RESUMEN
OBJECTIVE: To determine survival to discharge and neurological outcomes on long-term follow-up of pediatric patients attended for out of-hospital cardiac arrest (OHCA). METHODS: Retrospective study based on an ongoing OHCA registry. Patients aged 16 years or younger were included. Futile resuscitation attempts were excluded. Neurological outcome on hospital discharge and on follow-up was based on variables in the Pediatric Cerebral Performance Category (PCPC) scale. Cases from January 1, 2008, through December 31, 2019, were extracted, and 2 surveys were carried out in May 2021 and January 2023. Patient follow-up time ranged from 1 to 13 years. RESULTS: Of the 13 778 patients in the registry, we found 277 (2.0%) who were aged 16 years or younger. One hundred thirty-seven patients (49.5%) were transported to a hospital, and spontaneous circulation was restored in 99 (35.7%). Thirty-six patients (13%) were discharged. The median (interquartile range) follow-up time was 2172 (978-3035) days. Thirty-one of these patients (86.1%) were alive at follow-up, 3 had died, and 2 were lost to follow-up. Neurological outcomes had worsened in 2 and improved in 6 patients. The neurological outcome of 27 of the 31 patients with complete follow-up data (87.1%) was good (PCPC scores of 1 or 2). CONCLUSIONS: In spite of the low incidence of shockable rhythm in pediatric OHCA, survival with a good neurological outcome is comparable to survival in adults. Children who are discharged after OHCA maintained or improved their neurological function over the long term.
OBJETIVO: Conocer la supervivencia al alta y la evolución neurológica tras seguimiento a largo plazo de pacientes pediátricos atendidos por parada cardíaca extrahospitalaria. METODO: Estudio retrospectivo basado en un registro continuo de parada cardiaca extrahospitalaria. Se incluyeron los pacientes pediátricos (edad menor o igual a 16 años). Se excluyeron reanimaciones consideradas fútiles. Se tomaron como variables resultado el estado neurológico al alta hospitalaria y al seguimiento de los pacientes, siguiendo el modelo de la Pediatric Cerebral Performance Category. El periodo fue del 1 de enero de 2008 al 31 de diciembre de 2019. Se realizaron dos encuestas, en mayo del 2021 y enero del 2023 con un periodo de seguimiento entre 1 y 13 años. RESULTADOS: De los 13.778 pacientes, 277 (2,0%) eran menores de 16 años; 137 (49,5%) trasladados al hospital, 99 de ellos (35,7%) con recuperación de circulación espontánea. Recibieron el alta hospitalaria 36 pacientes (13%). En el seguimiento, mediana (RIC) de 2.172 [978-3.035] días, 31 pacientes (86,1%) seguían con vida, 3 pacientes fallecieron y en dos casos no obtuvimos información. Dos pacientes sufrieron un empeoramiento del estado neurológico y 6 mejoraron. Finalmente, 27 de los 31 pacientes (87,1%) que completaron el seguimiento tenían una buena situación neurológica (PCPC1-2). CONCLUSIONES: A pesar de presentar una incidencia baja, la supervivencia con buen estado neurológico al alta hospitalaria de la parada cardiorrespiratoria extrahospitalaria pediátrica es comparable a la del adulto. Los pacientes pediátricos que recibieron el alta hospitalaria tras una parada cardiorrespiratoria extrahospitalaria mantuvieron o mejoraron su estado neurológico en el seguimiento a largo plazo.
Asunto(s)
Paro Cardíaco Extrahospitalario , Sistema de Registros , Humanos , Paro Cardíaco Extrahospitalario/mortalidad , Paro Cardíaco Extrahospitalario/terapia , Niño , Estudios Retrospectivos , Masculino , Femenino , Preescolar , Adolescente , Lactante , España/epidemiología , Reanimación Cardiopulmonar/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Estudios de Seguimiento , Tasa de Supervivencia , Factores de TiempoRESUMEN
BACKGROUND: For nearly 20âyears, in international guidelines, mild therapeutic hypothermia (MTH) was an important component of postresuscitation care. However, recent randomised controlled trials have questioned its benefits. At present, international guidelines only recommend actively preventing fever, but there are ongoing discussions about whether the majority of cardiac arrest patients could benefit from MTH treatment. OBJECTIVE: The aim of this study was to compare the outcome of adult patients treated with and without MTH after cardiac arrest. DESIGN: Observational cohort study. SETTING: German Resuscitation Registry covering more than 31 million inhabitants of Germany and Austria. PATIENTS: All adult patients between 2006 and 2022 with out-of-hospital or in-hospital cardiac arrest and comatose on admission. MAIN OUTCOME MEASURES: Primary endpoint: hospital discharge with good neurological outcome [cerebral performance categories (CPC) 1 or 2]. Secondary endpoint: hospital discharge. We used a multivariate binary logistic regression analysis to identify the effects on outcome of all known influencing variables. RESULTS: We analysed 33â933 patients (10â034 treated with MTH, 23â899 without MTH). The multivariate regression model revealed that MTH was an independent predictor of CPC 1/2 survival and of hospital discharge with odds ratio (95% confidence intervals) of 1.60 (1.49 to 1.72), Pâ<â0.001 and 1.89 (1.76 to 2.02), Pâ<â0.001, respectively. CONCLUSION: Our data indicate the existence of a positive association between MTH and a favourable neurological outcome after cardiac arrest. It therefore seems premature to refrain from giving MTH treatment for the entire spectrum of patients after cardiac arrest. Further prospective studies are needed.
