Abstract 284: Looking Back to Glance Ahead: The Impact of Last Minute's Qrs Width & Frequency in Pulseless Electrical Activity

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_4) ◽  
Author(s):  
Anders Norvik ◽  
Eirik Unneland ◽  
Gunnar W Skjeflo ◽  
David Buckler ◽  
Unai Irusta ◽  
...  
Keyword(s):  
Heart Rate ◽  
Electrical Activity ◽  
Additive Model ◽  
Pulseless Electrical Activity ◽  
Transition Intensity ◽  
Current Time ◽  
Visual Appearance ◽  
Time To Event Data ◽  
Average Transition ◽  
The Impact

Background: Observed heart rate and QRS-width during CPR in Pulseless Electrical Activity (PEA) develop differently in patients who gain ROSC compared to those who do not. In this study we investigated the impact of heart rate and QRS width on the transition from PEA to ROSC. Method: Defibrillator data from 293 episodes of cardiac arrest at two US and one Norwegian hospital were reviewed. The files contained ECG, impedance signal and compression depth. In total 178 episodes containing PEA intervals were included. Episodes with excessive ECG noise and signs of an active pacemaker were excluded. The files were processed in a MATLAB graphical application, and the clinical states were determined based on clinical documentation and the visual appearance of the ECG. ROSC was defined as an organized rhythm lasting longer than 1 minute without ongoing compressions. During pauses in compressions, heart rate and QRS-width was automatically measured and averaged over the preceding minute until current time and controlled and corrected manually. The results were analyzed using Aalen’s additive model for time-to-event data, using R version 3.6.3. Results: The average transition intensity, corresponding to the probability of gaining ROSC in one minute, was about 0.20 per min of CPR peaking at approximately 7 min. An increase in the average heart rate by 10/min increased the transition intensity by 0.03/min (p <0.01). Narrowing of the QRS in average by 100 milliseconds (ms) increased the transition intensity by 0.14/min (p <0.01). Our figure shows QRS width and heart rate for one patient with PEA approaching ROSC (gray area), with smoothed curves overlaid. Conclusion: Higher heart rates and narrower QRS complexes during PEA are strongly and significantly associated with a transition from PEA to ROSC. These changes could indicate whether a patient responds to ongoing CPR. In addition, there is a potential for predicting the immediate outcome based on these ECG characteristics.

Abstract 157: Multicenter Evaluation of Etiology and Observed Transition Intensities Between Pulseless Electrical Activity and Return of Spontaneous Circulation

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_4) ◽  
Author(s):  
Eirik Unneland ◽  
Anders Norvik ◽  
Shaun K. McGovern ◽  
David G. Buckler ◽  
Unai Irusta ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Electrical Activity ◽  
Additive Model ◽  
Pulseless Electrical Activity ◽  
Spontaneous Circulation ◽  
Time To Event ◽  
Transition Intensity ◽  
Time To Event Data ◽  
Current State ◽  
Average Patient

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

Abstract 13102: Outcomes of Primary and Secondary Pulseless Electrical Activity During In-Hospital Cardiac Arrest

Circulation ◽  
2021 ◽  
Vol 144 (Suppl_2) ◽  
Author(s):  
Eirik Unneland ◽  
Anders Norvik ◽  
Shaun McGovern ◽  
David Buckler ◽  
Unai Irusta ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Electrical Activity ◽  
Additive Model ◽  
Pulseless Electrical Activity ◽  
Spontaneous Circulation ◽  
Clinical State ◽  
Time To Event ◽  
Time To Event Data ◽  
Average Patient ◽  
Hospital Cardiac Arrest

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

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

Circulation ◽  
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.

scholarly journals How senior paramedics decide to cease resuscitation in pulseless electrical activity out of hospital cardiac arrest: a mixed methods study

2021 ◽  
Vol 29 (1) ◽  
Author(s):  
Ali Coppola ◽  
Sarah Black ◽  
Ruth Endacott
Keyword(s):  
Cardiac Arrest ◽  
Electrical Activity ◽  
Pulseless Electrical Activity ◽  
Structured Interview ◽  
Ambulance Service ◽  
Local Context ◽  
Clinical Judgement ◽  
Framework Analysis ◽  
Senior Clinician ◽  
The Impact

