ANZCOR February 2012 Research Updates...pharmacoinvasive management of acute ST-segment elevation ... 176-81 An early invasive strategy after fibrinolysis for ST-elevation myocardial

1 ANZCOR February 2012 Research Updates

Australian and New Zealand Resuscitation Councils: February 2012 Research Updates ________________________________________________________________________________________________________

Clinical trials ___________________________________________________________________________________________

1. Breil M, Krep H, Heister U, Bartsch A, et al. Randomised study of hypertonic saline infusion during resuscitation from out-of-hospital cardiac arrest. Resuscitation 2012; 83 (3): 347-52 Animal models of hypertonic saline infusion during cardiopulmonary resuscitation (CPR) improve survival, as well as myocardial and cerebral perfusion during CPR. We studied the effect of hypertonic saline infusion during CPR (Guidelines 2000) on survival to hospital admission and hospital discharge, and neurological outcome on hospital discharge. Methods: The study was performed by the EMS of Bonn, Germany, with ethical committee approval. Study inclusion criteria were non-traumatic out-of-hospital cardiac arrest, aged 18-80 years, and given of adrenaline (epinephrine) during CPR. Patients were randomly infused 2 ml/kg HHS (7.2% NaCl with 6% hydroxyethyl starch 200,000/0.5 [HES]) or HES over 10 min. RESULTS: 203 patients were randomised between May 2001 and June 2004. After HHS infusion, plasma sodium concentration increased significantly to 162+/-36 mmol/l at 10 min after infusion and decreased to near normal (144+/-6 mmol/l) at hospital admission. Survival to hospital admission and hospital discharge was similar in both groups (50/100 HHS vs. 49/103 HES for hospital admission, 23/100 HHS vs. 22/103 HES for hospital discharge). There was a small improvement in neurological outcome in survivors on discharge (cerebral performance category 1 or 2) in the HHS group compared to the HES group (13/100 HHS vs. 5/100 HES, p<0.05, odds-ratio 2.9, 95% confidence interval 1.004-8.5). Conclusion: Hypertonic saline infusion during CPR using Guidelines 2000 did not improve survival to hospital admission or hospital discharge. There was a small improvement with hypertonic saline in the secondary endpoint of neurological outcome on discharge in survivors. Further adequately powered studies using current guidelines are needed. Guideline 11.5 Medications in Adult Advanced Life Support 2. Lavi S, Cantor WJ, Casanova A, Tan MK, et al. Efficacy and safety of enoxaparin compared with unfractionated heparin in the pharmacoinvasive management of acute ST-segment elevation myocardial infarction: Insights from the TRANSFER-AMI trial. Am Heart J 2012; 163 (2): 176-81 An early invasive strategy after fibrinolysis for ST-elevation myocardial infarction (STEMI) improves outcomes, but the relative efficacy and safety of enoxaparin compared with unfractionated heparin (UFH) as part of this approach are unknown. Methods and Results: In the TRANSFER-AMI trial, patients with high-risk STEMI received fibrinolysis and were then randomized to either standard treatment or to immediate transfer for coronary angiography. In this substudy, the outcome of patients aged ≥75 years treated with enoxaparin is compared with that of patients who received UFH. Logistic regression and propensity score models were used to evaluate the efficacy and safety of these anticoagulants. Enoxaparin was administered to 498 patients, and UFH, to 448 patients, at the time of fibrinolysis. Approximately 50% in each group were randomized to the early invasive strategy. The primary composite end point of death, re-infarction, recurrent ischemia, new or