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Paro Cardíaco , Hipotermia Inducida , Sistema de Registros , Humanos , Masculino , Femenino , Hipotermia Inducida/métodos , Persona de Mediana Edad , Anciano , Paro Cardíaco/terapia , Paro Cardíaco/mortalidad , Resultado del Tratamiento , Estudios de Cohortes , Ensayos Clínicos Controlados Aleatorios como Asunto , Alemania/epidemiología , Austria/epidemiología , Alta del Paciente , Anciano de 80 o más Años , Coma/terapia , Coma/mortalidad , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/mortalidadRESUMEN
Importance: Ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) are the most treatable causes of out-of-hospital cardiac arrest (OHCA). Yet, it remains unknown if defibrillator pad position, placement in the anterior-posterior (AP) or anterior-lateral (AL) locations, impacts patient outcomes in VF or pVT OHCA. Objective: To determine the association between initial defibrillator pad placement position and OHCA outcomes for patients presenting with VF or pVT. Design, Setting, and Participants: This prospective cohort study included patients with OHCA and VF or pVT treated by a single North American emergency medical services (EMS) agency from July 1, 2019, through June 30, 2023. The study included patients with OHCA treated by a large suburban fire-based EMS agency that covers a population of 550â¯000. Consecutive patients with an initial EMS-assessed rhythm of VF or pVT receiving EMS defibrillation were included. Pediatric patients (younger than 18 years), interfacility transfers, arrests of obvious traumatic etiology, and patients with preexisting do-not-resuscitate status were excluded. Exposure: AP or AL pad placement. Main Outcomes and Measures: Return of spontaneous circulation (ROSC) at any time with secondary outcomes of pulses present at emergency department (ED) arrival, survival to hospital admission, survival to hospital discharge, and functional survival at hospital discharge (cerebral performance category score of 2 or less). Measures included adjusted odds ratios (aOR), multivariable logistic regressions, and Fine-Gray competing risks regression. Results: A total of 255 patients with OHCA were included (median [IQR] age, 66 [55-74] years; 63 females [24.7%]), with initial pad positioning documented as either AP (158 patients [62.0%]; median [IQR] age, 65 [54-74] years; 37 females [23.4%]) or AL (97 patients [38.0%]; median [IQR] age, 66 [57-74] years; 26 females [26.8%]). Patients with AP placement had higher adjusted odds ratio (aOR) of ROSC at any time (aOR, 2.64 [95% CI, 1.50-4.65]), but not significantly different odds of pulses present at ED arrival (1.34 [95% CI, 0.78-2.30]), survival to hospital admission (1.41 [0.82-2.43]), survival to hospital discharge (1.55 [95% CI, 0.83-2.90]), or functional survival at hospital discharge (1.86 [95% CI, 0.98-3.51]). Competing risk analysis found significantly greater cumulative incidence of ROSC among those at risk with initial AP placement compared with AL (subdistribution hazard ratio, 1.81 [95% CI, 1.23-2.67]; P = .003). Conclusions and Relevance: In this cohort study of patients with OHCA and VF or pVT, AP defibrillator pad placement was associated with higher ROSC compared with AL placement.
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Desfibriladores , Paro Cardíaco Extrahospitalario , Humanos , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/mortalidad , Femenino , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Anciano , Desfibriladores/estadística & datos numéricos , Servicios Médicos de Urgencia/métodos , Servicios Médicos de Urgencia/estadística & datos numéricos , Fibrilación Ventricular/terapia , Resultado del Tratamiento , Cardioversión Eléctrica/estadística & datos numéricos , Cardioversión Eléctrica/métodos , Cardioversión Eléctrica/instrumentación , Taquicardia Ventricular/terapia , Reanimación Cardiopulmonar/métodosRESUMEN
As of now, a model for predicting the survival of patients with out-of-hospital cardiac arrest has not been established. This study aimed to develop a model for identifying predictors of survival over time in patients with out-of-hospital cardiac arrest during their stay in the emergency department, using ensemble-based machine learning. A total of 26 013 patients from the Korean nationwide out-of-hospital cardiac arrest registry were enrolled between January 1 and December 31, 2019. Our model, comprising 38 variables, was developed using the Survival Quilts model to improve predictive performance. We found that changes in important variables of patients with out-of-hospital cardiac arrest were observed 10 minutes after arrival at the emergency department. The important score of the predictors showed that the influence of patient age decreased, moving from the highest rank to the fifth. In contrast, the significance of reperfusion attempts increased, moving from the fourth to the highest rank. Our research suggests that the ensemble-based machine learning model, particularly the Survival Quilts, offers a promising approach for predicting survival in patients with out-of-hospital cardiac arrest. The Survival Quilts model may potentially assist emergency department staff in making informed decisions quickly, reducing preventable deaths.
