Kelly N. Sawyer

Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

This Part of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) addresses cardiac arrest in situations that require special treatments or procedures other than those provided during basic life support (BLS) and advanced cardiovascular life support (ACLS). This Part summarizes recommendations for the management of resuscitation in several critical situations, including cardiac arrest associated with pregnancy (Part 10.1), pulmonary embolism (PE) (10.2), and opioid-associated resuscitative emergencies, with or without cardiac arrest (10.3). Part 10.4 provides recommendations on intravenous lipid emulsion (ILE) therapy, an emerging therapy for cardiac arrest due to drug intoxication. Finally, updated guidance for the management of cardiac arrest during percutaneous coronary intervention (PCI) is presented in Part 10.5. A table of all recommendations made in this 2015 Guidelines Update as well as those made in the 2010 Guidelines is contained in the Appendix. The special situations of resuscitation section (Part 12) of the 2010 AHA Guidelines for CPR and ECC 1 covered 15 distinct topic areas. The following topics were last updated in 2010: Additional information about drowning is presented in Part 5 of this publication, “Adult Basic Life Support and Cardiopulmonary Resuscitation Quality.” The recommendations in this 2015 Guidelines Update are based on an extensive evidence review process that was begun by the International Liaison Committee on Resuscitation (ILCOR) with the publication of the ILCOR 2010 International Consensus on CPR and ECC Science With Treatment …

Rapid epinephrine administration improves early outcomes in out-of-hospital cardiac arrest

INTRODUCTION Early administration of epinephrine (Epi) improves outcomes in animal models of cardiac arrest, but there is limited time-dependent clinical data regarding its benefit. OBJECTIVE Our objective was to assess whether timing of Epi administration was associated with improved outcomes after out of hospital cardiac arrest (OHCA). METHODS We performed a retrospective analysis of a cardiac arrest database from a suburban EMS system from November 2005 to April 2011. Data was abstracted from EMS run sheets, including drug treatment, route and timing of drug administration, and other Utstein variables. Our primary outcome was return of spontaneous circulation (ROSC). Secondary outcomes measured were survival to hospital admission and discharge. For analysis, data were dichotomized according to timing of Epi administration: early Epi group (defined as 911 call to Epi administration of ≤10 min) and late Epi group (>10 min). Further, exploratory analyses were conducted looking at subgroups sorted by initial rhythm and whether the arrest was witnessed. Wilcoxon rank sum tests, chi-square tests, 95% confidence intervals, and multi-variable regression were used for statistical analysis. RESULTS We reviewed 809 patients from study communities: 123 patients were excluded, leaving a sample size of 686 for study analysis. The mean time from 911-Epi was 14.3±5.5 min, with 155 (22.6%) receiving early Epi. Key arrest and treatment characteristics were similar between groups. Patients who received early Epi were more likely to have ROSC (32.9% vs. 23.4%, OR 1.59 (1.07, 2.38)), however, no significant increase in survival to admission or discharge was observed. Patients with an initial rhythm of PEA had an increased rate of ROSC (48.6% vs. 21.5%, OR 3.45 (1.56, 7.62)) but not survival to discharge (5.9% vs. 2.6%), OR 2.35 (0.38, 14.7) with early Epi. In a multivariable analysis of bystander witnessed arrests, early Epi was associated with a higher rate of ROSC (OR 3.20 (1.75, 5.88) but not survival to discharge (OR 1.48 (0.50, 4.36)). No improvement in ROSC or secondary outcomes was noted in patients with other arrest rhythms or un-witnessed arrest with Early Epi. CONCLUSIONS Within the limitations of our study, this data suggests improved rates of ROSC with early Epi administration during OHCA resuscitation, but this study lacks adequate sample size to demonstrate impact on survival to discharge. Large prospective trials are needed to further delineate the benefit of early Epi administration in OHCA.