Abstract Background Evidenced-based guidelines on when to cease resuscitation for pulseless electrical activity are limited and support for paramedics typically defaults to the senior clinician. Senior clinicians include paramedics employed to work beyond the scope of clinical guidelines as there may be a point at which it is reasonable to cease resuscitation. To support these decisions, one ambulance service has applied a locally derived cessation of resuscitation checklist. This study aimed to describe the patient, clinical and system factors and examine senior clinician experiences when ceasing resuscitation for pulseless electrical activity. Design and methods An explanatory sequential mixed method study was conducted in one ambulance service in the South West of England. A consecutive sample of checklist data for adult pulseless electrical activity were retrieved from 1st December 2015 to 31st December 2018. Unexpected results which required exploration were identified and developed into semi-structured interview questions. A purposive sample of senior clinicians who ceased resuscitation and applied the checklist were interviewed. Content framework analysis was applied to the qualitative findings. Results Senior clinicians ceased resuscitation for 50 patients in the presence of factors known to optimise survival: Witnessed cardiac arrest (n = 37, 74%), bystander resuscitation (n = 30, 60%), defibrillation (n = 22, 44%), return of spontaneous circulation (n = 8, 16%). Significant association was found between witnessed cardiac arrest and bystander resuscitation (p = .00). Six senior clinicians were interviewed, and analysis resulted in four themes: defining resuscitation futility, the impact of ceasing resuscitation, conflicting views and clinical decision tools. In the local context, senior clinicians applied their clinical judgement to balance survivability. Multiple factors were considered as the decision to cease resuscitation was not always clear. Senior clinicians deviated from the checklist when the patient was perceived as non-survivable. Conclusion Senior clinicians applied clinical judgement to assess patients as non-survivable or when continued resuscitation was considered harmful with no patient benefit. Senior clinicians perceived pre-existing factors with duration of resuscitation and clinical factors known to optimise patient survival. Future practice could look beyond a set criteria in which to cease resuscitation, however, it would be helpful to investigate the value or threshold of factors associated with patient outcome.

Abstract 232: Delayed Administration of Epinephrine is Associated with Worse Neurological Outcomes in Patients with Out-of-hospital Cardiac Arrest and Initial Pulseless Electrical Activity

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_4) ◽  
Author(s):  
Nobuyuki Enzan ◽  
Ken-ichi Hiasa ◽  
Kenzo Ichimura ◽  
Masaaki Nishihara ◽  
Takeshi Iyonaga ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Electrical Activity ◽  
Odds Ratio ◽  
Primary Outcome ◽  
Pulseless Electrical Activity ◽  
Cubic Spline ◽  
Epinephrine Administration ◽  
Neurological Outcomes ◽  
The Impact ◽  
Hospital Cardiac Arrest

Background: Delayed administration of epinephrine has been proven to worsen the neurological outcomes of patients with out-of-hospital cardiac arrest (OHCA) and initial shockable rhythm. We aimed to investigate whether delayed administration of epinephrine might also worsen the neurological outcomes of patients with witnessed OHCA and initial pulseless electrical activity (PEA). Methods: The Japanese Association for Acute Medicine - out-of-hospital cardiac arrest (JAAM-OHCA) Registry is a multicenter, prospective, observational registry including 34,754 OHCA patients between 2014 and 2017. The present study assessed the impact of the time to epinephrine administration on neurological outcomes in patients with witnessed non-traumatic OHCA with initial rhythm of PEA. The primary outcome was defined as Cerebral Performance Categories (CPC) Scale 1-2 at 30 days after OHCA. The association between the odds ratio for the primary outcome and the time from witnessed OHCA to epinephrine administration was assessed with a restricted cubic spline analysis. Results: Out of 34,754 patients with OHCA, 3,050 patients with OHCA and initial PEA who received epinephrine were included in the present study. Mean age was 73.7 years and 1836 (60.2%) was male. After adjusting for potential confounders, the time from witnessed OHCA to epinephrine administration was associated with lower likelihood of favorable neurological outcomes (odds ratio [OR] 0.92; 95% confidence interval [CI] 0.89-0.96; P&lt;0.001). The restricted cubic spline analysis demonstrated that delayed epinephrine administration could decrease the likelihood of a favorable neurological outcome; this was significant within the first 10 minutes. Conclusions: Delayed administration of epinephrine was associated with worse neurological outcomes in patients with witnessed OHCA patients with initial PEA.

scholarly journals LO018: The utility of ECG characteristics as prognostic markers in pulseless electrical activity arrests: a retrospective observational cohort study

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S36-S36
Author(s):  
M. Ho ◽  
M. Gatien ◽  
C. Vaillancourt ◽  
V. Whitham ◽  
I.G. Stiell
Keyword(s):  
Electrical Activity ◽  
Pulseless Electrical Activity ◽  
Multivariate Regression Analysis ◽  
Spontaneous Circulation ◽  
Qrs Complex ◽  
P Waves ◽  
Initial Rhythm ◽  
Observational Cohort ◽  
Kappa Agreement ◽  
The Impact