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Aprendizaje Automático , Paro Cardíaco Extrahospitalario , Humanos , Paro Cardíaco Extrahospitalario/mortalidad , Paro Cardíaco Extrahospitalario/terapia , Masculino , Femenino , República de Corea , Anciano , Persona de Mediana Edad , Servicio de Urgencia en Hospital/estadística & datos numéricos , Sistema de Registros/estadística & datos numéricos , Análisis de SupervivenciaRESUMEN
BACKGROUND: The demand for organ transplants, both globally and in South Korea, substantially exceeds the supply, a situation that might have been aggravated by the enactment of the Life-Sustaining Treatment Decision Act (LSTDA) in February 2018. This legislation may influence emergency medical procedures and the availability of organs from brain-dead donors. This study aimed to assess LSTDA's impact, introduced in February 2018, on organ donation status in out-of-hospital cardiac arrest (OHCA) patients in a metropolitan city and identified related factors. METHODS: We conducted a retrospective analysis of a regional cardiac arrest registry. This study included patients aged 16 or older with cardiac arrest and a cerebral performance category (CPC) score of 5 from January 2015 to December 2022. The exclusion criteria were CPC scores of 1-4, patients under 16 years, and patients declared dead or transferred from emergency departments. Logistic regression analysis was used to analyse factors affecting organ donation. RESULTS: Of the 751 patients included in this study, 47 were organ donors, with a median age of 47 years. Before the LSTDA, there were 30 organ donations, which declined to 17 after its implementation. In the organ donation group, the causes of cardiac arrest included medical (34%), hanging (46.8%), and trauma (19.2%). The adjusted odds ratio for organ donation before the LSTDA implementation was 6.12 (95% CI 3.09-12.12), with non-medical aetiology as associated factors. CONCLUSION: The enactment of the LSTDA in 2018 in South Korea may be linked to reduced organ donations among patients with OHCA, underscoring the need to re-evaluate the medical and legal aspects of organ donation, especially considering end-of-life care decisions.
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Paro Cardíaco Extrahospitalario , Obtención de Tejidos y Órganos , Humanos , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/mortalidad , República de Corea/epidemiología , Obtención de Tejidos y Órganos/legislación & jurisprudencia , Estudios Retrospectivos , Masculino , Persona de Mediana Edad , Femenino , Adulto , Anciano , Toma de Decisiones , Donantes de Tejidos/legislación & jurisprudencia , Cuidados para Prolongación de la Vida/legislación & jurisprudencia , Cuidados para Prolongación de la Vida/ética , Sistema de RegistrosRESUMEN
BACKGROUND: Bystander cardiopulmonary resuscitation (CPR) is associated with higher survival for out-of-hospital cardiac arrest, but whether its association with survival differs by patients' sex and race and ethnicity is less clear. METHODS: Within a large US registry, we identified 623 342 nontraumatic out-of-hospital cardiac arrests during 2013 to 2022 for this observational cohort study. Using hierarchical logistic regression, we examined whether there was a differential association between bystander CPR and survival outcomes by patients' sex and race and ethnicity, overall and by neighborhood strata. RESULTS: Mean age was 62.1±17.1 years, and 35.9% were women. Nearly half of patients (49.8%) were non-Hispanic White; 20.6% were non-Hispanic Black; 7.3% were Hispanic; 2.9% were Asian; and 0.4% were Native American. Overall, 58 098 (9.3%) survived to hospital discharge. Although bystander CPR was associated with higher survival in each race and ethnicity group, the association of bystander CPR compared with patients without bystander CPR in each racial and ethnic group was highest in individuals who were White (adjusted odds ratio [OR], 1.33 [95% CI, 1.30-1.37]) and Native American (adjusted OR, 1.40 [95% CI, 1.02-1.90]) and lowest in individuals who were Black (adjusted OR, 1.09 [95% CI, 1.04-1.14]; Pinteraction<0.001). The adjusted OR for bystander CPR compared with those without bystander CPR for Hispanic patients was 1.29 (95% CI, 1.20-1.139), for Asian patients, it was 1.27 (95% CI, 1.12-1.42), and for those of unknown race, it was 1.31 (95% CI, 1.25-1.36). Similarly, bystander CPR was associated with higher survival in both sexes, but its association with survival was higher in men (adjusted OR, 1.35 [95% CI, 1.31-1.38]) than women (adjusted OR, 1.15 [95% CI, 1.12-1.19]; Pinteraction<0.001). The weaker association of bystander CPR in Black individuals and women was consistent across neighborhood race and ethnicity and income strata. Similar results were observed for the outcome of survival without severe neurological deficits. CONCLUSIONS: Although bystander CPR was associated with higher survival in all patients, its association with survival was weakest for Black individuals and women with out-of-hospital cardiac arrest.
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Reanimación Cardiopulmonar , Paro Cardíaco Extrahospitalario , Sistema de Registros , Humanos , Femenino , Masculino , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/mortalidad , Paro Cardíaco Extrahospitalario/etnología , Persona de Mediana Edad , Anciano , Factores Sexuales , Estados Unidos/epidemiología , Anciano de 80 o más Años , Grupos Raciales , Estudios de CohortesRESUMEN
Out-of-hospital cardiac arrest (OHCA) is associated with very poor outcomes. Extracorporeal cardiopulmonary resuscitation (eCPR) for selected patients is a potential therapeutic option for refractory cardiac arrest. However, randomised controlled studies applying eCPR after refractory OHCA have demonstrated conflicting results regarding survival and good functional neurological outcomes. eCPR is an invasive, labour-intensive, and expensive therapeutic approach with associated side-effects. A rapid monitoring device would be valuable in facilitating selection of appropriate patients for this expensive and complex treatment. To this end, rapid diagnosis of hyperfibrinolysis, or premature clot dissolution, diagnosed by viscoelastic testing might represent a feasible option. Hyperfibrinolysis is an evolutionary response to low or no-flow states. Studies in trauma patients demonstrate a high mortality rate in those with established hyperfibrinolysis upon emergency room admission. Similar findings have now been reported for the first time in OHCA patients. Hyperfibrinolysis upon admission diagnosed by rotational thromboelastometry was strongly associated with mortality and poor neurological outcomes in a small cohort of patients treated with extracorporeal membrane oxygenation.