The impact of severe acidemia on neurologic outcome of cardiac arrest survivors undergoing therapeutic hypothermia

INTRODUCTION Therapeutic Hypothermia (TH) has become a standard of care in improving neurological outcomes in cardiac arrest (CA) survivors. Previous studies have defined severe acidemia as plasma pH<7.20. We investigated the influence of severe acidemia at the time of initiation of TH on neurological outcome in CA survivors. METHODS A retrospective analysis was performed on 196 consecutive CA survivors (out-of-hospital CA and in-hospital CA) who underwent TH with endovascular cooling between January 2007 and October 2012. Arterial blood gas drawn prior to initiation of TH was utilized to measure pH in all patients. Shockable and non-shockable CA patients were divided into two sub-groups based on pH (pH<7.2 and pH≥7.2). The primary end-point was measured using the Pittsburgh Cerebral Performance Category (CPC) scale prior to discharge from the hospital: good (CPC 1 and 2) and poor (CPC 3 to 5) neurologic outcome. RESULTS Sixty-two percent of shockable CA patients with pH≥7.20 had good neurological outcome as compared to 34% patients with pH<7.20. Shockable CA patients with pH≥7.20 were 3.3 times more likely to have better neurological outcome when compared to those with pH <7.20 [p=0.013, OR 3.3, 95% CI (1.28-8.45)]. In comparison, non-shockable CA patients with p≥7.20 did not have a significantly different neurological outcome as compared to those with pH<7.20 [p=0.97, OR 1.02, 95% CI (0.31-3.3)]. CONCLUSION Presence of severe acidemia at initiation of TH in shockable CA survivors is significantly associated with poor neurological outcomes. This effect was not observed in the non-shockable CA survivors.

An observational study of patient selection criteria for post-cardiac arrest therapeutic hypothermia.

BACKGROUND To date, there is no comprehensive assessment of how therapeutic hypothermia and post-arrest care are being implemented clinically. At this stage in the translation of post-arrest science to clinical practice, this analysis is overdue. This study examines the first step of post-arrest care--the selection of patients for TH and post-arrest care. METHODS We conducted a systematic review to search for all publicly available TH and post-arrest protocols. Observational data was reported and no statistical inferences were made. RESULTS Notable variation was observed in the following selection criteria: total ischemic time and hemodynamic requirements. Additionally, only some of the criteria were evidence based. CONCLUSION This study demonstrates the wide range and variety of patient selection criteria that are being used for implementation of post-cardiac arrest care. The consequences of this selection criteria variability are currently unmeasured and likely underestimated. Variability is likely to breed inefficiency. Some patients who could benefit do not get treated. Other patients get cooled, yet will never regain consciousness. This variability may be important when considering inter-hospital variation in post-arrest care and outcomes.

Prevalence, natural history, and time-dependent outcomes of a multi-center North American cohort of out-of-hospital cardiac arrest extracorporeal CPR candidates

AIM Estimate prevalence of ECPR-eligible subjects in a large, North American, multi-center cohort, describe natural history with conventional resuscitation, and predict optimal timing of transition to ECPR. METHODS Secondary analysis of clinical trial enrolling adults with non-traumatic OHCA. Primary outcome was survival to discharge with favorable outcome (mRS 0-3). Subjects were additionally classified as survival with unfavorable outcome (mRS 4-5), ROSC without survival (mRS 6), or without ROSC. We plotted subject accrual as a function of resuscitation duration (CPR onset to return of spontaneous circulation (ROSC) or termination of resuscitation), and estimated time-dependent probabilities of ROSC and mRS 0-3 at discharge. Adjusted logistic regression models tested the association between resuscitation duration and survival with mRS 0-3. RESULTS Of 11,368 subjects, 1237 (10.9%; 95%CI 10.3-11.5%) were eligible for ECPR, Of these, 778 (63%) achieved ROSC, 466 (38%) survived to discharge, and 377 (30%) had mRS 0-3 at discharge. Half with eventual mRS 0-3 achieved ROSC within 8.8min (95%CI 8.3-9.2min) of resuscitation, and 90% within 21.0min (95%CI 19.1-23.7min). Time-dependent probabilities of ROSC and mRS 0-3 declined over elapsed resuscitation, and the likelihood of additional cases with mRS 0-3 beyond 20min was 8.4% (95%CI 5.9-11.0%). Resuscitation duration was independently associated with survival to discharge with mRS 0-3 (OR 0.95; 95%CI 0.92-0.97). CONCLUSION Approximately 11% of subjects were eligible for ECPR. Only one-third survived to discharge with favorable outcome. Performing 9-21min of conventional resuscitation captured most ECPR-eligible subjects with eventual mRS 0-3 at hospital discharge.

Assessing cardiac arrest beyond hospital discharge--We are only as "Good" as the outcomes we measure.

