The fundamentals of cardiac resuscitation include the immediate provision of high-quality cardiopulmonary resuscitation combined with rapid defibrillation (as appropriate). These mainstays of therapy ...set the groundwork for other possible interventions such as medications, advanced airways, extracorporeal cardiopulmonary resuscitation, and post–cardiac arrest care, including targeted temperature management, cardiorespiratory support, and percutaneous coronary intervention. Since 2015, an increased number of studies have been published evaluating some of these interventions, requiring a reassessment of their use and impact on survival from cardiac arrest. This 2019 focused update to the American Heart Association advanced cardiovascular life support guidelines summarizes the most recent published evidence for and recommendations on the use of advanced airways, vasopressors, and extracorporeal cardiopulmonary resuscitation during cardiac arrest. It includes revised recommendations for all 3 areas, including the choice of advanced airway devices and strategies during cardiac arrest (eg, bag-mask ventilation, supraglottic airway, or endotracheal intubation), the training and retraining required, the administration of standard-dose epinephrine, and the decisions involved in the application of extracorporeal cardiopulmonary resuscitation and its potential impact on cardiac arrest survival.
Omicron subvariants continuingly challenge current vaccination strategies. Here, we demonstrate nearly complete escape of the XBB.1.5, CH.1.1, and CA.3.1 variants from neutralizing antibodies ...stimulated by three doses of mRNA vaccine or by BA.4/5 wave infection, but neutralization is rescued by a BA.5-containing bivalent booster. CH.1.1 and CA.3.1 show strong immune escape from monoclonal antibody S309. Additionally, XBB.1.5, CH.1.1, and CA.3.1 spike proteins exhibit increased fusogenicity and enhanced processing compared with BA.2. Homology modeling reveals the key roles of G252V and F486P in the neutralization resistance of XBB.1.5, with F486P also enhancing receptor binding. Further, K444T/M and L452R in CH.1.1 and CA.3.1 likely drive escape from class II neutralizing antibodies, whereas R346T and G339H mutations could confer the strong neutralization resistance of these two subvariants to S309-like antibodies. Overall, our results support the need for administration of the bivalent mRNA vaccine and continued surveillance of Omicron subvariants.
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•Bivalent booster induces 2- to 8-fold higher nAb titer than monovalent against XBB and XBB.1.5•CH.1.1 and CA.3.1 exhibit nearly complete escape of neutralization from bivalent booster•XBB.1.5, CH.1.1, and CA.3.1 show increased fusogenicity compared with BA.2•Homology modeling shows impacts of F486P mutation present in XBB.1.5 on ACE2 binding
Qu et al. show that bivalent booster recipients, compared with monovalent recipients, exhibit higher nAb titers against Omicron subvariants XBB, XBB.1, and XBB.1.5. The CH.1.1 and CA.3.1 variants show more substantial neutralization escape than the XBB variants. Further, structural modeling reveals that the F486P mutation in XBB.1.5 enhances ACE2 binding.
Survival after cardiac arrest requires an integrated system of people, training, equipment, and organizations working together to achieve a common goal. Part 7 of the 2020 American Heart Association ...Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care focuses on systems of care, with an emphasis on elements that are relevant to a broad range of resuscitation situations. Previous systems of care guidelines have identified a Chain of Survival, beginning with prevention and early identification of cardiac arrest and proceeding through resuscitation to post–cardiac arrest care. This concept is reinforced by the addition of recovery as an important stage in cardiac arrest survival. Debriefing and other quality improvement strategies were previously mentioned and are now emphasized. Specific to out-of-hospital cardiac arrest, this Part contains recommendations about community initiatives to promote cardiac arrest recognition, cardiopulmonary resuscitation, public access defibrillation, mobile phone technologies to summon first responders, and an enhanced role for emergency telecommunicators. Germane to in-hospital cardiac arrest are recommendations about the recognition and stabilization of hospital patients at risk for developing cardiac arrest. This Part also includes recommendations about clinical debriefing, transport to specialized cardiac arrest centers, organ donation, and performance measurement across the continuum of resuscitation situations.