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Reanimación Cardiopulmonar , Oxigenación por Membrana Extracorpórea , Fibrinólisis , Paro Cardíaco Extrahospitalario , Humanos , Oxigenación por Membrana Extracorpórea/métodos , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/mortalidad , Reanimación Cardiopulmonar/métodos , Tromboelastografía/métodos , Toma de Decisiones Clínicas/métodos , Inutilidad MédicaRESUMEN
AIMS: Out-of-hospital cardiac arrest (OHCA) is a leading cause of death worldwide, with cardiovascular disease (CVD) being a key risk factor. This study aims to investigate disparities in patient/OHCA characteristics and survival after OHCA among patients with vs. without depression. METHODS AND RESULTS: This is a retrospective cohort study using data from the AmsteRdam REsuscitation Studies (ARREST) registry from 2008 to 2018. History of comorbidities, including depression, was obtained from the patient's general practitioner. Out-of-hospital cardiac arrest survival was defined as survival at 30 days post-OHCA or hospital discharge. Logistic regression models were used to obtain crude and adjusted odds ratios (ORs) for the association between depression and OHCA survival and possible effect modification by age, sex, and comorbidities. The potential mediating effects of initial heart rhythm and provision of bystander cardiopulmonary resuscitation were explored. Among 5594 OHCA cases, 582 individuals had pre-existing depression. Patients with depression had less favourable patient and OHCA characteristics and lower odds of survival after adjustment for age, sex, and comorbidities [OR 0.65, 95% confidence interval (CI) 0.51-0.82], with similar findings by sex and age groups. The association remained significant among the Utstein comparator group (OR 0.63, 95% CI 0.45-0.89) and patients with return of spontaneous circulation (OR 0.60, 95% CI 0.42-0.85). Initial rhythm and bystander cardiopulmonary resuscitation partially mediated the observed association (by 27 and 7%, respectively). CONCLUSION: Out-of-hospital cardiac arrest patients with depression presented more frequently with unfavourable patient and OHCA characteristics and had reduced chances of survival. Further investigation into potential pathways is warranted.
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Reanimación Cardiopulmonar , Depresión , Paro Cardíaco Extrahospitalario , Sistema de Registros , Humanos , Paro Cardíaco Extrahospitalario/mortalidad , Paro Cardíaco Extrahospitalario/terapia , Masculino , Femenino , Anciano , Persona de Mediana Edad , Reanimación Cardiopulmonar/estadística & datos numéricos , Depresión/psicología , Depresión/epidemiología , Estudios Retrospectivos , Factores de Riesgo , Países Bajos/epidemiología , Comorbilidad , Tasa de Supervivencia , Anciano de 80 o más Años , Factores de TiempoRESUMEN
Out-of-hospital cardiac arrest (OHCA) is a critical condition with low survival rates. In patients with a return of spontaneous circulation, brain injury is a leading cause of death. In this study, we propose an interpretable machine learning approach for predicting neurologic outcome after OHCA, using information available at the time of hospital admission. METHODS: The study population were 55 615 OHCA cases registered in the Swedish Cardiopulmonary Resuscitation Registry between 2010 and 2020. The dataset was split to training and validation sets (for model development) and test set (for evaluation of the final model). We used an XGBoost algorithm with stratified, repeated 10-fold cross-validation along with Optuna framework for hyperparameters tuning. The final model was trained on 10 features selected based on the importance scores and evaluated on the test set in terms of discrimination, calibration and bias-variance tradeoff. We used SHapley Additive exPlanations to address the 'black-box' model and align with eXplainable artificial intelligence. RESULTS: The final model achieved: area under the receiver operating characteristic value 0.964 (95% confidence interval (CI) [0.960-0.968]), sensitivity 0.606 (95% CI [0.573-0.634]), specificity 0.975 (95% CI [0.972-0.978]), positive predictive value (PPV) 0.664 (95% CI [0.625-0.696]), negative predictive value (NPV) 0.969 (95% CI [0.966-0.972]), macro F1 0.803 (95% CI [0.788-0.816]), and showed a very good calibration. SHAP features with the highest impact on the model's output were:'ROSC on arrival to hospital', 'Initial rhythm asystole' and 'Conscious on arrival to hospital'. CONCLUSIONS: The XGBoost machine learning model with 10 features available at the time of hospital admission showed good performance for predicting neurologic outcome after OHCA, with no apparent signs of overfitting.
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Reanimación Cardiopulmonar , Aprendizaje Automático , Paro Cardíaco Extrahospitalario , Sistema de Registros , Humanos , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/mortalidad , Masculino , Femenino , Anciano , Suecia/epidemiología , Reanimación Cardiopulmonar/métodos , Persona de Mediana Edad , Curva ROCRESUMEN
AIM: To investigate the performance of the 2021 ERC/ESICM-recommended algorithm for predicting poor outcome after cardiac arrest (CA) and potential tools for predicting neurological recovery in patients with indeterminate outcome. METHODS: Prospective, multicenter study on out-of-hospital CA survivors from 28 ICUs of the AfterROSC network. In patients comatose with a Glasgow Coma Scale motor score ≤3 at ≥72 h after resuscitation, we measured: (1) the accuracy of neurological examination, biomarkers (neuron-specific enolase, NSE), electrophysiology (EEG and SSEP) and neuroimaging (brain CT and MRI) for predicting poor outcome (modified Rankin scale score ≥4 at 90 days), and (2) the ability of low or decreasing NSE levels and benign EEG to predict good outcome in patients whose prognosis remained indeterminate. RESULTS: Among 337 included patients, the ERC-ESICM algorithm predicted poor neurological outcome in 175 patients, and the positive predictive value for an unfavourable outcome was 100% [98-100]%. The specificity of individual predictors ranged from 90% for EEG to 100% for clinical examination and SSEP. Among the remaining 162 patients with indeterminate outcome, a combination of 2 favourable signs predicted good outcome with 99[96-100]% specificity and 23[11-38]% sensitivity. CONCLUSION: All comatose resuscitated patients who fulfilled the ERC-ESICM criteria for poor outcome after CA had poor outcome at three months, even if a self-fulfilling prophecy cannot be completely excluded. In patients with indeterminate outcome (half of the population), favourable signs predicted neurological recovery, reducing prognostic uncertainty.
