Accidental hypothermia designates an unintentional drop in body temperature below 35 °C. There is a major risk of ventricular fibrillation below 28 °C and cardiac arrest is almost inevitable below ...24 °C. In such cases, conventional cardiopulmonary resuscitation is often inefficient. In urban areas with temperate climates, characterized by mild year-round temperatures, the outcome of patients with refractory hypothermic out-of-hospital cardiac arrest (OHCA) treated with extracorporeal cardiopulmonary resuscitation (ECPR) remains uncertain.
We conducted a retrospective monocentric observational study involving patients admitted to a university hospital in Paris, France. We reviewed patients admitted between January 1, 2011 and April 30, 2022. The primary outcome was survival at 28 days with good neurological outcomes, defined as Cerebral Performance Category 1 or 2. We performed a subgroup analysis distinguishing hypothermic refractory OHCA as either asphyxic or non-asphyxic.
A total of 36 patients were analysed, 15 of whom (42%) survived at 28 days, including 13 (36%) with good neurological outcomes. Within the asphyxic subgroup, only 1 (10%) patient survived at 28 days, with poor neurological outcomes. A low-flow time of less than 60 min was not significantly associated with good neurological outcomes (P = 0.25). Prehospital ECPR demonstrated no statistically significant difference in terms of survival with good neurological outcomes compared with inhospital ECPR (P = 0.55). Among patients treated with inhospital ECPR, the HOPE score predicted a 30% survival rate and the observed survival was 6/19 (32%).
Hypothermic refractory OHCA occurred even in urban areas with temperate climates, and survival with good neurological outcomes at 28 days stood at 36% for all patients treated with ECPR. We found no survivors with good neurological outcomes at 28 days in submersed patients.
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Out-of-hospital sudden cardiac arrest (OHCA) is a major public health issue, with a survival rate at hospital discharge that remains below 10% in most cities, despite huge investments ...in this domain. Early basic life support (BLS) and early defibrillation using automated external defibrillators (AEDs) stand as key elements for improving OHCA survival rate. Nevertheless, the use of AEDs in OHCA remains low, for a variety of reasons, including the number, accessibility and ease of locating AEDs, as well as bystanders’ awareness of BLS manœuvres and of the need to use AEDs. Several measures have been proposed to improve the rate of AED use, including optimization of AED deployment strategies as well as the use of drones to bring the AEDs to the OHCA scene and of mobile applications to locate the nearest AED. If they are to be effective, these measures should be combined with large communication campaigns on OHCA, and wide-scale education of the public in BLS and AEDs, to reduce the burden of OHCA.
L’arrêt cardiorespiratoire (ACR) extrahospitalier constitue un véritable problème de santé publique, avec un taux de survie qui reste inférieur à 10 % dans la plupart des pays, malgré de considérables investissements dans ce domaine. La réanimation précoce et une défibrillation précoce grâce à l’usage des défibrillateurs automatiques externes (DAE) ont été identifiées comme des éléments clés pour améliorer la survie des ACR. Pourtant, le taux d’utilisation des DAEs dans les ACR reste faible. Plusieurs limites empêchent une plus ample utilisation des DAE, dont leur nombre, leur accessibilité et la facilité de leur localisation, ainsi que l’éducation des témoins aux gestes qui sauvent et à la nécessité d’utiliser un DAE. Plusieurs pistes ont été testées pour améliorer ces différents paramètres, incluant une optimisation du déploiement des DAEs, ainsi que l’utilisation de drones permettant de ramener les DAEs sur le site d’ACR et d’applications permettant de localiser le DAE le plus proche. Ces mesures doivent systématiquement être associées à de vastes campagnes de communication sur la mort subite et à une éducation du grand public aux manœuvres de réanimation et à l’intérêt de l’utilisation des DAEs.
The cognitive outcome of CPR is poor. This study aims to evaluate if enhancing blood flow to the brain and oxygen dissociation from the hemoglobin improve cerebral O2 transport during CPR in cardiac ...arrest swine.
Standard swine-CPR model of induced VF and recovery was treated with an auto-transfusion tourniquet (A-TT®; HemaShock® (HS) Oneg HaKarmel Ltd. Israel) and ventilation with a novel mixture of 30% Oxygen, 5% CO2, and 65% Argon (COXAR™). Five swine received the study treatment and 5 controls standard therapy. Animals were anesthetized, ventilated, and instrumented for blood draws and pressure measurements. Five minutes of no-CPR arrest were followed by 10 min of mechanical CPR with and without COXAR-HS™ enhancement followed by defibrillation and 45 min post ROSC follow-up.