Antiarrhythmic medications are commonly administered during and immediately after a ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest. However, it is unclear whether these ...medications improve patient outcomes. This 2018 American Heart Association focused update on advanced cardiovascular life support guidelines summarizes the most recent published evidence for and recommendations on the use of antiarrhythmic drugs during and immediately after shock-refractory ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest. This article includes the revised recommendation that providers may consider either amiodarone or lidocaine to treat shock-refractory ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest.
An online, cross-sectional survey was distributed via email using the National EMS Certification database maintained by the National Registry of Emergency Medical Technicians (NREMT) to a random ...sample of nationally-certified paramedics. Eligible respondents were aged 18 and older, employed as paramedics and had administered care in a prehospital setting within the previous 12 months. Survey items explored difficulties experienced and coping strategies used when difficulty was encountered identifying or opening medications and/or medical supplies. Descriptive statistics and logistic regression were calculated to analyse responses for trends. Of the 12,000 emails sent, 1,912 participants responded (response rate = 16%). After removing respondents who had not administered care within the past 12 months and partial surveys, data from 1,702 respondents were analysed. Nearly 20% of all respondents reported that they had experienced difficulties identifying (21.1%) or opening (20.5%) medications and identifying (17.0%) or opening (23.4%) medical supplies within the past year. Between 1.2% (identifying a medication) and 3.0% (opening supplies) of those included in the analysis indicated that reported difficulties had negatively impacted patient care. Common coping strategies reported to deal with difficulty opening included partner assistance, tool use (scissors, pens, and knives), and the use of teeth, all potential pathways for the transmission of microbes, conceivably further impacting outcomes. More thoughtfully designed packaging for prehospital settings has the potential to benefit both EMS providers and the patients that they care for.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
High quality cardiopulmonary resuscitation (CPR) is critical to improve survival from cardiac arrest. While low dose- high frequency case-based training enhances CPR skill retention, it is unclear if ...this training method is feasible in a clinical environment and if it yields improved clinical CPR quality during in-hospital cardiac arrest. We evaluated the implementation of a novel platform providing low dose- high frequency psychomotor CPR training and its impact upon CPR quality.
The described training platform was launched on two nursing units (60 beds) in a university teaching hospital. Quarterly utilization of the platform was integrated into normal clinical duties of hospital staff. Simulated CPR performance and staff compliance were evaluated pre- and post-intervention. In addition, clinical CPR performance was evaluated for periods of six months before and after four quarters of implementation (median, IQR).
The low dose, high frequency CPR training led to retention of simulated CPR skills (compression rate, depth and fraction) during each quarter exceeding high-quality guideline thresholds. Clinical CPR quality, measured by compression fraction (Pre: 83% (73, 95) and Post: 93% (88, 98), p < 0.001) and rate (Pre: 109 (96, 126) and Post: 120 (108, 130), p = 0.008) increased significantly following platform implementation. Over the intervention period, program compliance was greater than 97%.
Low dose-high frequency case based psychomotor CPR training is feasible in a clinical setting with high compliance. In two nursing units, this method of training resulted in enhanced CPR skill retention and improved in-hospital clinical CPR quality.
The prehospital phase is a critical component of delivering high-quality acute stroke care. This topical review discusses the current state of prehospital acute stroke screening and transport, as ...well as new and emerging advances in prehospital diagnosis and treatment of acute stroke. Topics include prehospital stroke screening, stroke severity screening, emerging technologies to aid in the identification and diagnosis of acute stroke in the prehospital setting, prenotification of receiving emergency departments, decision support for destination determination, and the capabilities and opportunities for prehospital stroke treatment in mobile stroke units. Further evidence-based guideline development and implementation of new technologies are critical for ongoing improvements in prehospital stroke care.
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