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Algoritmos , Electroencefalografía , Paro Cardíaco Extrahospitalario , Humanos , Estudios Prospectivos , Masculino , Femenino , Persona de Mediana Edad , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/mortalidad , Anciano , Pronóstico , Electroencefalografía/métodos , Examen Neurológico/métodos , Coma/etiología , Coma/diagnóstico , Reanimación Cardiopulmonar/métodos , Fosfopiruvato Hidratasa/sangre , Biomarcadores/sangre , Escala de Coma de Glasgow , Valor Predictivo de las Pruebas , Neuroimagen/métodos , Potenciales Evocados SomatosensorialesRESUMEN
AIM: While intravenous (IV) vascular access for out-of-hospital cardiac arrest (OHCA) resuscitation is standard, humeral-intraosseous (IO) access is commonly used, despite few supporting data. We investigated the association between IV vs. humeral-IO and outcomes. METHODS: We utilized BC Cardiac Arrest Registry data, including adult OHCA where the first-attempted intra-arrest vascular access route performed by advanced life support (ALS)-trained paramedics was IV or humeral-IO. We fit a propensity-score adjusted model with inverse probability treatment weighting to estimate the association between IV vs. humeral-IO routes and favorable neurological outcomes (CPC 1-2) and survival at hospital discharge. We repeated models within subgroups defined by initial cardiac rhythm. RESULTS: We included 2,112 cases; the first-attempted route was IV (n = 1,575) or humeral-IO (n = 537). Time intervals from ALS-paramedic on-scene arrival to vascular access (6.6 vs. 6.9 min) and epinephrine administration (9.0 vs. 9.3 min) were similar between IV and IO groups, respectively. Among IV and humeral-IO groups, 98 (6.2%) and 20 (3.7%) had favorable neurological outcomes. Compared to humeral-IO, an IV-first approach was associated with improved hospital-discharge favorable neurological outcomes (AOR 1.7; 95% CI 1.1-2.7) and survival (AOR 1.5; 95% CI 1.0-2.3). Among shockable rhythm cases, an IV-first approach was associated with improved favorable neurological outcomes (AOR 4.2; 95% CI 2.1-8.2), but not among non-shockable rhythm cases (AOR 0.73; 95% CI 0.39-1.4). CONCLUSION: An IV-first approach, compared to humeral-IO, for intra-arrest resuscitation was associated with an improved odds of favorable neurological outcomes and survival to hospital discharge. This association was seen among an initial shockable rhythm, but not non-shockable rhythm, subgroups.
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Reanimación Cardiopulmonar , Infusiones Intraóseas , Paro Cardíaco Extrahospitalario , Sistema de Registros , Humanos , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/mortalidad , Masculino , Femenino , Infusiones Intraóseas/métodos , Persona de Mediana Edad , Reanimación Cardiopulmonar/métodos , Anciano , Húmero , Servicios Médicos de Urgencia/métodos , Resultado del Tratamiento , Adulto , Puntaje de PropensiónRESUMEN
BACKGROUND: The post-cardiac arrest syndrome (PCAS) after out-of-hospital cardiac arrest (OHCA) is characterized by a series of pathological events, including inflammation. In the randomized "STERoid for OHCA" (STEROHCA) trial, prehospital high-dose glucocorticoid decreased interleukin (IL) 6 and C-reactive protein levels following resuscitated OHCA. The aim of this predefined sub-study was to assess the inflammatory response the first three days of admission. METHODS: The STEROHCA trial enrolled 137 OHCA patients randomized to either a single prehospital injection of methylprednisolone 250 mg or placebo. Inflammatory markers, including pro- and anti-inflammatory cytokines, were analyzed in plasma samples, from 0-, 24-, 48-, and 72 h post-admission. Mixed-model analyses were applied using log-transformed data to assess group differences. RESULTS: The 137 patients included in this sub-study had a median age of 67 years (57 to 74), and the 180-day survival rates were 75% (n = 51/68) and 64% (n = 44/69) in the glucocorticoid and placebo group, respectively. A total of 130 (95%) patients had at least one plasma sample available. The anti-inflammatory cytokine IL-10 was increased at hospital admission in the glucocorticoid group (ratio 2.74 (1.49-5.05), p = 0.006), but the intervention showed the strongest effect after 24 h, decreasing pro-inflammatory levels of IL-6 (ratio 0.06 (0.03-0.10), p < 0.001), IL-8 (ratio 0.53 (0.38-0.75), p < 0.001), macrophage chemokine protein-1 (MCP-1, ratio 0.02 (0.13-0.31), p < 0.001), macrophage inflammatory protein-1-beta (MIP-1b, ratio 0.28 (0.18-0.45), p < 0.001), and tumor necrosis factor-α (TNF-α, ratio 0.6 (0.4-0.8), p = 0.01). CONCLUSION: Administering high-dose glucocorticoid treatment promptly after resuscitation from OHCA influenced the inflammatory response with a reduction in several systemic proinflammatory cytokines after 24 h. TRIAL REGISTRATION: EudraCT number: 2020-000855-11; submitted March 30, 2020. URL: https://www. CLINICALTRIALS: gov; Unique Identifier: NCT04624776.