All 5 COXAR-HS™ animals were resuscitated successfully as opposed to 3 of the control animals. Systolic (p < 0.05), and diastolic (p < 0.01) blood pressures, and coronary (p < 0.001) and cerebral (p < 0.05) perfusion pressures were higher in the COXAR-HS™ group after ROSC, as well as cerebral flow and O2 provided to the brain (p < 0.05). Blood pressure maintenance after ROSC required much higher doses of norepinephrine in the 3 resuscitated control animals vs. the 5 COXAR-HS™ animals (p < 0.05). jugular vein PO2 and SO2 exceeded 50 mmHg and 50%, respectively with COXAR-HS™.
In this pilot experimental study, COXAR-HS™ was associated with higher diastolic blood pressure and coronary perfusion pressure with lower need of vasopressors after ROSC without significant differences prior to ROSC. The higher PjvO2 and SjvO2 suggest enhanced O2 provision to the brain mitochondria, while limb compression by the HS counteracts the vasodilatory effect of the CO2. Further studies are needed to explore and validate the COXAR-HS™ effects on actual post-ROSC brain functionality.
Sequestration of vancomycin in ST
filters used in continuous renal therapy is a pending question. Direct vancomycin-ST
interaction was assessed using the in vitro NeckEpur
technology.
ST150
filter ...and Prismaflex dialyzer, Baxter-Gambro, were used. Two modes were assessed in duplicate: (i) continuous diafiltration (CDF): 4 L/h, (ii) continuous dialysis (CD): 2.5 L/h post-filtration.
The mean initial vancomycin concentration in the central compartment (CC) was 51.4 +/- 5.0 mg/L. The mean percentage eliminated from the CC over 6 h was 91 +/- 4%. The mean clearances from the CC by CDF and CD were 2.8 and 1.9 L/h, respectively. The mean clearances assessed using cumulative effluents were 4.4 and 2.2 L/h, respectively. The mean percentages of the initial dose eliminated in the effluents from the CC by CDF and CD were 114 and 108% with no detectable sequestration of vancomycin in both modes of elimination.
Significant sequestration adds a clearance to that provided by CDF and CD. The study provides multiple evidence from the CC, the filter, and the effluents of the lack of an increase in total clearance in comparison with the flow rates without significant sequestration in the ST
filter comparing cumulative effluents to the initial dose in the CC.
There is no evidence ST
filters directly sequestrate vancomycin.
While ultrasound (US) has continued to expedite diagnosis and therapy for critical care physicians inside the hospital system, the technology has been slow to diffuse into the pre-hospital system. ...Given the diagnostic benefits of thoracic ultrasound (TUS), we sought to evaluate image recognition skills for two important TUS applications; the identification of B-lines (used in the US diagnosis of pulmonary edema) and the identification of lung sliding and comet tails (used in the US diagnosis of pneumothorax). In particular we evaluated the impact of a focused training module in a pre-hospital system that utilizes physicians as pre-hospital providers.
27 Paris Service D'Aide Médicale Urgente (SAMU) physicians at the Hôpital Necker with varying levels of US experience were given two twenty-five image recognition pre-tests; the first test had examples of both normal and pneumothorax lung US and the second had examples of both normal and pulmonary edema lung US. All 27 physicians then underwent the same didactic training modules. A post-test was administered upon completing the training module and results were recorded.
Pre and post-test scores were compared for both the pneumothorax and the pulmonary edema modules. For the pneumothorax module, mean test scores increased from 10.3 +/- 4.1 before the training to 20.1 +/- 3.5 after (p < 0.0001), out of 25 possible points. The standard deviation decreased as well, indicating a collective improvement. For the pulmonary edema module, mean test scores increased from 14.1 +/- 5.2 before the training to 20.9 +/- 2.4 after (p < 0.0001), out of 25 possible points. The standard deviation decreased again by more than half, indicating a collective improvement.
This brief training module resulted in significant improvement of image recognition skills for physicians both with and without previous ultrasound experience. Given that rapid diagnosis of these conditions in the pre-hospital system can change therapy, especially in systems where physicians can integrate this information into treatment decisions, the further diffusion of this technology would seem to be beneficial and deserves further study.
Background
Extracorporeal cardiopulmonary resuscitation (ECPR) is widely proposed for the treatment of refractory cardiac arrest. It should be associated with coronary angiography if coronary artery ...disease is suspected. However, the prioritization of care remains unclear in this situation. Our goal was to determine whether coronary reperfusion should be instituted as soon as possible in such situations in a pig model.
