Accidental Hypothermia: 2021 Update

Accidental hypothermia is an unintentional drop of core temperature below 35 °C. Annually, thousands die of primary hypothermia and an unknown number die of secondary hypothermia worldwide. Hypothermia can be expected in emergency patients in the prehospital phase. Injured and intoxicated patients cool quickly even in subtropical regions. Preventive measures are important to avoid hypothermia or cooling in ill or injured patients. Diagnosis and assessment of the risk of cardiac arrest are based on clinical signs and core temperature measurement when available. Hypothermic patients with risk factors for imminent cardiac arrest (temperature < 30 °C in young and healthy patients and <32 °C in elderly persons, or patients with multiple comorbidities), ventricular dysrhythmias, or systolic blood pressure < 90 mmHg) and hypothermic patients who are already in cardiac arrest, should be transferred directly to an extracorporeal life support (ECLS) centre. If a hypothermic patient arrests, continuous cardiopulmonary resuscitation (CPR) should be performed. In hypothermic patients, the chances of survival and good neurological outcome are higher than for normothermic patients for witnessed, unwitnessed and asystolic cardiac arrest. Mechanical CPR devices should be used for prolonged rescue, if available. In severely hypothermic patients in cardiac arrest, if continuous or mechanical CPR is not possible, intermittent CPR should be used. Rewarming can be accomplished by passive and active techniques. Most often, passive and active external techniques are used. Only in patients with refractory hypothermia or cardiac arrest are internal rewarming techniques required. ECLS rewarming should be performed with extracorporeal membrane oxygenation (ECMO). A post-resuscitation care bundle should complement treatment.

Abstract 13163: Use of a QR Code Accessed Debrief Tool is Associated With Higher Rates of Debrief After In-Hospital Cardiac Arrest

Introduction: In-hospital cardiac arrest (IHCA) affects over 200 000 patients in the US annually. Approximately 20% will survive to hospital discharge, although outcomes vary between hospitals. Debriefing has been shown to improve resuscitation quality and teamwork and has been associated with improved IHCA outcomes. All IHCA at NYU Langone Health are attended by the ALERT team, a dedicated team of critical care nurses who perform active patient surveillance and respond to acute in-hospital emergencies. IHCA debriefs at NYU Langone Health have historically been performed on paper forms but were limited by low rates of compliance. As part of an ongoing quality improvement (QI) initiative, we designed and implemented an electronic debriefing tool for use after IHCA (eDebrief). Methods: The eDebrief tool was developed by the NYU Interdisciplinary Resuscitation Committee. The tool captures cardiopulmonary resuscitation (CPR) quality metrics, teamwork and leadership, use of resuscitation equipment (mechanical CPR, advanced airway adjuncts, and ultrasound), and outcomes. ALERT team nurses received an educational session and ad hoc refresher sessions if required. Data were collected at the conclusion of the event using an electronic device (iPhone, Apple, Cupertino CA). The tool is accessible using a QR code located on every code cart. Rates of IHCA debrief post-implementation (2/13/20-06/10/21) were compared to prior years (01/01/19 - 12/31/19 and 01/01/18-12/31/19). Results: The eDebrief tool was implemented on 2/13/20. During the post-implementation phase, there were 254 IHCA at NYU Langone Health. The eDebrief form was used in 175 events (69%). The debrief rate from previous calendar years were 38% and 42% for 2019 and 2018 respectively. Use of the eDebrief form has identified three targets for ongoing quality improvement and research projects: room overcrowding (identified in 64/175 IHCAs, 37%); ultrasound use (39/175 IHCAs, 22%); and optimization of mechanical CPR. Conclusions: Use of electronic debriefing is feasible at a large academic medical center and has been associated with increased uptake of IHCA debrief. Regular debriefs at our center have identified several targets for further quality improvement and research initiatives.

The Effect of Implementing Mechanical Cardiopulmonary Resuscitation Devices on Out-of-Hospital Cardiac Arrest Patients in an Urban City of Taiwan

High-quality cardiopulmonary resuscitation (CPR) is a key element in out-of-hospital cardiac arrest (OHCA) resuscitation. Mechanical CPR devices have been developed to provide uninterrupted and high-quality CPR. Although human studies have shown controversial results in favor of mechanical CPR devices, their application in pre-hospital settings continues to increase. There remains scant data on the pre-hospital use of mechanical CPR devices in Asia. Therefore, we conducted a retrospective cohort study between September 2018 and August 2020 in an urban city of Taiwan to analyze the effects of mechanical CPR devices on the outcomes of OHCA; the primary outcome was attainment of return of spontaneous circulation (ROSC). Of 552 patients with OHCA, 279 received mechanical CPR and 273 received manual CPR, before being transferred to the hospital. After multivariate adjustment for the influencing factors, mechanical CPR was independently associated with achievement of any ROSC (OR = 1.871; 95%CI:1.195–2.930) and sustained (≥24 h) ROSC (OR = 2.353; 95%CI:1.427–3.879). Subgroup analyses demonstrated that mechanical CPR is beneficial in shorter emergency medical service response time (≤4 min), witnessed cardiac arrest, and non-shockable cardiac rhythm. These findings support the importance of early EMS activation and high-quality CPR in OHCA resuscitation.