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Reanimación Cardiopulmonar , Servicios Médicos de Urgencia , Glucocorticoides , Metilprednisolona , Paro Cardíaco Extrahospitalario , Humanos , Paro Cardíaco Extrahospitalario/mortalidad , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/sangre , Paro Cardíaco Extrahospitalario/tratamiento farmacológico , Masculino , Femenino , Anciano , Persona de Mediana Edad , Metilprednisolona/administración & dosificación , Glucocorticoides/administración & dosificación , Reanimación Cardiopulmonar/métodos , Servicios Médicos de Urgencia/métodos , Inflamación/sangre , Inflamación/tratamiento farmacológico , Citocinas/sangre , Proteína C-Reactiva/análisis , Biomarcadores/sangre , Método Doble Ciego , Interleucina-6/sangreRESUMEN
OBJECTIVE: The Efficacy of Inhaled Hydrogen on Neurologic Outcome Following Brain Ischemia During Post-Cardiac Arrest Care (HYBRID) II trial (jRCTs031180352) suggested that hydrogen inhalation may reduce post-cardiac arrest brain injury (PCABI). However, the combination of hypothermic target temperature management (TTM) and hydrogen inhalation on outcomes is unclear. The aim of this study was to investigate the combined effect of hydrogen inhalation and hypothermic TTM on outcomes after out-of-hospital cardiac arrest (OHCA). DESIGN: Post hoc analysis of a multicenter, randomized, controlled trial. SETTING: Fifteen Japanese ICUs. PATIENTS: Cardiogenic OHCA enrolled in the HYBRID II trial. INTERVENTIONS: Hydrogen mixed oxygen (hydrogen group) versus oxygen alone (control group). MEASUREMENTS AND MAIN RESULTS: TTM was performed at a target temperature of 32-34°C (TTM32-TTM34) or 35-36°C (TTM35-TTM36) per the institutional protocol. The association between hydrogen + TTM32-TTM34 and 90-day good neurologic outcomes was analyzed using generalized estimating equations. The 90-day survival was compared between the hydrogen and control groups under TTM32-TTM34 and TTM35-TTM36, respectively. The analysis included 72 patients (hydrogen [ n = 39] and control [ n = 33] groups) with outcome data. TTM32-TTM34 was implemented in 25 (64%) and 24 (73%) patients in the hydrogen and control groups, respectively ( p = 0.46). Under TTM32-TTM34, 17 (68%) and 9 (38%) patients achieved good neurologic outcomes in the hydrogen and control groups, respectively (relative risk: 1.81 [95% CI, 1.05-3.66], p < 0.05). Hydrogen + TTM32-TTM34 was independently associated with good neurologic outcomes (adjusted odds ratio 16.10 [95% CI, 1.88-138.17], p = 0.01). However, hydrogen + TTM32-TTM34 did not improve survival compared with TTM32-TTM34 alone (adjusted hazard ratio: 0.22 [95% CI, 0.05-1.06], p = 0.06). CONCLUSIONS: Hydrogen + TTM32-TTM34 was associated with improved neurologic outcomes after cardiogenic OHCA compared with TTM32-TTM34 monotherapy. Hydrogen inhalation is a promising treatment option for reducing PCABI when combined with TTM32-TTM34.
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Isquemia Encefálica , Hidrógeno , Hipotermia Inducida , Paro Cardíaco Extrahospitalario , Humanos , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/tratamiento farmacológico , Paro Cardíaco Extrahospitalario/mortalidad , Hidrógeno/administración & dosificación , Hidrógeno/uso terapéutico , Hipotermia Inducida/métodos , Masculino , Femenino , Administración por Inhalación , Persona de Mediana Edad , Anciano , Isquemia Encefálica/prevención & control , Isquemia Encefálica/tratamiento farmacológico , Terapia CombinadaRESUMEN
Background and Objectives: Out-of-hospital cardiac arrest (OHCA) and survival is a pressing matter all around the world. Despite years of research and great strides and advancements, survival remains alarmingly low. The aim of this study was to measure the survival and characteristics of patients having an OHCA in Slovenia, with an in-depth look at how the bystanders affect the return of spontaneous circulation (ROSC) and survival of OHCA. Materials and Methods: In this observational cross-sectional prospective study, we enrolled patients between 1 September 2022 and 30 November 2022, with a follow-up period of 1 month. All OHCAs attended by the emergency medical services were included. Data were collected and analyzed according to the Utstein 2015 reporting template. Independent predictors of ROSC and 30-day survival or survival were explored using ridge regression. Results: ROSC was achieved in 41% of cases where resuscitation was attempted. The overall 30-day survival rate where resuscitation was attempted was 14%. In 13% of all cases where resuscitation was attempted, patients had a favorable neurological outcome. Using our prediction model, we found that defibrillation under 20 min and ventricular fibrillation as an initial rhythm improves survival, whilst no defibrillation and bystander full cardiopulmonary resuscitation negatively predicted survival. Conclusions: Slovenia has OHCA 30-day survival comparable to the rest of the European Union. The favorable neurological outcome is high. Our data show that bystanders do not significantly improve survival. This represents an untapped potential of general public education in cardiopulmonary resuscitation and automatic external defibrillator use. Following good practices from abroad and improving layperson CPR knowledge could further improve OHCA survival.
