Abstract 260: Regional Routing for Extracorporeal Membrane Oxygenation to Increase Survival From Refractory Ventricular Fibrillation/Ventricular Tachycardia Out-of-Hospital Cardiac Arrest

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_4) ◽  
Author(s):  
Nichole E Bosson ◽  
Amy H Kaji ◽  
James T Niemann ◽  
Shira Schlesinger ◽  
David Shavelle ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Ventricular Tachycardia ◽  
Ventricular Fibrillation ◽  
Extracorporeal Membrane Oxygenation ◽  
Neurologic Outcome ◽  
Transport Time ◽  
Regional System ◽  
Good Neurologic Outcome ◽  
Hospital Cardiac Arrest ◽  
Actual Survival

Introduction: Extracorporeal membrane oxygenation (ECMO) is increasingly used to support patients with refractory ventricular fibrillation/ventricular tachycardia (rVF/VT) out-of-hospital cardiac arrest (OHCA). Los Angeles County (LAC) operates a regional system of care for 10.2 million persons, routing patients with OHCA to the closest cardiac receiving center. The purpose of this study was to determine 1) the number of patients eligible and 2) the potential for increased neurologically intact survival routing patients with rVF/VT OHCA to ECMO-capable cardiac centers. Methods: This was a retrospective study utilizing LAC quality improvement databases. Patients 18-75 years treated by EMS from 2011-2017 for rVF/VT OHCA, defined as persistent VF/VT after 3 defibrillations, were included in the analysis. Actual survival with good neurologic outcome, defined as cerebral performance category (CPC) 1 or 2, was abstracted from the LAC OHCA Registry. Theoretical patient outcome with routing directly to an ECMO-capable center was determined by applying outcomes as described by the Minnesota Resuscitation Consortium (MRC) for rVF/VT transported for ECMO. Assumptions included the availability of ECMO within a 30-minute transport time, and similar proportions of patients meeting criteria for transport/cannulation and surviving with CPC 1-2 as the MRC cohort, 78% and 40% respectively. For the remaining patients, we assumed no change in outcome. We compared the actual to the theoretical outcome with regional ECMO to determine the annual increase in survival with good neurologic outcome. Results: During the 7-year study period, there were 1862 patients with rVT/VT OHCA with outcomes available for 1454 (78%) patients. Median age was 59 years (IQR 51-66); 76% were male. Actual survival with CPC 1-2 was 13% (187 patients). Theoretical survival with CPC 1-2 in a regional ECMO-capable system was 34% (495 patients); OR 3.5 (95%CI 2.9-4.2), p<0.0001 with ECMO routing versus without. Conclusion: Assuming ECMO availability within a 30-minute transport time throughout the regional system, routing patients with rVF/VT to ECMO-capable centers could improve survival with CPC 1-2 nearly three-fold and result in 44 additional patients/year with meaningful survival.

scholarly journals P021: Outcomes of out of hospital cardiac arrest in London, Ontario

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S64-S64
Author(s):  
M. D. Clemente ◽  
K. Woolfrey ◽  
K. Van Aarsen ◽  
M. Columbus
Keyword(s):  
Cardiac Arrest ◽  
Ventricular Tachycardia ◽  
Ventricular Fibrillation ◽  
Mortality Rate ◽  
Hospital Discharge ◽  
Outcome Data ◽  
Neurologic Outcome ◽  
Exclusion Criteria ◽  
Hospital Cardiac Arrest ◽  
Very High

Introduction: Out of hospital cardiac arrest (OHCA) continues to carry a very high mortality rate, with approximately 10% surviving to hospital discharge. We sought to determine if outcomes from out of hospital cardiac arrest (OHCA) at our centre were consistent with recently published North American outcomes data from the Resuscitation Outcomes Consortium (ROC). Methods: We performed a retrospective analysis (Sept 2011 June 2015) of the Resuscitation Outcomes Consortium (ROC) database, which contains pre-hospital, in-hospital and outcomes data on adult, EMS-treated, non-traumatic OHCA. Patients under 18 years, with missing age data or with obvious non-cardiac causes of arrest were excluded. Results: During the study period, there were a total of 997 OHCA; 86 met exclusion criteria. Of the 911 remaining patients, 557 (61.1%) were transported to a local ED. 92 (35.1%) were receiving ongoing CPR at the time of their presentation to the ED. Of those transported to the ED, 262 (47.0%) achieved sustained ROSC, defined as survival to ED discharge. A total of 95 patients survived to hospital discharge (36.3% of patients who achieved sustained ROSC, 17.1% of those who were transported to the ED, and 10.4% of the all OHCA). Of those who survived to hospital discharge who had neurologic outcome data, 90.5% had a modified Rankin score of 2. Initial presenting rhythm with EMS was ventricular fibrillation or pulseless ventricular tachycardia in 233 patients. Of these, 212 (91.0%) were transported to the ED, 134 (57.5%) achieved sustained ROSC, and 71 (30.5%) survived to hospital discharge. 54/60 (90.0%) of those with a documented neurologic exam had a favourable neurologic outcome. Initial presenting rhythm with EMS was PEA or asystole in 636 patients. Of these, 320 (50.3%) were transported to the ED, 115 (18.1%) achieved sustained ROSC, and 17 (2.7%) survived to hospital discharge. 9/10 (90%) of those with a documented neurologic exam had a favourable neurologic outcome. 358 of the arrests were witnessed. Of these, 274 (76.5%) were transported to the ED, 150 (41.9%) achieved sustained ROSC, and 51 (15.9%) survived to hospital discharge. 47/53 (88.7%) of those with a documented neurologic exam had a favourable neurologic outcome. Conclusion: Outcomes from out of hospital cardiac arrest in London, Ontario are comparable to other sites across North America.