Differences between manual CPR and corpuls cpr in regard to quality and outcome: study protocol of the comparing observational multi‐center prospective registry study on resuscitation (COMPRESS)

Background The effect of mechanical CPR is diversely described in the literature. Different mechanical CPR devices are available. The corpuls cpr is a new generation of piston-driven devices and was launched in 2015. The COMPRESS-trial analyzes quality of chest compression and CPR-related injuries in cases of mechanical CPR by the corpuls cpr and manual CPR. Methods This article describes the design and study protocol of the COMPRESS-trial. This observational multi-center study includes all patients who suffered an out-of-hospital cardiac arrest (OHCA) where CPR is attempted in four German emergency medical systems (EMS) between January 2020 and December 2022. EMS treatment, in-hospital-treatment and outcome are anonymously reported to the German Resuscitation Registry (GRR). This information is linked with data from the defibrillator, the feedback system and the mechanical CPR device for a complete dataset. Primary endpoint is chest compression quality (complete release, compression rate, compression depth, chest compression fraction, CPR-related injuries). Secondary endpoint is survival (return of spontaneous circulation (ROSC), admission to hospital and survival to hospital discharge). The trial is sponsored by GS Elektromedizinische Geräte G. Stemple GmbH. Discussion This observational multi-center study will contribute to the evaluation of mechanical chest compression devices and to the efficacy and safety of the corpuls cpr. Trial registration DRKS, DRKS-ID DRKS00020819. Registered 31 July 2020.

Automated mechanical cardiopulmonary resuscitation devices versus manual chest compressions in the treatment of cardiac arrest: protocol of a systematic review and meta-analysis comparing machine to human

IntroductionCardiac arrest is a leading cause of death in industrialised countries. Cardiopulmonary resuscitation (CPR) guidelines follow the principles of closed chest compression as described for the first time in 1960. Mechanical CPR devices are designed to improve chest compression quality, thus considering the improvement of resuscitation outcomes. This protocol outlines a systematic review and meta-analysis methodology to assess trials investigating the therapeutic effect of automated mechanical CPR devices at the rate of return of spontaneous circulation, neurological state and secondary endpoints (including short-term and long-term survival, injuries and surrogate parameters for CPR quality) in comparison with manual chest compressions in adults with cardiac arrest.Methods and analysisA sensitive search strategy will be employed in established bibliographic databases from inception until the date of search, followed by forward and backward reference searching. We will include randomised and quasi-randomised trials in qualitative analysis thus comparing mechanical to manual CPR. Studies reporting survival outcomes will be included in quantitative analysis. Two reviewers will assess independently publications using a predefined data collection form. Standardised tools will be used for data extraction, risks of bias and quality of evidence. If enough studies are identified for meta-analysis, the measures of association will be calculated by dint of bivariate random-effects models. Statistical heterogeneity will be evaluated by I2-statistics and explored through sensitivity analysis. By comprehensive subgroup analysis we intend to identify subpopulations who may benefit from mechanical or manual CPR techniques. The reporting follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.Ethics and disseminationNo ethical approval will be needed because data from previous studies will be retrieved and analysed. Most resuscitation studies are conducted under an emergency exception for informed consent. This publication contains data deriving from a dissertation project. We will disseminate the results through publication in a peer-reviewed journal and at scientific conferences.PROSPERO registration numberCRD42017051633.

Abstract 299: Effect of Start Position and Compression Depth on Mechanical CPR Hemodynamics in Swine