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Reanimación Cardiopulmonar , Servicios Médicos de Urgencia , Paro Cardíaco Extrahospitalario , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/mortalidad , Humanos , Eslovenia/epidemiología , Masculino , Femenino , Estudios Prospectivos , Persona de Mediana Edad , Anciano , Estudios Transversales , Reanimación Cardiopulmonar/estadística & datos numéricos , Reanimación Cardiopulmonar/métodos , Servicios Médicos de Urgencia/estadística & datos numéricos , Servicios Médicos de Urgencia/métodos , Servicios Médicos de Urgencia/normas , Anciano de 80 o más Años , AdultoRESUMEN
Importance: The incidence of opioid-associated out-of-hospital cardiac arrest (OA-OHCA) has grown from less than 1% of OHCA in 2000 to between 7% and 14% of OHCA in recent years; American Heart Association (AHA) protocols suggest that emergency medical service (EMS) clinicians consider naloxone in OA-OHCA. However, it is unknown whether naloxone improves survival in these patients or in patients with undifferentiated OHCA. Objective: To evaluate the association of naloxone with clinical outcomes in patients with undifferentiated OHCA. Design, Setting, and Participants: Retrospective cohort study of EMS-treated patients aged 18 or older who received EMS treatment for nontraumatic OHCA in 3 Northern California counties between 2015 and 2023. Data were analyzed using propensity score-based models from February to April 2024. Exposure: EMS administration of naloxone. Main Outcomes and Measures: The primary outcome was survival to hospital discharge; the secondary outcome was sustained return of spontaneous circulation (ROSC). Covariates included patient and cardiac arrest characteristics (eg, age, sex, nonshockable rhythm, any comorbidity, unwitnessed arrest, and EMS agency) and EMS clinician determination of OHCA cause as presumed drug-related. Results: Among 8195 patients (median [IQR] age, 65 [51-78] years; 5540 male [67.6%]; 1304 Asian, Native Hawaiian, or Pacific Islander [15.9%]; 1119 Black [13.7%]; 2538 White [31.0%]) with OHCA treated by 5 EMS agencies from 2015 to 2023, 715 (8.7%) were believed by treating clinicians to have drug-related OHCA. Naloxone was administered to 1165 patients (14.2%) and was associated with increased ROSC using both nearest neighbor propensity matching (absolute risk difference [ARD], 15.2%; 95% CI, 9.9%-20.6%) and inverse propensity-weighted regression adjustment (ARD, 11.8%; 95% CI, 7.3%-16.4%). Naloxone was also associated with increased survival to hospital discharge using both nearest neighbor propensity matching (ARD, 6.2%; 95% CI, 2.3%-10.0%) and inverse propensity-weighted regression adjustment (ARD, 3.9%; 95% CI, 1.1%-6.7%). The number needed to treat with naloxone was 9 for ROSC and 26 for survival to hospital discharge. In a regression model that assessed effect modification between naloxone and presumed drug-related OHCA, naloxone was associated with improved survival to hospital discharge in both the presumed drug-related OHCA (odds ratio [OR], 2.48; 95% CI, 1.34-4.58) and non-drug-related OHCA groups (OR, 1.35; 95% CI, 1.04-1.77). Conclusions and Relevance: In this retrospective cohort study, naloxone administration as part of EMS management of OHCA was associated with increased rates of ROSC and increased survival to hospital discharge when evaluated using propensity score-based models. Given the lack of clinical practice data on the efficacy of naloxone in OA-OHCA and OHCA in general, these findings support further evaluation of naloxone as part of cardiac arrest care.
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Servicios Médicos de Urgencia , Naloxona , Antagonistas de Narcóticos , Paro Cardíaco Extrahospitalario , Humanos , Naloxona/uso terapéutico , Paro Cardíaco Extrahospitalario/tratamiento farmacológico , Paro Cardíaco Extrahospitalario/mortalidad , Paro Cardíaco Extrahospitalario/epidemiología , Masculino , Femenino , California/epidemiología , Persona de Mediana Edad , Estudios Retrospectivos , Anciano , Antagonistas de Narcóticos/uso terapéutico , Servicios Médicos de Urgencia/estadística & datos numéricos , Resultado del Tratamiento , Adulto , Reanimación Cardiopulmonar/métodos , Reanimación Cardiopulmonar/estadística & datos numéricosRESUMEN
INTRODUCTION: Out of hospital cardiac arrest (OHCA) is a major public health problem with substantial mortality rates worldwide. Genetic diseases and primary electrical disorders are the most common etiologies at younger ages, while ischemic heart disease and cardiomyopathies are common causes at older ages. Despite improvement in prevention and treatment in recent years, OHCA is still a major cause of cardiovascular death. METHOD: We report prospective data regarding etiology, characteristics, clinical course, and outcomes of patients with OHCA who were admitted to a tertiary care center intensive cardiac care unit (ICCU) between 2020-2023. RESULTS: A total of 92 patients admitted after OHCA were included in the cohort. Mean age was 63.8 ± 13.8 years and 75 (82%) were males. The most common etiology of OHCA was acute coronary syndrome (ACS) in 54 (59%) patients, of whom 46 (85%) patients had ST elevation myocardial infarction and 8 (15%) had non-ST elevation myocardial infarction. During hospitalization, 42 (46%) patients underwent targeted temperature management and 13 (14%) received mechanical circulatory support. Interestingly, 77 (84%) patients underwent coronary angiography, while only 51 (55%) received percutaneous coronary intervention (PCI). Neurologic status was favorable in 49 (53%) patients with Cerebral Performance Category score of 1-2. Overall, mortality rates were relatively low, with 15 (16%) in-hospital deaths and 24 (26%) deaths at 30-day follow-up. CONCLUSION: Although ACS was the most common etiology for OHCA, only 55% of patients underwent PCI. Most OHCA patients admitted to the ICCU survived hospitalization and were discharged. Increased awareness, public education, worldwide registries, and specific evidence-based guidelines for the treatment of OHCA patients may lead to improved outcomes for these patients who often carry poor prognoses.