Abstract 18656: The Effect of Targeted Temperature Management is Dependent Upon the Duration of Out-of-hospital Cardiac Arrest

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Ian R Drennan ◽  
Steve Lin ◽  
Kevin E Thorpe ◽  
Jason E Buick ◽  
Sheldon Cheskes ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Hospital Discharge ◽  
Spontaneous Circulation ◽  
Targeted Temperature Management ◽  
Neurologic Outcome ◽  
Temperature Management ◽  
Neurologic Injury ◽  
Good Neurologic Outcome ◽  
The Impact ◽  
Hospital Cardiac Arrest

Introduction: Targeted temperature management (TTM) reduces neurologic injury from out-of-hospital cardiac arrest (OHCA). As the risk of neurologic injury increases with prolonged cardiac arrests, the benefit of TTM may depend upon cardiac arrest duration. We hypothesized that there is a time-dependent effect of TTM on neurologic outcomes from OHCA. Methods: Retrospective, observational study of the Toronto RescuNET Epistry-Cardiac Arrest database from 2007 to 2014. We included adult (>18) OHCA of presumed cardiac etiology that remained comatose (GCS<10) after a return of spontaneous circulation. We used multivariable logistic regression to determine the effect of TTM and the duration of cardiac arrest on good neurologic outcome (Modified Rankin Scale (mRS) 0-3) and survival to hospital discharge while controlling for other known predictors. Results: There were 1496 patients who met our inclusion criteria, of whom 981 (66%) received TTM. Of the patients who received TTM, 59% had a good neurologic outcome compared to 39% of patients who did not receive TTM (p< 0.001). After adjusting for the Utstein variables, use of TTM was associated with improved neurologic outcome (OR 1.60, 95% CI 1.10-2.32; p = 0.01) but not with survival to discharge (OR 1.23, 95% CI 0.90-1.67; p = 0.19). The impact of TTM on neurologic outcome was dependent on the duration of cardiac arrest (p<0.05) (Fig 1). Other significant predictors of good neurologic outcome were younger age, public location, initial shockable rhythm, and shorter duration of cardiac arrest (all p values < 0.05). A subgroup analysis found the use of TTM to be associated with neurologic outcome in both shockable (p = 0.01) and non-shockable rhythms (p = 0.04) but was not associated with survival to discharge in either group (p = 0.12 and p = 0.14 respectively). Conclusion: The use of TTM was associated with improved neurologic outcome at hospital discharge. Patients with prolonged durations of cardiac arrest benefited more from TTM.

scholarly journals Promising candidates for extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Yo Sep Shin ◽  
Youn-Jung Kim ◽  
Seung Mok Ryoo ◽  
Chang Hwan Sohn ◽  
Shin Ahn ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Cardiopulmonary Resuscitation ◽  
Cerebral Performance Category ◽  
Neurologic Outcome ◽  
Low Flow ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Neurologic Status ◽  
Good Neurologic Outcome ◽  
Hospital Stays ◽  
Hospital Cardiac Arrest

