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.
Cardiac arrest systems of care are successfully coordinating community, emergency medical services, and hospital efforts to improve the process of care for patients who have had a cardiac arrest. As ...a result, the number of people surviving sudden cardiac arrest is increasing. However, physical, cognitive, and emotional effects of surviving cardiac arrest may linger for months or years. Systematic recommendations stop short of addressing partnerships needed to care for patients and caregivers after medical stabilization. This document expands the cardiac arrest resuscitation system of care to include patients, caregivers, and rehabilitative healthcare partnerships, which are central to cardiac arrest survivorship.
BACKGROUND:Little evidence guides the appropriate duration of resuscitation in out-of-hospital cardiac arrest, and case features justifying longer or shorter durations are ill defined. We estimated ...the impact of resuscitation duration on the probability of favorable functional outcome in out-of-hospital cardiac arrest using a large, multicenter cohort.
METHODS:This was a secondary analysis of a North American, single-blind, multicenter, cluster-randomized, clinical trial (ROC-PRIMED Resuscitation Outcomes Consortium Prehospital Resuscitation Using an Impedance Valve and Early Versus Delayed) of consecutive adults with nontraumatic, emergency medical services–treated out-of-hospital cardiac arrest. Primary exposure was duration of resuscitation in minutes (onset of professional resuscitation to return of spontaneous circulation ROSC or termination of resuscitation). Primary outcome was survival to hospital discharge with favorable outcome (modified Rankin scale mRS score of 0–3). Subjects were additionally classified as survival with unfavorable outcome (mRS score of 4–5), ROSC without survival (mRS score of 6), or without ROSC. Subject accrual was plotted as a function of resuscitation duration, and the dynamic probability of favorable outcome at discharge was estimated for the whole cohort and subgroups. Adjusted logistic regression models tested the association between resuscitation duration and survival with favorable outcome.
RESULTS:The primary cohort included 11 368 subjects (median age, 69 years interquartile range, 56–81 years; 7121 men 62.6%). Of these, 4023 (35.4%) achieved ROSC, 1232 (10.8%) survived to hospital discharge, and 905 (8.0%) had an mRS score of 0 to 3 at discharge. Distribution of cardiopulmonary resuscitation duration differed by outcome (P<0.00001). For cardiopulmonary resuscitation duration up to 37.0 minutes (95% confidence interval, 34.9–40.9 minutes), 99% with an eventual mRS score of 0 to 3 at discharge achieved ROSC. The dynamic probability of an mRS score of 0 to 3 at discharge declined over elapsed resuscitation duration, but subjects with initial shockable cardiac rhythm, witnessed cardiac arrest, and bystander cardiopulmonary resuscitation were more likely to survive with favorable outcome after prolonged efforts (30–40 minutes). After adjustment for prehospital (odds ratio, 0.93; 95% confidence interval, 0.92–0.95) and inpatient (odds ratio, 0.97; 95% confidence interval, 0.95–0.99) covariates, resuscitation duration was associated with survival to discharge with an mRS score of 0 to 3.
CONCLUSIONS:Shorter resuscitation duration was associated with likelihood of favorable outcome at hospital discharge. Subjects with favorable case features were more likely to survive prolonged resuscitation up to 47 minutes.
CLINICAL TRIAL REGISTRATION:URLhttp://clinicaltrials.gov. Unique identifierNCT00394706.
Abstract 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, 1,237 (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 8.8 minutes (95%CI 8.3-9.2 minutes) of resuscitation, and 90% within 21.0 minutes (95%CI 19.1-23.7 minutes). Time-dependent probabilities of ROSC and mRS 0-3 declined over elapsed resuscitation, and the likelihood of additional cases with mRS 0-3 beyond 20 minutes 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 9–21 minutes of conventional resuscitation captured most ECPR-eligible subjects with eventual mRS 0-3 at hospital discharge.
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.
Withdrawal of life-sustaining therapies for perceived poor neurologic prognosis (WLST-N) is common after resuscitation from cardiac arrest and may bias outcome estimates from models trained using ...observational data. We compared several approaches to outcome prediction with the goal of identifying strategies to quantify and reduce this bias.
Retrospective observational cohort study.
Two academic medical centers ("UPMC" and "University of Alabama Birmingham" UAB).
Comatose adults resuscitated from cardiac arrest.
None.
As potential predictors, we considered clinical, laboratory, imaging, and quantitative electroencephalography data available early after hospital arrival. We followed patients until death, discharge, or awakening from coma. We used penalized Cox regression with a least absolute shrinkage and selection operator penalty and five-fold cross-validation to predict time to awakening in UPMC patients and then externally validated the model in UAB patients. This model censored patients after WLST-N, considering subsequent potential for awakening to be unknown. Next, we developed a penalized logistic model predicting awakening, which treated failure to awaken after WLST-N as a true observed outcome, and a separate logistic model predicting WLST-N. We scaled and centered individual patients' Cox and logistic predictions for awakening to allow direct comparison and then explored the difference in predictions across probabilities of WLST-N. Overall, 1,254 patients were included, and 29% awakened. Cox models performed well (mean area under the curve was 0.93 in the UPMC test sets and 0.83 in external validation). Logistic predictions of awakening were systematically more pessimistic than Cox-based predictions for patients at higher risk of WLST-N, suggesting potential for self-fulfilling prophecies to arise when failure to awaken after WLST-N is considered as the ground truth outcome.
Compared with traditional binary outcome prediction, censoring outcomes after WLST-N may reduce potential for bias and self-fulfilling prophecies.
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.
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.
Survival after out-of-hospital cardiac arrest requires an integrated system of care (chain of survival) between the community elements responding to an event and the healthcare professionals who ...continue to care for and transport the patient for appropriate interventions. As a result of the dynamic nature of the prehospital setting, coordination and communication can be challenging, and identification of methods to optimize care is essential. This 2019 focused update to the American Heart Association systems of care guidelines summarizes the most recent published evidence for and recommendations on the use of dispatcher-assisted cardiopulmonary resuscitation and cardiac arrest centers. This article includes the revised recommendations that emergency dispatch centers should offer and instruct bystanders in cardiopulmonary resuscitation during out-of-hospital cardiac arrest and that a regionalized approach to post–cardiac arrest care may be reasonable when comprehensive postarrest care is not available at local facilities.
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