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.

Abstract 16924: Initial AMSA and Increased AMSA After CPR Predict Second Shock Success in Initially Shock-resistant VF During Out-of-hospital Cardiac Arrest

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Ulrich Herken ◽  
Weilun Quan
Keyword(s):  
Logistic Regression ◽  
Cardiac Arrest ◽  
Ventricular Fibrillation ◽  
Success Rate ◽  
Fourier Transformation ◽  
Amplitude Spectrum ◽  
Fast Fourier Transformation ◽  
Shock Delivery ◽  
Spectrum Area ◽  
Hospital Cardiac Arrest

Purpose: Amplitude spectrum area (AMSA), which is calculated from the ventricular fibrillation (VF) waveform using fast Fourier transformation, has been recognized as a predictor of successful defibrillation (DF) and as an index of myocardial perfusion and viability during resuscitation. In this study, we investigated whether a change in AMSA occurring during CPR would predict DF outcome for subsequent DF attempts after a failed DF. We hypothesized that a patient responding to CPR with an increase in AMSA would have an increased likelihood of DF success. Methods: This was a retrospective analysis of out-of-hospital cardiac arrest patients who received a second DF due to initially shock-resistant VF. A total of 193 patients with an unsuccessful first DF were identified in a manufacturer database of electrocardiographic defibrillator records. AMSA was calculated for the first DF (AMSA1) and the second DF (AMSA2) during a 2.1 sec window ending 0.5 sec prior to DF. A successful DF attempt was defined as the presence of an organized rhythm with a rate ≥ 40 / min starting within 60 sec from the DF and lasting for > 30 sec. After the failed first DF, all patients received CPR for 2 to 3 minutes before delivery of the second DF. Change in AMSA (dAMSA) was calculated as dAMSA = AMSA2 - AMSA1. Results: The overall second DF success rate was 14.5%. Multivariable logistic regression showed that both AMSA1 and dAMSA were independent predictors of second DF success with odds ratios of 1.24 (95% CI 1.12 - 1.38, p<0.001) and 1.27 (95% CI 1.16 - 1.41, p<0.001) for each mVHz change in AMSA or dAMSA, respectively. Conclusions: In initially DF-resistant VF, a high initial AMSA value predicted an increased likelihood of second shock success. An increase of AMSA in response to CPR also predicted a higher second shock success rate. Monitoring of AMSA during resuscitation therefore may be useful to guide CPR efforts, possibly including timing of second shock delivery. These findings also further support the value of AMSA as indicator of myocardial viability.

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 DOuble SEquential External Defibrillation for Refractory Ventricular Fibrillation (DOSE VF): study protocol for a randomized controlled trial

Trials ◽  
2020 ◽  
Vol 21 (1) ◽  
Author(s):  
Ian R. Drennan ◽  
Paul Dorian ◽  
Shelley McLeod ◽  
Ruxandra Pinto ◽  
Damon C. Scales ◽  
...  
Keyword(s):  
Randomized Controlled Trial ◽  
Cardiac Arrest ◽  
Ventricular Tachycardia ◽  
Ventricular Fibrillation ◽  
Hospital Discharge ◽  
Controlled Trial ◽  
Research Question ◽  
Cluster Randomized Trial ◽  
Randomized Controlled ◽  
Hospital Cardiac Arrest