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Paro Cardíaco Extrahospitalario , Sistema de Registros , Humanos , Masculino , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/mortalidad , Persona de Mediana Edad , Femenino , Anciano , Estudios Prospectivos , Guías de Práctica Clínica como Asunto , Reanimación CardiopulmonarRESUMEN
BACKGROUND: In patients resuscitated from cardiac arrest and displaying no ST-segment elevation on initial electrocardiogram (ECG), recent randomized trials indicated no benefits from early coronary angiography. How the results of such randomized studies apply to a real-world clinical context remains to be established. METHODS: We retrospectively analyzed a clinical database including all patients 18 yo or older admitted to our tertiary University Hospital from January 2017 to August 2020 after successful resuscitation of out-of-Hospital (OHCA) or In-Hospital (IHCA) cardiac arrest of presumed cardiac origin, and undergoing immediate coronary angiography, regardless of the initial rhythm and post-resuscitation ECG. The primary outcome of the study was survival at day 90 after cardiac arrest. Demographic data, characteristics of cardiac arrest, duration of resuscitation, laboratory values at admission, angiographic data and revascularization status were collected. Comparisons were performed according to the initial ECG (ST-segment elevation or not), and between survivors and non-survivors. Variables associated with the primary outcome were evaluated by univariate and multivariate regression analyses. RESULTS: We analyzed 147 patients (130 OHCA and 17 IHCA), including 67 with STEMI and 80 without STEMI (No STEMI). Immediate revascularization was performed in 65/67 (97%) STEMI and 15/80 (19%) no STEMI. Day 90 survival was significantly higher in STEMI (48/67, 72%) than no STEMI (44/80, 55%). In the latter patients, survival was not influenced by the revascularization status. In univariate and multivariate analyses, lower age, a shockable rhythm, shorter durations of no flow and low flow, and a lower initial blood lactate were associated with survival in both STEMI and no STEMI. In contrast, metabolic abnormalities, including lower initial plasma sodium and higher potassium were significantly associated with mortality only in the subgroup of no STEMI patients. CONCLUSIONS: Our results, obtained in a real-world clinical setting, indicate that an immediate coronary angiography is not associated with any survival advantage in patients resuscitated from cardiac arrest of presumed cardiac etiology without ST-segment elevation on initial ECG. Furthermore, we found that some early metabolic abnormalities may be associated with mortality in this population, which should deserve further investigation.
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Reanimación Cardiopulmonar , Angiografía Coronaria , Paro Cardíaco Extrahospitalario , Intervención Coronaria Percutánea , Humanos , Estudios Retrospectivos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/mortalidad , Paro Cardíaco Extrahospitalario/diagnóstico , Paro Cardíaco Extrahospitalario/diagnóstico por imagen , Paro Cardíaco Extrahospitalario/fisiopatología , Intervención Coronaria Percutánea/mortalidad , Intervención Coronaria Percutánea/efectos adversos , Factores de Tiempo , Resultado del Tratamiento , Reanimación Cardiopulmonar/efectos adversos , Reanimación Cardiopulmonar/mortalidad , Factores de Riesgo , Bases de Datos Factuales , Valor Predictivo de las Pruebas , Electrocardiografía , Infarto del Miocardio con Elevación del ST/mortalidad , Infarto del Miocardio con Elevación del ST/terapia , Infarto del Miocardio con Elevación del ST/diagnóstico por imagen , Infarto del Miocardio con Elevación del ST/diagnóstico , Infarto del Miocardio con Elevación del ST/fisiopatología , Medición de Riesgo , Paro Cardíaco/terapia , Paro Cardíaco/mortalidad , Paro Cardíaco/diagnóstico , Paro Cardíaco/fisiopatología , Paro Cardíaco/etiología , Anciano de 80 o más AñosRESUMEN
Out-of-hospital cardiac arrest (OHCA) occurs in nearly 350,000 people each year in the United States (US). Despite advances in pre and in-hospital care, OHCA survival remains low and is highly variable across systems and regions. The critical barrier to improving cardiac arrest outcomes is not a lack of knowledge about effective interventions, but rather the widespread lack of systems of care to deliver interventions known to be successful. The RAndomized Cluster Evaluation of Cardiac ARrest Systems (RACE-CARS) trial is a 7-year pragmatic, cluster-randomized trial of 62 counties (57 clusters) in North Carolina using an established registry and is testing whether implementation of a customized set of strategically targeted community-based interventions improves survival to hospital discharge with good neurologic function in OHCA relative to control/standard care. The multifaceted intervention comprises rapid cardiac arrest recognition and systematic bystander CPR instructions by 9-1-1 telecommunicators, comprehensive community CPR training and enhanced early automated external defibrillator (AED) use prior to emergency medical systems (EMS) arrival. Approximately 20,000 patients are expected to be enrolled in the RACE CARS Trial over 4 years of the assessment period. The primary endpoint is survival to hospital discharge with good neurologic outcome defined as a cerebral performance category (CPC) of 1 or 2. Secondary outcomes include the rate of bystander CPR, defibrillation prior to arrival of EMS, and quality of life. We aim to identify successful community- and systems-based strategies to improve outcomes of OHCA using a cluster randomized-controlled trial design that aims to provide a high level of evidence for future application.