Introduction: Mechanical devices offer the ability to provide consistent fixed-depth chest compressions during CPR. Although compression depth is considered a primary determinant of CPR quality, the influence of other device settings has received less attention. Accordingly, we evaluated the combined effect of compression depth and device start position on CPR hemodynamics in a porcine model of cardiac arrest (CA). Methods: Swine (n=119) were subjected to 7-10 min of CA following electrical induction of ventricular fibrillation. CPR was subsequently performed manually (target peak aortic pressure: 100 mmHg; n=73) or with a mechanical compression system (LUCAS 3.1, Stryker; n=46). Within the mechanical CPR group, animals received 102 compressions/min using either factory default settings (“QuickFit” automated suction cup start position; compression depth: 2.1”; n=13) or custom settings (manual suction cup start position; compression depth: 1.8”; n=33). Aortic pressure (Ao), coronary perfusion pressure (CPP), and regional cerebral oxygen saturation (rSO 2 ; via near infrared spectroscopy) were compared between groups after 1 min of CPR. Results: Mechanical CPR with automated suction cup start position and compression depth of 2.1” resulted in significantly higher peak Ao and CPP than mechanical CPR with manual start position and compression depth of 1.8” ( Table ). Compared with manual CPR, only mechanical CPR with automated start position and compression depth of 2.1” led to a higher CPP. However, cerebral rSO 2 values fell from 61±1 % at baseline to 49±1 % during CA (p<0.01) and did not increase during CPR in any group. Conclusion: Compared with a manual start position and compression depth of 1.8”, use of the LUCAS “QuickFit” feature and compression depth of 2.1” led to a significantly higher CPP during mechanical CPR. Future studies are necessary to determine if differences persist during prolonged CPR with and without concomitant vasopressor administration.

Abstract 247: Cardiac Arrest Management in Rural Prehospital Care

Introduction: Rural prehospital care settings are underrepresented in the out-of-hospital cardiac arrest (OHCA) literature. We analyzed a nationwide database of emergency medical services (EMS) incidents in the US to describe treatment patterns and the odds of return of spontaneous circulation (ROSC) among rural OHCA patients. Methods: Using the 2018 National EMS Informational System dataset, we analyzed OHCA incidents where CPR provided by EMS was documented. We excluded incidents in which trauma was involved, patient age <18 years, transport was not by completed by an advanced life support unit, or response time >60 minutes. The primary outcome was ROSC during the EMS incident. Multivariable logistic regression was performed comparing rural, suburban, and urban settings while controlling for age and gender, incident location type, response time, CPR prior to EMS arrival, arrest witnessed by EMS, initial rhythm, epinephrine administration, mechanical CPR, and advanced airway used. Results: A total of 60,281 OHCA incidents were identified for inclusion, including 5,013 (8.6%) in rural settings. Rural OHCA patients achieved ROSC in 28.8% of cases, compared to 33.0% in urban or suburban settings (p<0.001). Neither age nor gender significantly differed between settings (Table 1). Rural OHCA incidents had greater response times (7.5 vs. 5.9 minutes, p<0.001) and were less likely to receive epinephrine (71.6% vs. 74.9%, p<0.001). Further, EMS were more likely to use mechanical CPR (29.8% vs. 28.1%, p=0.01) and less likely to provide an advanced airway (56.3% vs. 50.5%, p<0.001) for rural OHCA. On multivariable logistic regression, rural OHCA patients had lower odds of achieving ROSC than urban OHCA patients after controlling for other factors (0.80, 95%CI: 0.75-0.86). Conclusion: In this national sample of EMS-treated OHCA, rural patients were less likely to achieve ROSC than patients in urban or suburban settings.

Abstract 130: Mechanical, Team-focused, Video-Reviewed Cardiopulmonary Resuscitation Improves Trends in Survival to Discharge and Cardiac Arrest Performance Measures

Background: Our previous research demonstrated an improvement in ROSC after implementing a bundle including mechanical, team-focused, video-reviewed cardiopulmonary resuscitation (MTV-CPR) for cardiac arrest patients in our ED. The aims of this study are to assess trends in cardiac arrest outcomes and improvements in cardiac arrest performance measures after the implementation of our MTV-CPR intervention. Methods: In 2018, our ED began using mechanical CPR; a new team-focused strategy with nurse led ACLS; and biweekly video-review of cardiac arrests. The primary outcome of this study was to evaluate the annual trend in survival to discharge from 2017 (the year before implementing MTV-CPR) through 2019. Secondary outcomes included ROSC and survival to admission. The Cochrane-Armitage test was used to evaluate annual trends in outcomes over the 3-year study period. We also sought to determine if an improvement in cardiac arrest performance measures occurred over the two years of our MTV-CPR intervention using Wilcoxon rank sum and two-sample t-tests. Cardiac arrest performance measures are listed in the table. Results: The groups were similar at baseline over the 3-year study period. 291 patients were included in the study (96 in 2017, 96 in 2018, and 99 in 2019). Survival to discharge improved from 3.1% in 2017 to 5.2% in 2018 to 10.1% in 2019 (p= 0.043); ROSC improved from 26% to 41.7% to 40.4% (p=0.038); survival to admission went from 19.8% to 25% to 29.3% but was not significantly different (p=0.124). Results for cardiac arrest performance measures are reported in the table. There were significant reductions in time to bed transfer, rhythm determination, mechanical CPR placement, and duration of each chest compression interruption due to ultrasound. Conclusions: Implementation of our MTV-CPR intervention for cardiac arrest patients resulted in improved trends in survival to discharge and ROSC, as well as improvements in multiple cardiac arrest performance measures.