AbstractPrecise criteria for extracorporeal cardiopulmonary resuscitation (ECPR) are still lacking in patients with out-of-hospital cardiac arrest (OHCA). We aimed to investigate whether adopting our hypothesized criteria for ECPR to patients with refractory OHCA could benefit. This before-after study compared 4.5 years after implementation of ECPR for refractory OHCA patients who met our criteria (Jan, 2015 to May, 2019) and 4 years of undergoing conventional CPR (CCPR) prior to ECPR with patients who met the criteria (Jan, 2011 to Jan, 2014) in the emergency department. The primary and secondary outcomes were good neurologic outcome at 6-months and 1-month respectively, defined as 1 or 2 on the Cerebral Performance Category score. A total of 70 patients (40 with CCPR and 30 with ECPR) were included. For a good neurologic status at 6-months and 1-month, patients with ECPR (33.3%, 26.7%) were superior to those with CCPR (5.0%, 5.0%) (all Ps < 0.05). Among patients with ECPR, a group with a good neurologic status showed shorter low-flow time, longer extracorporeal membrane oxygenation duration and hospital stays, and lower epinephrine doses used (all Ps < 0.05). The application of the detailed indication before initiating ECPR appears to increase a good neurologic outcome rate.

Abstract 01: The Importance of Time to Cooling in Out-Of-Hospital Cardiac Arrest Patients to Influence Neurologically Intact Survival: A Sub-Analysis of the Princess Trial

Circulation ◽  
2019 ◽  
Vol 140 (Suppl_2) ◽  
Author(s):  
Akil Awad ◽  
Fabio Silvio Taccone ◽  
Martin Jonsson ◽  
Sune Forsberg ◽  
Jacob Hollenberg ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Propensity Score ◽  
Life Support ◽  
Cerebral Performance Category ◽  
Neurologic Outcome ◽  
Secondary Outcome ◽  
Control Group ◽  
Shockable Rhythm ◽  
Good Neurologic Outcome ◽  
Hospital Cardiac Arrest

Background: Early initiation of hypothermia has shown to be important to reduce brain injuries in experimental cardiac arrest models. The aim of this study was to investigate the association between time to initiate cooling and neurological intact survival in patients with out-of-hospital cardiac arrest (OHCA). Methods: A secondary analysis of prospectively collected data from the PRINCESS trial (NCT01400373) including 677 OHCA patients randomized to transnasal evaporative intra-arrest cooling or standard advanced life support and cooling started subsequent to hospital arrival. Time to randomization was used a proxy measurement for time to initiate cooling. An early treatment group was defined as patients randomized by the EMS <20 minutes from the time of the cardiac arrest. Propensity scores were used to find matching patients in the control group. Patients with initial shockable rhythms were analyzed as a predefined subgroup. The primary outcome was good neurologic outcome, Cerebral Performance Category (CPC) 1-2 at 90 days. Secondary outcome was complete recovery (CPC 1). Results: In total 406 patients were randomized <20 minutes from the cardiac arrest and were propensity score matched (1:1). In the propensity score matched analysis the proportion of patients with CPC 1-2 was 21.7% in the intervention and 17.2% in the control group, odds ratio (OR) 1.33, 95% confidence interval (CI) 0.80-2.21, p=0.273. In patients with initial shockable rhythm (79 intervention, 79 control) the difference in CPC 1-2 was 48.1% versus 32.0%, OR 2.05, 95%CI 1.00-4.21, p=0.0498. The proportion of patients with complete neurologic recovery, CPC 1, was 19.7% in the intervention and 13.3% in the control group, OR 1.60, 95% CI 0.92-2.79, p=0.097. In patients with initial shockable rhythm the proportion with CPC 1 was 45.6% versus 24.6%, OR 2.81, 95% CI 1.23-6.42, p=0.014. Conclusions: In this ancillary study of OHCA patients receiving intra-arrest cooling, there were differences in survival with good neurologic outcome and in complete neurological recovery in favor of early intra-arrest cooling patient group compared to standard care. These differences were statistically significant in the subgroup of patients with initial shockable rhythms.

HYPOCAPNEA IMMEDIATELY AFTER ROSC IS ASSOCIATED WITH GOOD NEUROLOGIC OUTCOME IN PEDIATRIC IN-HOSPITAL CARDIAC ARREST

2006 ◽  
Vol 7 (5) ◽  
pp. 512
Author(s):  
Akira Nishisaki ◽  
Joseph Sullivan ◽  
Bernhard Steger ◽  
Carey Bayer ◽  
Rebecca Ichord ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Neurologic Outcome ◽  
Good Neurologic Outcome ◽  
Hospital Cardiac Arrest

scholarly journals How many prehospital defibrillation attempts should be performed in out-of-hospital cardiac arrest patients with shockable rhythm?