Defining and measuring outcomes after cardiac arrest have hisorically been a crude proposition.1,2 Limited by relatively few urvivors, early studies focused upon outcomes that were numerus enough to be meaningful: return of spontaneous circulation or urvival to hospital admission. As resuscitation science advanced nd the number of patients achieving a “good” outcome grew, the utcome of interest evolved to survival at hospital discharge. Surival, regardless of the time point, is reliable, valid, and difficult to isclassify – all desirable properties of an outcome measure.3 Howver, using survival as a dichotomous outcome measure captures nly universal endpoints of a complex spectrum involving funcional, cognitive, and psychosocial components. Today, patients ischarged from the hospital alive vary widely in terms of physcal and neurologic disability, illuminating why simple survival etermination is no longer an adequate, meaningful outcome after ardiac arrest. Various ordinal assessment tools for cardiac arrest survivors ave been used, including discharge location and the Glasgow coma cale (range 3-15). The cerebral performance category (CPC) scale as specifically developed to grade cardiac arrest outcomes with ore detail.4 Its use is recommended by Utstein guidelines5 and herefore is the most common measure used for assessing patients ollowing cardiac arrest. CPC grades level of consciousness, ability o work, and reliance on others, resulting in a 5-tier scale incorpoating estimates of impairment, function, and participation. Though his additional information is modest, assignment is typically based n chart review rather than actual patient interview and CPC is outinely condensed back into a binary endpoint. As a result, neuologic outcome after cardiac arrest is reduced to “good” (CPC 1–2) ersus “poor” (CPC 3–5). In this construct conscious patients who ely heavily on others for daily activities (CPC 3) are treated as equal o those who are brain dead (CPC 5), eliminating any benefit from he granularity of the 5-tier CPC scale beyond alive versus dead. While combining CPC 1 and 2 is largely a matter of statistical ragmatism and a result of feasible study resources, distinguishng the individual level of impairment within these groups is nything but simple.6,7 The hospital represents a sheltered environent with intense social support: others prepare food and orient atients to day, time, and daily events; medical questions and conitions can be addressed at the bedside. In contrast, upon arriving ome patients may realize they cannot safely cook, handle peronal hygiene, or manage their affairs. These complex activities f independent living are rarely examined in the in-patient seting. The assessment of CPC at hospital discharge, an administrative

Challenges of Using Probabilistic Linkage Methodology to Characterize Post-Cardiac Arrest Care in Michigan

Abstract Background: To improve survival of patients resuscitated from out of hospital cardiac arrest (OCHA), data is needed to assess and improve inpatient post-resuscitation care. Our objective was to apply probabilistic linkage methodology to link EMS and inpatient databases and evaluate whether it may be used to describe post-arrest care in Michigan. Methods: We performed a retrospective study to describe post-cardiac arrest care in adult OHCA patients who were transported to Michigan hospitals from July 1, 2010, to June 30, 2013. Using probabilistic linkage methodology we linked two databases, the Michigan EMS Information System (MI_EMSIS) and the Michigan Inpatient Database (MIDB), which describes inpatient care and outcome of all admissions. Rates of case incidence and survival were compared to published literature. We compared the linked dataset to existing cardiac arrest databases from three counties to evaluate the quality of this linkage. Results: Multiple iterations of match strategies were used to create a linked EMS-inpatient dataset. There were 12,838 MI_EMSIS cardiac arrest records of which 1,977 were matched with MIDB records, identifying them as surviving to hospital admission. Of these 590 (30.0%) survived to hospital discharge. The annual survival incidence/100,000 population to admission was 6.93/100,000 and survival incidence to discharge was 2.1/100,000. The matched dataset was compared to county databases identified a limited sensitivity [48.2%, 95% CI 42.1%–55.3%)] and positive predictive value [64.4%, 95% CI 56.8%–71.3%)]. Conclusion: Use of the MI_EMSISEMS database and the Michigan Inpatient database was feasible and produced rates of cardiac arrest admission and survival rates similar to published literature. This process yielded a limited match compared to existing county cardiac arrest databases. We conclude that such a linked dataset is useful for descriptive purposes but not as a population based dataset to evaluate statewide post-cardiac arrest care.