Abstract 203: Thoracic Impedance Reflects Differences Between Endotracheal and Laryngeal Advanced Airway During Mechanical Chest Compressions

Background: Ventilations during out-of-hospital cardiac arrest (OHCA) produce thoracic impedance(TI) waveforms due to air volume changes in the lungs. Different airway management techniques, i.e. laryngeal tube (LT) and endotracheal intubation (ETI), may produce distinct TI waveforms as a result of different air flows and dead space volumes. Methods: Adult OHCA cases from the Pragmatic Airway Resuscitation Trial were analyzed. Cases recorded with Philips MRx monitor-defibrillators and treated with LUCAS mechanical CPR devices were considered, ensuring homogeneous TI acquisition and compression therapy. Impedance and capnogram signal intervals were extracted after successful airway insertion and during ongoing chest compressions. Ventilations were confirmed in the capnogram, and the associated TI waveforms were analyzed. Adaptive filtering was applied to remove compression artifacts, and the amplitudes (A i , A e ) and durations (D i , D e ) of the insufflation and exhalation phases were computed (see Figure). Each case was characterized by its observed median values. Differences between airway groups were assessed with a Wilcoxon rank sum test. Results: Data from 100 OHCA cases (57 LT and 43 ETI) were analyzed, totaling 10348 ventilations, with median (IQR) of 87 (51 - 146) ventilations per case. Median TI amplitudes for ETI and LT groups showed significant differences (p<0.05), with 1.1 (0.7 - 1.8) Ω and 0.7 (0.3 - 1.3) Ω for A i , and 1.0 (0.7 - 1.6) Ω and 0.6 (0.3 - 1.2) Ω for A e . No significant differences were observed for phase durations, 1.6 (1.3 - 2.0) s and 1.6 (1.2 - 1.8) s for D i , and 2.3 (1.8 - 3.3) s and 2.6 (2.0 - 3.3) s for D e . Conclusions: Significant differences on ventilation impedance waveform amplitudes were observed between patients treated with ETI and LT. This might be related to higher insufflated air volumes for ETI or larger dead space volumes for LT.

CPR related injuries

Introduction CPR related injuries were not properly observed since were established new guidlines for resuscitation (CPR) 2015 Objectives To describe incidency and seriousness of injuries related to CPR, compare it and try identify factors for seriousness of injury. Methods Multicentric study, retrospective analysis of autopsy reports of patients after CPR, trauma were excluded. We objectivised the most serious injury with Abbreviated injury scale (AIS)and summary of all injuries with New injury severity score (NISS). Results We have analyzed 628 autopsies: 80,4% men, age median 67 years, out of hospital cardiac arrests 89,2%, bystander CPR 56,8% and cardiac ethiology 78,2%. Ribs injury were founded by 94,6%, injury of lung by 9,9%, sternal injury by 62,4%, liver by 2,5% and spleen by 1,8% Median of the most serious injury was 3 (AIS) and median of summry of injuries was 13 by NISS-low risk of fatal injury. By out of hospital cardiac arrest was hifgher incidency of pleural injury and thorax vessles injuries without influence on total seriousness of injury compared to hospital cardiac arrests. Bystanders provided CPR had similar incidency and seriousness of injury like CPR provided only by professional emergency stuff. Women are significant older (p=0,0001), frequency of their injuries are similar to men, but seriousness of their injuries by NISS is significant higher (p=0,01). Patients with life threatening injury (AIS 4 and more) has similar baseline profil to their without injury (AIS 0), except of significant higher cardiac etiology of cardiac arrest by AIS 4+. Manually CPR were provided by 559 patients and mechanical by 64 (11,4%) patients. Both groups are no diferent in baseline. Mechanical CRP was significantly longer (p=0,0005). Both groups have no diferences in incidency of injuries of visceral organs. We have observed injuries by 80% of manual and 87,5% of mechanical CPR (p=0,18). The most frequent was thorax sceleton injury 85,5% vs. 87,5%. Median of the most seriuos injury was 3 (serious by AIS), median of summary of injuries (NISS) was 13 in both groups (low probability of fatal injury). If we analysed CPR by LUCAS 2 compared to manual, results are similar, only pericard injuries are higher with LUCAS 2. Conclusion Incidency of CPR related injuries from autopsy reports is very high, but life threatening injuries create only 3%. The highest incidency have injuries of thoreax sceleton, especially ribs. There is no difereneces if patients were resuscitated by bystander or compared to those by professional stuff or manually. Women has similar frequency of injuries like men, but significant more serious by NISS. Incidency a seriousness of CPR related injuries according to autopsy reports are no diferent in comapring of manually and mechanical CPR. Mechanical CPR is significant longer a LUCAS 2 leads to significant more pericard injuries without influence to total seriousness of injury Funding Acknowledgement Type of funding source: None