2020 ◽  
Author(s):  
Byuk Sung Ko ◽  
Youn-Jung Kim ◽  
Kap Su Han ◽  
You Hwan Jo ◽  
Jonghwan Shin ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Odds Ratio ◽  
Cerebral Performance Category ◽  
Spontaneous Circulation ◽  
Neurologic Outcome ◽  
Secondary Outcome ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Shockable Rhythm ◽  
Good Neurologic Outcome ◽  
Hospital Cardiac Arrest

Abstract Background: Early defibrillation is vital to improve outcomes after out-of-hospital cardiac arrest (OHCA) with shockable rhythm. Currently, there is no agreed consensus on the number of defibrillation attempts before transfer to a hospital. This study aimed to evaluate the correlation between the number of defibrillations on the prehospital return of spontaneous circulation (ROSC).Methods: A multicenter, prospective, observational registry-based study was conducted for OHCA in patients with presumed cardiac etiology that underwent prehospital defibrillation between October 2015 and June 2017. The primary outcome was prehospital ROSC, and the secondary outcome was a good neurologic outcome at hospital discharge, defined as Cerebral Performance Category score 1 or 2. Results: Among 2,155 OHCA patients’ data, 178 patients with missing data were excluded, a total of 1,983 OHCA patients who received prehospital defibrillation were included. The median age was 61 years and prehospital ROSC was observed in 738 patients (37.2%). The median time from arrest to first defibrillation was 10 (interquartile range: 7-15) minutes. The cumulative ROSC rates and good neurologic outcome from the initial defibrillation to the sixth defibrillation were 43%, 68%, 81%, 90%, 95%, 98% and 42%, 66%, 81%, 90%, 95%, 98%, respectively. After clinical characteristics adjustment and time to defibrillation, the number of defibrillations were independently associated with ROSC (odds ratio 0.81 95% CI 0.76-0.86) and good neurologic outcome (odds ratio 0.86 95% CI 0.80-0.91). Moreover, subgroup analysis results with patients that underwent the initial defibrillation within 10 minutes from arrest were consistent (95% up to five times).Conclusion: More than 95% of prehospital ROSC was achieved within five times of defibrillation in OHCA patients. This result provides a basis for the ideal number of defibrillation attempts before transfer to hospital with the possibility of extracorporeal cardiopulmonary resuscitation in these refractory ventricular fibrillation patients.

Abstract 9764: Prevalence of Inappropriate Defibrillation Attempts During Pediatric In-Hospital Cardiac Arrest

Circulation ◽  
2021 ◽  
Vol 144 (Suppl_2) ◽  
Author(s):  
James M Gray ◽  
Tia T Raymond ◽  
Dianne L Atkins ◽  
Ken Tegtmeyer ◽  
Dana E Niles ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Ventricular Tachycardia ◽  
Ventricular Fibrillation ◽  
Age Groups ◽  
Inappropriate Shock ◽  
Shock Delivery ◽  
Inappropriate Shocks ◽  
Hospital Cardiac Arrest ◽  
Significant Opportunity ◽  
Age Category

Introduction: Shockable rhythms (ventricular fibrillation [VF] and ventricular tachycardia [VT]) occur in <25% of pediatric in-hospital cardiac arrest (IHCA) events, yet the prevalence of inappropriate defibrillation attempts for non-VF/VT rhythms is unknown. We aim to describe the prevalence of inappropriate shocks across a large, multi-national pediatric cardiac arrest network. Methods: We included children <18y reported to the pedi atric RES uscitation- Q uality (pediRES-Q) network from 2015-2019 with complete defibrillator files who received defibrillation attempts during IHCA (ZOLL R-Series, MA). Two pediatric cardiologists independently classified rhythms immediately prior to shock as: 1) appropriate (VF or wide complex ≥ 150/min), 2) indeterminate (narrow complex ≥150/min or wide complex 100-149/min), or 3) inappropriate (asystole, sinus, narrow complex <150/min, or wide complex <100/min). Rhythms that were undecipherable due to artifact were excluded from analysis (n=22). Disagreements were resolved by arbitration and consensus. Results: Of 896 IHCA events, 124 (14%) had defibrillation attempts. A total of 303 shocks were delivered: 87 (29%) in age <1y, 84 (28%) in 1-8y, and 132 (44%) in 9-17y. Of shocks delivered, 206 (68%) were appropriate, 12 (4%) indeterminate, and 85 (28%) inappropriate. There was no difference in inappropriate shock delivery by age category: <1y (24/87, 28%), 1-8y (26/84, 31%), 9-17y (35/132, 27%) ( p =0.4). Conclusions: Across a multi-national pediatric cardiac arrest network, a large proportion (28%) of defibrillation attempts were inappropriate, suggesting significant opportunity for improvement in rhythm identification in pediatric cardiac arrest. There was no difference in inappropriate shock delivery across age groups. Figure 1. Representation of rhythm classification and appropriateness of defibrillation attempts with exemplar rhythms.

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