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worsening heart failure, or cardiogenic shock at 30 days occurred in 11.9% and 11.6% of the patients who received enoxaparin and UFH, respectively (adjusted odds ratio 0.95 [95% CI 0.60-1.51], P = .84). Enoxaparin use was associated with more access site bleeding (5.0% vs 2.9%, P = .04) and mild bleeding (12.1% vs 7.8%, P = .03). Conclusions: Among high-risk (aged ≥75 years) patients with STEMI undergoing early or late transfer for cardiac catheterization after fibrinolysis, enoxaparin was associated with similar efficacy compared with UFH, but there was more minor bleeding with enoxaparin. Guideline 14.2 ACS: Initial Medical Therapy 3. Ma MH-M, Chiang W-C, Ko PC-I, Yang C-W, et al. A randomized trial of compression first or analyze first strategies in patients with out-of-hospital cardiac arrest: Results from an Asian community. Resuscitation 2012; Online first (Jan 20): It is still under debate whether a period of cardiopulmonary resuscitation should be performed prior to rhythm analysis for defibrillation for out of hospital cardiac arrests (OHCA). This study compared outcomes of OHCA treated by “compression first” (CF) versus “analyze first” (AF) strategies in an Asian community with low rates of shockable rhythms. Methods: This randomized trial was conducted in Taipei City between February 2008 and December 2009. Dispatches of suspected OHCA that activated advanced life support teams were randomized into the CF and AF strategies. Patients assigned to CF strategy received 10 cycles of CPR prior to analysis by automatic external defibrillator. The primary outcome was sustained (>2 h) return of spontaneous circulation (ROSC) and secondary outcome was survival to hospital discharge. Results: We included 289 cases in the final analysis after exclusion by pre-specified criteria, 141 were allocated to CF strategy and 148 to AF strategy. Baseline characteristics were similar. Thirty-seven (26.2%) of those receiving CF strategy and 49 (33.1%) of the AF strategy achieved sustained ROSC (p = 0.25). In a post-hoc analysis of patients who achieved ROSC, those that received CF strategy were more likely to be discharged alive from the hospital (16/37 = 43.2% vs. 11/49 = 22.4%, p = 0.02). Conclusion: In this study population of low rates of shockable rhythms, there was no difference in ROSC for CF or AF strategies. Considering the EMS operation situations, a period of paramedic-administered CPR for up to 10 cycles prior to rhythm analysis could be a feasible strategy in this community. Guideline 8 Cardiopulmonary Resuscitation 4. Olasveengen TM, Wik L, Sunde K, Steen PA. Outcome when adrenaline (epinephrine) was actually given vs. not given - post hoc analysis of a randomized clinical trial. Resuscitation 2012; 83 (3): 327-32 IV line insertion and drugs did not affect long-term survival in an out-of-hospital cardiac arrest (OHCA) randomized clinical trial (RCT). In a previous large registry study adrenaline was negatively associated with survival from OHCA. The present post hoc analysis of the RCT data compares outcomes for patients actually receiving adrenaline to those not receiving adrenaline. MATERIALS AND METHODS: Patients from a RCT performed May 2003 to April 2008 were included. Three patients from the original intention-to-treat analysis were excluded due to insufficient documentation of adrenaline administration. Quality of cardiopulmonary resuscitation (CPR) and clinical outcomes were compared. RESULTS: Clinical characteristics were similar and CPR quality comparable and within guideline recommendations for 367 patients receiving adrenaline and 481 patients not receiving adrenaline. Odds ratio (OR) for being admitted to hospital, being discharged from hospital and surviving with favourable neurological outcome for the adrenaline vs. no-adrenaline group was 2.5 (CI 1.9, 3.4), 0.5 (CI 0.3, 0.8) and 0.4 (CI 0.2, 0.7), respectively. Ventricular fibrillation, response interval, witnessed arrest, gender, age and endotracheal intubation were confounders in multivariate logistic regression analysis. OR for survival for adrenaline vs. no-adrenaline adjusted for confounders was 0.52 (95% CI: 0.29,

