiac Life Support in Patients Who Achieve Return of Spontaneous Circulation

Journal of Intensive Care Medicine ◽

10.1177/0885066620906802 ◽

2020 ◽

pp. 088506662090680

Author(s):

Natalie Achamallah ◽

Jeffrey Fried ◽

Rebecca Love ◽

Yuri Matusov ◽

Rohit Sharma

Keyword(s):

Cardiac Arrest ◽

Life Support ◽

Advanced Cardiac Life Support ◽

Spontaneous Circulation ◽

Pupillary Light Reflex ◽

Return Of Spontaneous Circulation ◽

Neurologic Recovery ◽

Light Reflex ◽

Pupillary Light ◽

Hospital Cardiac Arrest

Introduction: Absence of pupillary light reflex (PLR) is a well-studied indicator of poor neurologic recovery after cardiac arrest. Interpretation of absent PLR is difficult in patients with hypothermia or hypotension, or who have electrolyte or acid-base disturbances. Additionally, many studies exclude patients who receive epinephrine or atropine from their analysis on the basis that these drugs are thought to abolish the PLR. This observational cohort study assessed for presence or absence of PLR in in-hospital cardiac arrest patients who received epinephrine with or without atropine during advanced cardiac life support and achieved return of spontaneous circulation (ROSC). Methods: Pupil size and reactivity were assessed in adult patients who had an in-hospital cardiac arrest, received epinephrine with or without atropine, and achieved ROSC. Measurements were taken using a NeurOptics NPi-200 infrared pupillometer. Results: Forty patients had pupillometry performed within 1 hour (median: 6 minutes) after ROSC. Of these only 1 (2.5%) patient had nonreactive pupils at first measurement after ROSC. The remaining 39 (97.5%) had reactive pupils. Of the 19 patients who had pupils checked within 3 minutes of ROSC, 100% had reactive pupils. Degree of pupil responsiveness was not correlated with cumulative dose of epinephrine. Ten patients received atropine in addition to epinephrine, including the sole patient with nonreactive pupils. The remaining 9 (90%) had reactive pupils. Conclusion: Epinephrine and atropine do not abolish the PLR in patients who achieve ROSC after in-hospital cardiac arrest. Lack of pupillary response in the post-arrest patient should not be attributed to these drugs.

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