Athanasios Chalkias

Pathophysiology and pathogenesis of post-resuscitation myocardial stunning

The prognosis for cardiac arrest victims remains dismal, as only 17% survives to hospital discharge. Post-resuscitation myocardial stunning is the mechanical dysfunction that persists after the restoration of spontaneous circulation. Our knowledge regarding myocardial stunning has grown dramatically over the years, and several hypotheses have been proposed in order to explain its pathophysiology; however, the interrelationships among various mechanisms remain unclear. This review deals primarily with the basic aspects of the pathophysiology of post-resuscitation myocardial stunning. Given the large number of relevant studies and the fragmented information, an effort was made to summarize current knowledge in order to present a comprehensive pathophysiological mechanism. In this review, the pathophysiological disturbances occurring from the onset of cardiac arrest until the restoration of spontaneous circulation are addressed. Then, the pathophysiology of myocardial stunning during the post-resuscitation period is critically reviewed in 4 parts, the immediate, the early, the intermediate, and the recovery post-arrest phase. This article covers a huge gap in the existing literature regarding the pathophysiology of post-resuscitation period and provides a better understanding of the pathophysiology and pathogenesis of post-resuscitation myocardial stunning.

Post-cardiac arrest brain injury: Pathophysiology and treatment

Cardiac arrest is a leading cause of death that affects more than a million individuals worldwide every year. Despite the recent advancement in the field of cardiac arrest and resuscitation, the management and prognosis of post-cardiac arrest brain injury remain suboptimal. The pathophysiology of post-cardiac arrest brain injury involves a complex cascade of molecular events, most of which remain unknown. Considering that a potentially broad therapeutic window for neuroprotective drug therapy is offered in most successfully resuscitated patient after cardiac arrest, the need for further research is imperative. The aim of this article is to present the major pathophysiological disturbances leading to post-cardiac arrest brain injury, as well as to review the available pharmacological therapies.

European Resuscitation Council Guidelines for Resuscitation 2015 Section 9. First aid

Imperial College Healthcare NHS Trust, London, UK Centre for Evidence-Based Practice, Belgian Red Cross-Flanders, Mechelen, Belgium Department of Emergency Medicine, University of Virginia, Charlottesville, VA, USA Global First Aid Reference Centre, International Federation of Red Cross and Red Crescent Societies, Paris, France National and Kapodistrian University of Athens, Medical School, MSc “Cardiopulmonary Resuscitation”, Athens, Greece Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece Wellington Hospital, Wellington Place, London, UK Department of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria Colchester University Hospitals NHS Foundation Trust, Colchester, UK French Red-Cross, Paris, France Austrian Red Cross, National Training Center, Vienna, Austria Belgian Red Cross-Flanders, Mechelen, Belgium Department of Public Health and Primary Care, Faculty of Medicine, Catholic University of Leuven, Leuven, Belgium Faculty of Medicine, University of Ghent, Ghent, Belgium

Part 9: First Aid 2015 International Consensus on First Aid Science With Treatment Recommendations

### Definition of First Aid The International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force first met in June 2013. Comprising nominated members from around the globe appointed by each ILCOR member organization, the task force members first agreed to the goals of first aid and produced a definition of first aid as it might apply to the international setting. Task force members considered an agreed-upon definition essential for the subsequent development of research questions, evidence evaluation, and treatment recommendations. First aid is defined as the helping behaviors and initial care provided for an acute illness or injury. First aid can be initiated by anyone in any situation. A first aid provider is defined as someone trained in first aid who should The goals of first aid are to preserve life, alleviate suffering, prevent further illness or injury, and promote recovery. This definition of first aid addresses the need to recognize injury and illness, the requirement to develop a specific skill base, and the need for first aid providers to simultaneously provide immediate care and activate emergency medical services (EMS) or other medical care as required. First aid assessments and interventions should be medically sound and based on evidence-based medicine or, in the absence of such evidence, on expert medical consensus. The scope of first aid is not purely scientific, as both training and regulatory requirements will influence it. Because the scope of first aid varies among countries, states, and provinces, the treatment recommendations contained herein may need to be refined according to circumstances, need, and regulatory constraints. One difference between this 2015 definition and that used for the 2010 process is that the …

Education and age affect skill acquisition and retention in lay rescuers after a European Resuscitation Council CPR/AED course

OBJECTIVES To examine whether education and age affect skill acquisition and retention in lay rescuers after a European Resuscitation Council (ERC) CPR/AED course. BACKGROUND Because of the importance of bystander CPR/AED skills in the setting of cardiac arrest, acquisition and retention of resuscitation skills has gained a great amount of interest. METHODS The ERC CPR/AED course format for written and practical evaluation was used. Eighty lay people were trained and evaluated at the end of the course, as well as at one, three, and six months. RESULTS Retention of CPR/AED skills improved over time, recording the lowest practical scores at one month after initial training and the lowest written scores at initial training. In practical evaluation scores, when examined longitudinally, age presented a significant adverse effect and higher background education presented a non-significant positive effect. Moreover, regarding written evaluation scores, when examined longitudinally, education presented a significant positive effect while age did not significantly correlate with written scores. CONCLUSIONS Education and age affected retention of CPR/AED skills in lay rescuers. Also, our results suggest that the ERC CPR/AED course format may be poorly designed to discriminate between participants with different levels of practical and written resuscitation skills and merit a thorough investigation in future studies.