Abstract Background Despite high-quality cardiopulmonary resuscitation (CPR), early defibrillation, and antiarrhythmic medications, some patients remain in refractory ventricular fibrillation (VF) during out-of-hospital cardiac arrest. These patients have worse outcomes compared to patients who respond to initial treatment. Double sequential external defibrillation (DSED) and vector change (VC) defibrillation have been proposed as viable options for patients in refractory VF. However, the evidence supporting the use of novel defibrillation strategies is inconclusive. The objective of this study is to compare two novel therapeutic defibrillation strategies (DSED and VC) against standard defibrillation for patients with treatment refractory VF or pulseless ventricular tachycardia (pVT) during out-of-hospital cardiac arrest. Research question Among adult (≥ 18 years) patients presenting in refractory VF or pulseless ventricular tachycardia (pVT) during out-of-hospital cardiac arrest, does DSED or VC defibrillation result in greater rates of survival to hospital discharge compared to standard defibrillation? Methods This will be a three-arm, cluster randomized trial with repeated crossover conducted in six regions of Ontario, Canada (Peel, Halton, Toronto, Simcoe, London, and Ottawa), over 3 years. All adult (≥ 18 years) patients presenting in refractory VF (defined as patients presenting in VF/pVT and remaining in VF/pVT after three consecutive standard defibrillation attempts during out-of-hospital cardiac arrest of presumed cardiac etiology will be treated by one of three strategies: (1) continued resuscitation using standard defibrillation, (2) resuscitation involving DSED, or (3) resuscitation involving VC (change of defibrillation pads from anterior-lateral to anterior-posterior pad position) defibrillation. The primary outcome will be survival to hospital discharge. Secondary outcomes will include return of spontaneous circulation (ROSC), VF termination after the first interventional shock, VF termination inclusive of all interventional shocks, and number of defibrillation attempts to obtain ROSC. We will also perform an a priori subgroup analysis comparing rates of survival for those who receive “early DSED,” or first DSED shock is shock 4–6, to those who receive “late DSED,” or first DSED shock is shock 7 or later. Discussion A well-designed randomized controlled trial employing a standardized approach to alternative defibrillation strategies early in the treatment of refractory VF is urgently required to determine if the treatments of DSED or VC defibrillation impact clinical outcomes. Trial registration ClinicalTrials.gov NCT04080986. Registered on 6 September 2019.

scholarly journals Survival After Intravenous Versus Intraosseous Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Shock-Refractory Cardiac Arrest

Circulation ◽  
2020 ◽  
Vol 141 (3) ◽  
pp. 188-198 ◽  
Author(s):  
Mohamud R. Daya ◽  
Brian G. Leroux ◽  
Paul Dorian ◽  
Thomas D. Rea ◽  
Craig D. Newgard ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Ventricular Tachycardia ◽  
Ventricular Fibrillation ◽  
Drug Administration ◽  
Risk Ratio ◽  
Administration Route ◽  
Adjusted Risk ◽  
Survival Difference ◽  
Adjusted Risk Ratio ◽  
Hospital Cardiac Arrest

Background: Antiarrhythmic drugs have not proven to significantly improve overall survival after out-of-hospital cardiac arrest from shock-refractory ventricular fibrillation/pulseless ventricular tachycardia. How this might be influenced by the route of drug administration is not known. Methods: In this prespecified analysis of a randomized, placebo-controlled clinical trial, we compared the differences in survival to hospital discharge in adults with shock-refractory ventricular fibrillation/pulseless ventricular tachycardia out-of-hospital cardiac arrest who were randomly assigned by emergency medical services personnel to an antiarrhythmic drug versus placebo in the ALPS trial (Resuscitation Outcomes Consortium Amiodarone, Lidocaine or Placebo Study), when stratified by the intravenous versus intraosseous route of administration. Results: Of 3019 randomly assigned patients with a known vascular access site, 2358 received ALPS drugs intravenously and 661 patients by the intraosseous route. Intraosseous and intravenous groups differed in sex, time-to-emergency medical services arrival, and some cardiopulmonary resuscitation characteristics, but were similar in others, including time-to-intravenous/intrasosseous drug receipt. Overall hospital discharge survival was 23%. In comparison with placebo, discharge survival was significantly higher in recipients of intravenous amiodarone (adjusted risk ratio, 1.26 [95% CI, 1.06–1.50]; adjusted absolute survival difference, 5.5% [95% CI, 1.5–9.5]) and intravenous lidocaine (adjusted risk ratio, 1.21 [95% CI, 1.02–1.45]; adjusted absolute survival difference, 4.7% [95% CI, 0.7–8.8]); but not in recipients of intraosseous amiodarone (adjusted risk ratio, 0.94 [95% CI, 0.66–1.32]) or intraosseous lidocaine (adjusted risk ratio, 1.03 [95% CI, 0.74–1.44]). Survival to hospital admission also increased significantly when drugs were given intravenously but not intraosseously, and favored improved neurological outcome at discharge. There were no outcome differences between intravenous and intraosseous placebo, indicating that the access route itself did not demarcate patients with poor prognosis. The study was underpowered to assess intravenous/intraosseous drug interactions, which were not statistically significant. Conclusions: We found no significant effect modification by drug administration route for amiodarone or lidocaine in comparison with placebo during out-of-hospital cardiac arrest. However, point estimates for the effects of both drugs in comparison with placebo were significantly greater for the intravenous than for the intraosseous route across virtually all outcomes and beneficial only for the intravenous route. Given that the study was underpowered to statistically assess interactions, these findings signal the potential importance of the drug administration route during resuscitation that merits further investigation.

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