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0.92). CONCLUSION: Receiving adrenaline was associated with improved short-term survival, but decreased survival to hospital discharge and survival with favourable neurological outcome after OHCA. This post hoc survival analysis is in contrast to the previous intention-to-treat analysis of the same data, but agrees with previous non-randomized registry data. This shows limitations of non-randomized or non-intention-to-treat analyses. Guideline 11.5 Medications in Adult Advanced Life Support 5. Ong MEH, Tiah L, Leong BS-H, Tan ECC, et al. A randomised, double-blind, multi-centre trial comparing vasopressin and adrenaline in patients with cardiac arrest presenting to or in the Emergency Department. Resuscitation 2012; Online first (February 18) Objective: To compare vasopressin and adrenaline in the treatment of patients with cardiac arrest presenting to or in the Emergency Department (ED). Design: A randomised, double-blinded, multi-centre, parallel-design clinical trial in four adult hospitals. Method; Eligible cardiac arrest patients (confirmed by the absence of pulse, unresponsiveness and apnea) aged >16 (age > 21 for one hospital) were randomly assigned to intravenous adrenaline (1 mg) or vasopressin (40 IU) at ED. Patients with traumatic cardiac arrest or contraindication for cardiopulmonary resuscitation (CPR) were excluded. Patients received additional open label doses of adrenaline as per current guidelines. Primary outcome was survival to hospital discharge (defined as participant discharged alive or survival to 30 days post-arrest). Main results: The study recruited 727 participants (adrenaline = 353; vasopressin = 374). Baseline characteristics of the two groups were comparable. Eight participants (2.3%) from adrenaline and 11 (2.9%) from vasopressin group survived to hospital discharge with no significant difference between groups (p = 0.27, RR = 1.72, 95% CI = 0.65–4.51). After adjustment for race, medical history, bystander CPR and prior adrenaline given, more participants survived to hospital admission with vasopressin (22.2%) than with adrenaline (16.7%) (p = 0.05, RR = 1.43, 95% CI = 1.02–2.04). Sub-group analysis suggested improved outcomes for vasopressin in participants with prolonged arrest times. Conclusions: Combination of vasopressin and adrenaline did not improve long term survival but seemed to improve survival to admission in patients with prolonged cardiac arrest. Further studies on the effect of vasopressin combined with therapeutic hypothermia on patients with prolonged cardiac arrest are needed. Guideline 11.5 Medications in Adult Advanced Life Support

Observational studies ___________________________________________________________________________________________ 6. Axelsson C, Claesson A, Engdahl J, Herlitz J, et al. Outcome after out-of-hospital cardiac arrest witnessed by EMS Changes over




time and factors of importance for outcome in Sweden. Resuscitation 2012; Online first (Feb 28) Among patients who survive after out-of-hospital cardiac arrest (OHCA), a large proportion are recruited from cases witnessed by the Emergency Medical Service (EMS), since the conditions for success are most optimal in this subset. Aim: To evaluate outcome after EMS-witnessed OHCA in a 20-year perspective in Sweden, with the emphasis on changes over time and factors of importance. Methods: All patients included in the Swedish Cardiac Arrest Register from 1990-2009 were included. Results; There were 48,349 patients and 13.5% of them were EMS witnessed. There was a successive increase in EMS-witnessed OHCA from 8.5% in 1992 to 16.9% in 2009 (p for trend < 0.0001). Among EMS-witnessed OHCA, the survival to one month increased from 13.9% in 1992 to 21.8% in 2009 (p for trend < 0.0001). Among EMS-witnessed OHCA, 51% were found in ventricular fibrillation, which was higher than in bystander-witnessed OHCA, despite a lower proportion with a presumed cardiac aetiology in the EMS-witnessed group. Among EMS-witnessed OHCA overall, 16.0% survived to one month, which was significantly higher than among bystander-witnessed OHCA. Independent predictors of a favourable outcome were: 1/initial rhythm ventricular fibrillation; 2/cardiac aetiology; 3/OHCA outside home and 4/decreasing age. Conclusion: In Sweden, in an 20-year perspective, there was a successive increase in the proportion of EMS-witnessed OHCA. Among these patients, survival to one month increased over time. EMS-witnessed OHCA had a higher survival than bystander-witnessed OHCA. Independent predictors of an increased chance of survival were initial rhythm, aetiology, place and age. 7. Bonaca M, Wiviott S, Braunwald E, Murphy S, et al. American College of Cardiology/American Heart Association/European Society of Cardiology/World Heart Federation Universal Definition of Myocardial Infarction Classification System and the Risk of Cardiovascular