Methods and Results
Anesthetized pigs were instrumented and submitted to coronary artery occlusion and ventricular fibrillation. After 5 minutes of untreated cardiac arrest, conventional cardiopulmonary resuscitation (CPR) was started. Fifteen minutes later, ECPR was initiated for a total duration of 240 minutes. Animals randomly underwent either early or late coronary reperfusion at 20 or 120 minutes of ECPR, respectively. This timing was adapted to the kinetic of infarct extension in pigs. Return of spontaneous circulation was determined as organized electrocardiogram rhythm with systolic arterial pressure above 80 mm Hg. During conventional CPR, hemodynamic parameters were not different between groups. Carotid blood flow then increased by 70% after the onset of ECPR in both groups. No animal (0 of 7) elicited return of spontaneous circulation after late reperfusion versus 4 of 7 after early reperfusion (P=0.025). The hemodynamic parameters, such as carotid blood flow, were also improved in early versus late reperfusion groups (113±20 vs 43±17 mL/min after 240 minutes of ECPR, respectively; P=0.030), along with infarct size decrease (71±4% vs 84±2% of the risk zone, respectively; P=0.013).
Conclusions
Early reperfusion improved hemodynamic status and facilitated return of spontaneous circulation in a porcine model of ischemic cardiac arrest treated by ECPR.
Background We sought to evaluate frequency, characteristics, and outcomes of sudden cardiac arrest (SCA) during sports activities according to the location of occurrence (in sports facilities vs ...those occurring outside of sports facilities). Methods and results This is an observational 5-year prospective national French survey of subjects 10 to 75 years old presenting with SCA during sports (2005-2010), in 60 French administrative regions (covering a population of 35 million people). Of the 820 SCA during sports, 426 SCAs (52%) occurred in sports facilities. Overall, a substantially higher survival rate at hospital discharge was observed among SCA in sports facilities (22.8%, 95% CI 18.8-26.8) compared to those occurring outside (8.0%, 95% CI 5.3-10.7) ( P < .0001). Patients with SCA in sports facilities were younger (42.1 vs 51.3 years, P < .0001) and less frequently had known cardiovascular diseases ( P < .0001). The events were more often witnessed (99.8% vs 84.9%, 0.0001), and bystander cardiopulmonary resuscitation was more frequently initiated (35.4% vs 25.9%, P = .003). Delays of intervention were significantly shorter when SCA occurred in sports facilities (9.3 vs 13.6, P=0.03), and the proportion of initially shockable rhythm was higher (58.8% vs 33.1%, P < .0001). Better survival in sports facilities was mainly explained by concomitant circumstances of occurrence (adjusted odds ratio 1.48, 95% CI 0.88-2.49, P = .134). Conclusions Sports-related SCA is not a homogeneous entity. The 3-fold higher survival rate reported among sports-related SCA is mainly due to cases that occur in sports facilities, whereas SCA during sports occurring outside of sports facilities has the usual very low rate of survival.
Background: In-hospital mortality of ST-segment–elevation myocardial infarction (STEMI) has decreased drastically. In contrast, prehospital mortality from sudden cardiac arrest (SCA) remains high and ...difficult to reduce. Identification of the patients with STEMI at higher risk for prehospital SCA could facilitate rapid triage and intervention in the field. Methods: Using a prospective, population-based study evaluating all patients with STEMI managed by emergency medical services in the greater Paris area (11.7 million inhabitants) between 2006 and 2010, we identified characteristics associated with an increased risk of prehospital SCA and used these variables to build an SCA prediction score, which we validated internally and externally. Results: In the overall STEMI population (n=8112; median age, 60 years; 78% male), SCA occurred in 452 patients (5.6%). In multivariate analysis, younger age, absence of obesity, absence of diabetes mellitus, shortness of breath, and a short delay between pain onset and call to emergency medical services were the main predictors of SCA. A score built from these variables predicted SCA, with the risk increasing 2-fold in patients with a score between 10 and 19, 4-fold in those with a score between 20 and 29, and >18-fold in patients with a score ≥30 compared with those with scores <10. The SCA rate was 28.9% in patients with a score ≥30 compared with 1.6% in patients with a score ≤9 ( P for trend <0.001). The area under the curve values were 0.7033 in the internal validation sample and 0.6031 in the external validation sample. Sensitivity and specificity varied between 96.9% and 10.5% for scores ≥10 and between 18.0% and 97.6% for scores ≥30, with scores between 20 and 29 achieving the best sensitivity and specificity (65.4% and 62.6%, respectively). Conclusions: At the early phase of STEMI, the risk of prehospital SCA can be determined through a simple score of 5 routinely assessed predictors. This score might help optimize the dispatching and management of patients with STEMI by emergency medical services.
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