Introduction: Compared to pseudo-pulseless electrical activity (PEA with myocardial contractions present), true PEA is hypothesized to carry a poorer prognosis and to show bradycardia and a wide QRS complex on ECG. Our objective was to study the predictive potential of ECG characteristics on survival to hospital discharge (SHD) for out-of-hospital cardiac arrest (OHCA) patients with PEA initial rhythm. Methods: We studied a cohort of OHCA patients prospectively enrolled between Sept. 2007 and Oct. 2009 at the Ottawa/OPALS site (13 cities, 7 EMS, and 6 Fire services) of the ROC PRIMED study. We included adult (≥ 18) non-traumatic OHCA with PEA initial rhythm where resuscitation was attempted, and for which ECG characteristics were available. We measured mean heart rate (HR), mean QRS interval, and presence of P waves (each with kappa agreement) using the first six QRS complex available. We report patient and system characteristics using descriptive statistics and determined the impact of ECG characteristics (HR, QRS width, P waves) on return of spontaneous circulation (ROSC) and SHD using multivariate regression analysis. Results: Demographics of 332 included cases were: mean age 71.7; male 58.4%; home residence 76.5%; bystander witnessed 56.3%; bystander CPR 28.5%; interval from dispatch to paramedic arrival 6min:24sec; ROSC at ED arrival 26.5%; SHD 5.4%. Survivors had higher mean HR (66.1 vs. 52.0 bpm, p=0.83; kappa=0.69) and shorter mean QRS intervals (108.3 vs. 129.6 ms, p=0.01; kappa=0.74) compared to non-survivors. Presence of p waves could not reliably be ascertained (kappa=0.35). Predictors of ROSC were: ALS paramedic on scene (AdjOR=8.90, 95%CI 1.11-71.41; p=0.04), successful intubation (AdjOR=3.35, 1.75-6.39; p=0.0002), and use of atropine (AdjOR=0.27, 0.14 - 0.50; p<0.0001). Predictors of survival were: location of arrest (AdjOR=1.49, 1.11 - 1.99; p=0.007), and use of atropine (AdjOR=0.06, 0.02-0.22; p<0.0001). Despite various cutoff explorations, ECG characteristics were not predictive of ROSC or survival in multivariate analyses. Survivors had HR as low as 6 bpm and QRS as wide as 357 ms. Conclusion: Early ECG characteristics could not predict ROSC or SHD in a population of OHCA PEA victims, and should not be used to terminate resuscitation efforts. Atropine administration was consistently associated with decreased likelihood of ROSC and survival.

scholarly journals Cardiac arrest with pulseless electrical activity rhythm in newborn infants: a case series

2019 ◽  
Vol 104 (6) ◽  
pp. F572-F574 ◽  
Author(s):  
Deandra Luong ◽  
Po-Yin Cheung ◽  
Keith J Barrington ◽  
Peter G Davis ◽  
Jennifer Unrau ◽  
...  
Keyword(s):  
Heart Rate ◽  
Cardiopulmonary Resuscitation ◽  
Electrical Activity ◽  
Activity Rhythm ◽  
Healthcare Providers ◽  
Newborn Infants ◽  
Case Series ◽  
Neonatal Resuscitation ◽  
Pulseless Electrical Activity ◽  
Resuscitation Guidelines

The 2015 neonatal resuscitation guidelines added ECG to assess an infant’s heart rate when determining the need for resuscitation at birth. However, a recent case report raised concerns about this technique in the delivery room. We report four cases of pulseless electrical activity during neonatal cardiopulmonary resuscitation in levels II–III neonatal intensive care units in Canada (Edmonton [n=3] and Winnipeg [n=1]).Healthcare providers should be aware that pulseless electrical activity can occur in newborn infants during cardiopulmonary resuscitation. We propose an adapted neonatal resuscitation algorithm to include pulseless electrical activity. Furthermore, in compromised newborns, heart rate should be assessed using a combination of methods/techniques to ensure accurate heart rate assessment. When ECG displays a heart rate but the infant is unresponsive, pulseless electrical activity should be suspected and chest compression should be started.