Death: Observations From the TRITON-TIMI 38 Trial (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel-Thrombolysis in Myocardial Infarction 38). Circulation 2012; 125 (4): 577-83 The availability of more sensitive biomarkers of myonecrosis and a new classification system from the universal definition of myocardial infarction (MI) have led to evolution of the classification of MI. The prognostic implications of MI defined in the current era have not been well described. Methods and Results-: We investigated the association between new or recurrent MI by subtype according to the European Society of Cardiology/American College of Cardiology/American Heart Association/World Health Federation Task Force for the Redefinition of MI Classification System and the risk of cardiovascular death among 13 608 patients with acute coronary syndrome in the Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel-Thrombolysis in Myocardial Infarction 38 (TRITON-TIMI 38). The adjusted risk of cardiovascular death was evaluated by landmark analysis starting at the time of the MI through 180 days after the event. Patients who experienced an MI during follow-up had a higher risk of cardiovascular death at 6 months than patients without an MI (6.5% versus 1.3%, P<0.001). This higher risk was present across all subtypes of MI, including type 4a (peri-percutaneous coronary intervention, 3.2%; P<0.001) and type 4b (stent thrombosis, 15.4%; P<0.001). After adjustment for important clinical covariates, the occurrence of any MI was associated with a 5-fold higher risk of death at 6 months (95% confidence interval 3.8-7.1), with similarly increased risk across subtypes., Conclusions-: MI is associated with a significantly increased risk of cardiovascular death, with a consistent relationship across all types as defined by the universal classification system. These findings underscore the clinical relevance of these events and the importance of therapies aimed at preventing MI. Guideline 14 ACS: Overview & Summary

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8. Canto JG, Rogers WJ, Goldberg RJ, Peterson ED, et al. Association of Age and Sex With Myocardial Infarction Symptom Presentation and In-Hospital Mortality. JAMA 2012; 307 (8): 813-22 Women are generally older than men at hospitalization for myocardial infarction (MI) and also present less frequently with chest pain/discomfort. However, few studies have taken age into account when examining sex differences in clinical presentation and mortality. Objective: To examine the relationship between sex and symptom presentation and between sex, symptom presentation, and hospital mortality, before and after accounting for age in patients hospitalized with MI. Design, Setting, and Patients: Observational study from the National Registry of Myocardial Infarction, 1994-2006, of 1,143,513 registry patients (481,581 women and 661,932 men). Main Outcome Measures: We examined predictors of MI presentation without chest pain and the relationship between age, sex, and hospital mortality. Results: The proportion of MI patients who presented without chest pain was significantly higher for women than men (42.0% [95% CI, 41.8%-42.1%] vs 30.7% [95% CI, 30.6%-30.8%]; P<.001). There was a significant interaction between age and sex with chest pain at presentation, with a larger sex difference in younger than older patients, which became attenuated with advancing age. Multivariable adjusted age-specific odds ratios (ORs) for lack of chest pain for women (referent, men) were younger than 45 years, 1.30 (95% CI, 1.23-1.36); 45 to 54 years, 1.26 (95% CI, 1.22-1.30); 55 to 64 years, 1.24 (95% CI, 1.21-1.27); 65 to 74 years, 1.13 (95% CI, 1.11-1.15); and 75 years or older, 1.03 (95% CI, 1.02-1.04). Two-way interaction (sex and age) on MI presentation without chest pain was significant (P<.001). The in-hospital mortality rate was 14.6% for women and 10.3% for men. Younger women presenting without chest pain had greater hospital mortality than younger men without chest pain, and these sex differences decreased or even reversed with advancing age, with adjusted OR for age younger than 45 years, 1.18 (95% CI, 1.00-1.39); 45 to 54 years, 1.13 (95% CI, 1.02-1.26); 55 to 64 years, 1.02 (95% CI, 0.96-1.09); 65 to 74 years, 0.91 (95% CI, 0.88-0.95); and 75 years or older, 0.81 (95% CI, 0.79-0.83). The 3-way interaction (sex, age, and chest pain) on mortality was significant (P<.001). Conclusion: In this registry of patients hospitalized with MI, women were more likely than men to present without chest pain and had higher mortality than men within the same age group, but sex differences in clinical presentation without chest pain and in mortality were attenuated with increasing age. Guideline 14.1 ACS: Presentation with ACS 9. Chestnut JM, Kuklinski AA, Stephens SW, Wang HE. Cardiovascular collapse after return of spontaneous circulation in human out-of-hospital cardiopulmonary arrest. Emerg Med J 2012; 29 (2): 129-32 Animal studies describe cardiovascular collapse (CVC; hypotension or reoccurrence of cardiac arrest) after return of spontaneous circulation (ROSC) from cardiopulmonary arrest. Few studies describe CVC in humans. This study aimed to determine the occurrence of cardiovascular collapse (CVC) in human out-of-hospital cardiopulmonary arrest (OHCA). Methods: Using observational data from a site of the Resuscitation Outcomes Consortium, the study analysed treated, non-traumatic OHCA achieving initial ROSC. CVC was defined as post-ROSC hypotension (systolic blood pressure <80mmHg), post-ROSC administration of epinephrine, vasopressin or dopamine, or post-ROSC recurrent cardiac arrest. The time period from initial ROSC to emergency department (ED) arrival was measured. The prevalence of and elapsed time to post-ROSC CVC was determined, censoring cases at the point of ED arrival and comparing clinical characteristics between CVC and non-CVC cases. Results: Of 1081 treated OHCA, ROSC occurred in 58 (5%; 95% CI 4% to 7%). CVC occurred in three cases of 58 ROSC (5%; 95% CI 1% to 14%), all due to recurrent cardiac arrest. The median ROSC to ED arrival time was 6min (IQR 3‚ 13min). ROSC to CVC times were 1, 2 and 8min. Patient sex, age, initial ECG rhythm, endotracheal intubation, bystander cardiopulmonary resuscitation and bystander automated external defibrillation were similar between CVC and non-CVC cases (p=0.11). Conclusions: In this series of treated OHCA, only a small fraction



of patients experienced CVC after ROSC. Guideline 11.7 Post-Resuscitation Therapy in Adult Advanced Life Support 10. Clark CL, Berman AD, McHugh A, Roe EJ, Boura J, Swor RA. Hospital Process Intervals, not Ems Time Intervals, are the Most Important Predictors of Rapid Reperfusion in Ems Patients with St-Segment Elevation Myocardial Infarction. Prehosp Emerg Care 2012; 16 (1): 115-20 Objective. To assess the relationship of emergency medical services (EMS) intervals and internal hospital intervals to the rapid reperfusion of patients with ST-segment elevation myocardial infarction (STEMI). Methods. We performed a secondary analysis of a prospectively collected database of STEMI patients transported to a large academic community hospital between January 1, 2004, and December 31, 2009. EMS and hospital data intervals included EMS scene time, transport time, hospital arrival to myocardial infarction (MI) team activation (D2Page), page to catheterization laboratory arrival (P2Lab), and catheterization laboratory arrival to reperfusion (L2B). We used two outcomes: EMS scene arrival to reperfusion (S2B) ≤90 minutes and hospital arrival to reperfusion (D2B) ≤90 minutes. Means and proportions are reported. Pearson chi-square and multivariate regression were used for analysis. Results. During the study period, we included 313 EMS-transported STEMI patients with 298 (95.2%) MI team activations. Of these STEMI patients, 295 (94.2%) were taken to the cardiac catheterization laboratory and 244 (78.0%) underwent percutaneous coronary intervention (PCI). For the patients who underwent PCI, 127 (52.5%) had prehospital EMS activation, 202 (82.8%) had D2B ≤90 minutes, and 72 (39%) had S2B ≤90 minutes. In a multivariate analysis, hospital processes EMS activation (OR 7.1, 95% CI 2.7, 18.4], Page to Lab [6.7, 95% CI 2.3, 19.2] and Lab arrival to Reperfusion [18.5, 95% CI 6.1, 55.6]) were the most important predictors of Scene to Balloon ≤ 90 minutes. EMS scene and transport intervals also had a modest association with rapid reperfusion (OR 0.85, 95% CI 0.78, 0.93 and OR 0.89, 95% CI 0.83, 