Part 9: First aid

### Definition of First Aid The International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force first met in June 2013. Comprising nominated members from around the globe appointed by each ILCOR member organization, the task force members first agreed to the goals of first aid and produced a definition of first aid as it might apply to the international setting. Task force members considered an agreed-upon definition essential for the subsequent development of research questions, evidence evaluation, and treatment recommendations. First aid is defined as the helping behaviors and initial care provided for an acute illness or injury. First aid can be initiated by anyone in any situation. A first aid provider is defined as someone trained in first aid who should The goals of first aid are to preserve life, alleviate suffering, prevent further illness or injury, and promote recovery. This definition of first aid addresses the need to recognize injury and illness, the requirement to develop a specific skill base, and the need for first aid providers to simultaneously provide immediate care and activate emergency medical services (EMS) or other medical care as required. First aid assessments and interventions should be medically sound and based on evidence-based medicine or, in the absence of such evidence, on expert medical consensus. The scope of first aid is not purely scientific, as both training and regulatory requirements will influence it. Because the scope of first aid varies among countries, states, and provinces, the treatment recommendations contained herein may need to be refined according to circumstances, need, and regulatory constraints. One difference between this 2015 definition and that used for the 2010 process is that the …

Sagittal abdominal diameter may effectively predict future complications and increased mortality in intensive care unit patients with severe sepsis

PURPOSE To investigate whether increased visceral adipose tissue is a risk factor for increased morbidity and mortality in intensive care patients with severe sepsis. MATERIALS AND METHODS In this prospective cohort study, body mass index (BMI) and sagittal abdominal diameter (SAD) were measured in all patients with severe sepsis immediately after admission in the intensive care unit (ICU). The patients were followed up until death or discharge from ICU. The studys primary outcome measure was mortality until day 60 after admission, while secondary outcomes were morbidity, length of stay, and length of ventilation in ICU. RESULTS Of the 30 patients, 24 (80%) developed septic shock, 6 (20%) multiple organ dysfunction syndrome, 13 (43.3%) necessitated continuous venovenous hemodiafiltration, while 6 (20%) of them died. BMI and SAD had a statistically significant positive linear correlation with ICU length of stay (P < .001) and length of ventilation (P ≤ .001). However, only SAD was significantly correlated with the development of multiple organ dysfunction syndrome (P = .033), the need for continuous venovenous hemodiafiltration (P = .004), and death (P = .033). CONCLUSION An increased SAD may effectively predict future complications and increased mortality in intensive care unit patients with severe sepsis.

The Effect of Perioperative Ischemia and Reperfusion on Multiorgan Dysfunction following Abdominal Aortic Aneurysm Repair

Abdominal aortic aneurysms (AAAs) are relatively common and are potentially life-threatening medical problems. The aim of this review is to provide an overview of the effect of I/R injury on multiorgan failure following AAA repair. The PubMed, CINAHL, EMBASE, Medline, Cochrane Review, and Scopus databases were comprehensively searched for articles concerning the pathophysiology of I/R and its systemic effects. Cross-referencing was performed using the bibliographies from the articles obtained. Articles retrieved were restricted to those published in English. One of the most prominent characteristics of AAA open repair is the double physiological phenomenon of ischemia-reperfusion (I/R) that happens either at the time of clamping or following the aortic clamp removal. Ischemia-reperfusion injury causes significant pathophysiological disturbances to distant organs, increasing the possibility for postoperative multiorgan failure. Although tissue injury is mediated by diverse mechanisms, microvascular dysfunction seems to be the final outcome of I/R.

Anatomical structures underneath the sternum in healthy adults and implications for chest compressions

OBJECTIVE Chest compressions are pivotal determinants of successful resuscitation. The aim of our study was to identify the variations of the anatomical structures underneath the sternum and to investigate possible implications for chest compressions. METHODS A retrospective study of all patients who underwent a routine chest computed tomography from January 2009 to January 2010 in a tertiary teaching general hospital was performed. The sternum and the area underneath were divided in 2 regions, one consisting of the second and third intercostal spaces, referred to as 2-3 segment, and one consisting of the fourth and fifth intercostal spaces, referred to as 4-6 segment. RESULTS During the study period, 677 consecutive scans were analyzed. The most frequent structures beneath 2-3 segment were the left atrium (77.42%) and right atrium (69.82%), followed by the right ventricle (36.64%), left ventricle (35.94%), and left ventricular outflow (31.80%). Underneath 4-6 segment, the most frequent structures were the right ventricle (99.31%) and left ventricle (99.77%), followed by the right atrium (97%), left atrium (96.77%), and left ventricular outflow (36.64%). Interestingly, the difference in occurrence of atria and ventricles in both segments was significant irrespective of sex. CONCLUSIONS The occurrence of cardiac chambers under the lower part of the sternum is very high, making it a reasonable position for hand placement during chest compressions. However, optimal hand position may differ with age and among healthy individuals owing to variations in thoracic anatomy.

Vasoactive support in the optimization of post-cardiac arrest hemodynamic status: From pharmacology to clinical practice

As a critical component of post-resuscitation care, prompt optimization of hemodynamic status by means of targeted interventions is vital in order to maximize the likelihood of good outcome. Vasoactive agents play an essential role in the supportive care of post cardiac arrest patients. The administration of these agents is associated with serious side-effects and therefore they should be used in the minimal dose necessary to achieve low-normal mean arterial pressure and adequate systematic perfusion. Careful and frequent serial evaluation of the patient is important primarily to assess volume status and adequacy of circulatory support. Continuous monitoring of blood pressure and laboratory parameters is essential both to accurately titrate therapy and because inotropes and vasopressors have the potential to induce life-threatening side-effects. The clinical efficacy of inotropes and vasopressors has been largely investigated through examination of their impact on hemodynamic end points, and clinical practice has been driven in part by expert opinion, extrapolation from animal studies, and physician preference. Clearly these agents should all be considered as supportive measures to stabilize the patient prior to some form of definitive therapy.