Variability of Post-Cardiac Arrest Care Practices Among Cardiac Arrest Centers: United States and South Korean Dual Network Survey of Emergency Physician Research Principal Investigators

There is little consensus regarding many post-cardiac arrest care parameters. Variability in such practices could confound the results and generalizability of post-arrest care research. We sought to characterize the variability in post-cardiac arrest care practice in Korea and the United States. A 54-question survey was sent to investigators participating in one of two research groups in South Korea (Korean Hypothermia Network [KORHN]) and the United States (National Post-Arrest Research Consortium [NPARC]). Single investigators from each site were surveyed (N = 40). Participants answered questions based on local institutional protocols and practice. We calculated descriptive statistics for all variables. Forty surveys were completed during the study period with 30 having greater than 50% of questions completed (75% response rate; 24 KORHN and 6 NPARC). Most centers target either 33°C (N = 16) or vary the target based on patient characteristics (N = 13). Both bolus and continuous infusion dosing of sedation are employed. No single indication was unanimous for cardiac catheterization. Only six investigators reported having an institutional protocol for withdrawal of life-sustaining therapy (WLST). US patients with poor neurological prognosis tended to have WLST with subsequent expiration (N = 5), whereas Korean patients are transferred to a secondary care facility (N = 19). Both electroencephalography modality and duration vary between institutions. Serum biomarkers are commonly employed by Korean, but not US centers. We found significant variability in post-cardiac arrest care practices among US and Korean medical centers. These practice variations must be taken into account in future studies of post-arrest care.

An Assessment of Emergency Department Post-Cardiac Arrest Care Variation in Michigan

Implementation of postarrest care by individual physicians and systems has been slow. Deadoption, or discontinuation of therapeutic hypothermia (TH) treatment targets, after recent prospective study results has not been well reported. This study assesses practices in the early stages of postarrest care across emergency departments (EDs) in Michigan. A 27-question Internet-based survey was distributed to EDs in Michigan in September 2013. To assess changes in practice after publication of Nielsen et al., we sent follow-up questions to all original respondents a year later. Observational data and descriptive statistics are reported. From the 142 EDs identified, we excluded critical access hospitals (N = 35), free standing EDs (N = 7), EDs that transfer critical patients to tertiary centers (N = 21), and exclusive childrens hospitals (N = 3). Of the remaining 76 hospitals, we received 64 (84.2%) responses. We identified 15 respondents with a protocol to specifically initiate ED TH and transfer patients to a higher level of care. The 49 remaining were mostly teaching institutions (N = 34, 69%) and gave the ED physician the ability to initiate TH (N = 40, 82%). On follow-up 12 months later, we received 33/40 (83%) responses, of which only 5 indicated formal or informal change in TH practice or target temperature. There is substantial variation in the practice of ED postarrest care and initiation of TH across the state of Michigan, but few ED TH protocols were changed in a years time. The consequences of postarrest treatment variability at the state and ED levels are likely under-recognized as an influence on outcome variation between regions.

Variability of extracorporeal cardiopulmonary resuscitation utilization for refractory adult out-of-hospital cardiac arrest: an international survey study

Objective A growing interest in extracorporeal cardiopulmonary resuscitation (ECPR) as a rescue strategy for refractory adult out-of-hospital cardiac arrest (OHCA) currently exists. This study aims to determine current standards of care and practice variation for ECPR patients in the USA and Korea. Methods In December 2015, we surveyed centers from the Korean Hypothermia Network (KORHN) Investigators and the US National Post-Arrest Research Consortium (NPARC) on current targeted temperature management and ECPR practices. This project analyzes the subsection of questions addressing ECPR practices. We summarized survey results using descriptive statistics. Results Overall, 9 KORHN and 4 NPARC centers reported having ECPR programs and had complete survey data available. Two KORHN centers utilized extracorporeal membrane oxygenation only for postarrest circulatory support in patients with refractory shock and were excluded from further analysis. Centers with available ECPR generally saw a high volume of OHCA patients (10/11 centers care for >75 OHCA a year). Location of, and providers trained for cannulation varied across centers. All centers in both countries (KORHN 7/7, NPARC 4/4) treated comatose ECPR patients with targeted temperature management. All NPARC centers and four of seven KORHN centers reported having a standardized hospital protocol for ECPR. Upper age cutoff for eligibility ranged from 60 to 75 years. No absolute contraindications were unanimous among centers. Conclusion A wide variability in practice patterns exist between centers performing ECPR for refractory OHCA in the US and Korea. Standardized protocols and shared research databases might inform best practices, improve outcomes, and provide a foundation for prospective studies.