0.95, respectively). In a secondary analysis, Hospital processes (Door to Page [OR 44.8, 95% CI 8.6, 234.4], Page 2 Lab [OR 5.4, 95% CI 1.9, 15.3], and Lab arrival to Reperfusion [OR 14.6 95% CI 2.5, 84.3]), but not EMS scene and transport intervals were the most important predictors D2B ≤90 minutes. Conclusions. In our study, hospital process intervals (EMS activation, door to page, page to laboratory, and laboratory to reperfusion) are key covariates of rapid reperfusion for EMS STEMI patients and should be used when assessing STEMI care. Guideline 14.3 ACS: Reperfusion Strategy 11. Cudnik MT, Sasson C, Rea TD, Sayre MR, et al. Increasing hospital volume is not associated with improved survival in out of hospital cardiac arrest of cardiac etiology. Resuscitation 2012; Online first (Feb 18) Resuscitation centers may improve patient outcomes by achieving sufficient experience in post-resuscitation care. We analyzed the relationship between survival and hospital volume among patients suffering out-of-hospital cardiac arrest (OHCA). Methods: This prospective cohort investigation collected data from the Cardiac Arrest Registry to Enhance Survival database from 10/1/05 to 12/31/09. Primary outcome was survival to discharge. Hospital characteristics were obtained via 2005 American Hospital Association Survey. A hospital's use of hypothermia was obtained via direct survey. To adjust for hospital- and patient-level variation, multilevel, hierarchical logistic regression was performed. Hospital volume was modeled as a categorical (OHCA/year ≤ 10, 11–39, ≥40) variable. A stratified analysis evaluating those with ventricular fibrillation or pulseless ventricular tachycardia (VF/VT) was also performed. Results: The cohort included 4125 patients transported by EMS to 155 hospitals in 16 states. Overall survival to hospital discharge was 35% among those admitted to the hospital. Individual hospital rates of survival varied widely (0–100%). Unadjusted survival did not differ between the 3 hospital groups (36% for ≤10 OHCA/year, 35% for 11–39, and

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36% for ≥40; p = 0.75). After multilevel adjustment, differences in survival across the groups were not statistically significant. Compared to patients at hospitals with ≤10 OHCA/year, adjusted OR for survival was 1.04 (CI95 0.83–1.28) among 11–39 annual volume and 0.97 (CI95 0.73–1.30) among the ≥40 volume hospitals. Among patients presenting with VF/VT, no difference in survival was identified between the hospital groups. Conclusion: Survival varied substantially across hospitals. However, hospital OHCA volume was not associated with likelihood of survival. Additional efforts are required to determine what hospital characteristics might account for the variability observed in OHCA hospital outcomes. Guideline 11.7 Post-Resuscitation Therapy in Adult Advanced Life Support 12. Cudnik MT, Werman HA, White LJ, Opalek JM. Prehospital Factors Associated with Mortality in Injured Air Medical Patients. Prehosp Emerg Care 2012; 16 (1): 121-7 Air medical transport provides rapid transport to definitive care. Over-triage and the expense and risk of transport may offset survival benefits. Objective. We assessed the ability of prehospital factors to predict resource need for helicopter-transported patients. Methods. We performed a prospective, observational cohort analysis of injured scene patients taken to one of two level I trauma centers from October 2009 to September 2010. Variables analyzed included patient demographics, diagnoses, and clinical outcomes (in-hospital mortality, emergent surgery within 24 hours, blood transfusion within 24 hours, and intensive care unit [ICU] admission ≥24 hours, as well as a combined outcome of all clinical outcomes). Prehospital variables were prospectively obtained from air medical providers at the time of transport and included past medical history, mechanism of injury, and clinical factors. We compared those variables with and without the outcomes of interest via χ2 analysis and the Kruskal-Wallis test, where appropriate. Multivariate logistic regression identified factors associated with outcomes of interest with the intent of developing a clinical prediction tool. Results. Five hundred fifty-seven patients were transported