Abstract 166: Physiological Effects of Adrenaline in Human Cardiac Arrest With Pulseless Electrical Activity: A Pilot Study

Circulation ◽  
2019 ◽  
Vol 140 (Suppl_2) ◽  
Author(s):  
Magnus Bakke ◽  
Alexander Borgen ◽  
Anders Norvik ◽  
Gunnar W Skjeflo ◽  
Unai Irusta ◽  
...  
Keyword(s):  
Heart Rate ◽  
Cardiac Arrest ◽  
Pilot Study ◽  
Electrical Activity ◽  
Ad Hoc ◽  
Pulseless Electrical Activity ◽  
Spontaneous Circulation ◽  
Qrs Duration ◽  
The Individual ◽  
Adrenaline Administration

Introduction: During resuscitation from cardiac arrest with Pulseless Electrical Activity (PEA), studies show that adrenaline facilitates return of spontaneous circulation (ROSC) and possibly leads to an isolated increase in the heart rate (HR). In this study, we investigated the immediate effects of adrenaline on ECG characteristics; HR and QRS duration (duration of ventricle depolarization). Method: We studied 19 ECG segments of 300 s duration from emergency defibrillators in 10 adult patients during resuscitation from in-hospital cardiac arrest. Information on the exact timing of adrenaline administration (between 0.5 and 1 mg i.v.) was obtained from the defibrillators or the emergency personnel involved. HR (1/min) and QRS duration (ms) were annotated and registered using an ad-hoc Matlab (Mathworks, Natic, MA) graphical Data Annotator, and interpolated linearly between individual observations. Trends were identified with LOWESS. Results: The plots show the individual observations (red points) along with the trends (blue lines) of HR and QRS Duration during resuscitation, relative to the time of adrenaline administration. We observed a gradual increase in heart rate (peaking at 150 s after adrenaline administration) and a more pronounced narrowing of the QRS (levelling off also at about 150 s). Discussion: In this pilot study, administration of adrenaline was associated with narrowing of the QRS complex, while the relation to heart rate was less apparent. A limitation is that no adjustment for the individual patient’s trajectory was made. However, the results are fairly consistent with earlier studies on out-of-hospital resuscitation, when adrenaline was typically given much later.

PP10  How senior paramedics determine a futile resuscitation in pulseless electrical activity out of hospital cardiac arrest: a mixed methods study

2020 ◽  
Vol 37 (10) ◽  
pp. e6.1-e6
Author(s):  
Ali Coppola ◽  
Sarah Black ◽  
Ruth Endacott
Keyword(s):  
Decision Making ◽  
Cardiac Arrest ◽  
Electrical Activity ◽  
Pulseless Electrical Activity ◽  
Ambulance Service ◽  
Clinical Factors ◽  
Patient Demographics ◽  
System Factors ◽  
The Impact ◽  
Hospital Cardiac Arrest

BackgroundPulseless electrical activity, a non-shockable cardiac arrest, is treated using advanced life support resuscitation. When resuscitation fails, evidenced-based guidelines are limited on when to stop resuscitation. This led to one UK Ambulance Service developing a local guideline for senior paramedics to cease resuscitation when considered futile. The aim of this study was to examine clinical, patient and system factors of a futile resuscitation for pulseless electrical activity and how senior paramedics apply these factors to the decision-making process.Design and MethodsAn explanatory sequential mixed method design conducted in a single UK Ambulance Service. Cessation of resuscitation data was retrieved for all adult patients suffering an Out of Hospital Cardiac Arrest from 1st December 2015 to 31st December 2018. Cases subject to a coronial or police investigation were excluded. Senior paramedics made decisions to cease resuscitation for 50 patients at the scene and these were reviewed in detail. Interviews were conducted with six senior paramedics, who provide telephone clinical support to on-scene paramedics.ResultsThe mean patient age was 78 years, the majority were male (n=30, 60%) had a witnessed collapse (n=37, 74%) and had a PEA rate below 50 (n=46, 92%). There were no significant associations between patient demographics and clinical or system factors. Themes arising from paramedic interviews included concepts that defined futility, the impact of decision-making, conflicting views and supportive clinical decision tools.ConclusionWhilst there were no significant associations between variables, senior paramedics balanced patient survival with resuscitation futility by interpreting key factors, such as patient demographics and clinical factors. This multifactorial approach questions termination of resuscitation based on clinical factors alone. It identifies a group of PEA patients, when resuscitation is not successful, may be considered for termination of resuscitation. Research using a larger sample is warranted to explore the validity of these criteria.AcknowledgementsThe authors would like to thank Professor Jonathan Benger for his valuable input and guidance as the educational supervisor for this study. J. Lynde and H. Trebilcock for quantitative data extraction. L. Tremayne and E. Freeman, qualitative data coding. Thank you to all the paramedics who participated.

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