during the study period. The majority of the patients were male (67%) and white (95%) and had an injury that occurred in a rural location (58%). Most injuries were blunt (97%), and patients had a median Injury Severity Score (ISS) of 9. The overall mortality was 4%; 48% of the patients had one of the four outcomes. The most common reasons for requesting air transport were motor vehicle collision (MVC) with high-risk mechanism (18%), MVC at a speed greater than 20 mph (18%), Glasgow Coma Scale score (GCS) less than 14 (15%), and loss of consciousness (LOC) greater than 5 minutes (15%). Factors associated with mortality were age greater than 44 years, GCS less than 14, systolic blood pressure (SBP) less than 90 mmHg, and flail chest. This model had 100% sensitivity and 50% specificity and missed no deaths. The combined endpoint of all four outcomes (death, receipt of blood, surgery, ICU admission) included intubation by emergency medical services, two or more fractures of the humerus /femur, presence of a neurovascular injury, a crush injury to the head, failure to localize to pain on examination, GCS less than 14, or the presence of a penetrating head injury. This model had a sensitivity of 57% (53%–61%) and a specificity of 78% (75%–87%). Conclusions. Very few prehospital criteria were associated with clinically important outcomes in helicopter-transported patients. Evidence-based guidelines for the most appropriate utilization of air medical transport need to be further evaluated and developed for injured patients. 13. Hastbacka J, Tiainen M, Hynninen M, Kolho E, et al. Serum matrix metalloproteinases in patients resuscitated from cardiac arrest. The association with therapeutic hypothermia. Resuscitation 2012; 83 (2): 197-201 Aim: To study the systemic levels of matrix metalloproteinases (MMP) -7, -8 and -9 and their inhibitor TIMP-1 in cardiac arrest patients and the association with mild therapeutic hypothermia treatment on the serum concentration of these enzymes. Methods: MMP-7, -8 and -9 and tissue



inhibitor of metalloproteinases-1 (TIMP-1) were analysed in blood samples obtained from 51 patients resuscitated from cardiac arrest. The samples were taken at 24 and 48 h from restoration of spontaneous circulation (ROSC). The biomarker levels were compared between patients (N = 51) and healthy controls (N = 10) and between patients who did (N = 30) and patients who did not (N = 21) receive mild therapeutic hypothermia. Results: MMP-7 (median 0.47 ng/ml), MMP-8 (median 31.16 ng/ml) and MMP-9 (median 253.00 ng/ml) levels were elevated and TIMP-1 levels suppressed (median 78.50 ng/ml) in cardiac arrest patients as compared with healthy controls at 24 h from ROSC. Hypothermia treatment associated with attenuated elevation of MMP-9 (p = 0.001) but not MMP-8 (p = 0.02) or MMP-7 (p = 0.69). Concentrations of MMPs -7, -8 and -9 correlated with the leukocyte count but not with C-reactive protein (CRP) or neurone-specific enolase (NSE) levels. Conclusion: We demonstrated that the systemic levels of MMP-7, -8 and -9 but not TIMP-1 are elevated in cardiac arrest patients in the 48 h post-resuscitation period relative to the healthy controls. Patients who received therapeutic hypothermia had lower MMP-9 levels compared to non-hypothermia treated patients, which generates hypothesis about attenuation of inflammatory response by hypothermia treatment. Guideline 11.8 Therapeutic Hypothermia after Cardiac Arrest 14. Heradstveit B, Sunde K, Sunde G-A, Wentzel-Larsen T, Heltne J-K. Factors complicating interpretation of capnography during advanced life support in cardiac arrest: clinical retrospective study in 575 patients. Resuscitation 2012; Online first End tidal carbon dioxide (ETCO2) monitoring during Advanced Life Support (ALS) using capnography, is recommended in the latest international guidelines. However, several factors might complicate capnography interpretation during ALS. How the cause of cardiac arrest, initial rhythm, bystander cardiopulmonary resuscitation (CPR) and time impact on the ETCO2 values are not completely clear. Thus, we wanted to explore this in out-of-hospital cardiac arrested (OHCA) patients. Methods: The study was carried out by the Emergency Medical Service of Haukeland University Hospital, Bergen, Norway. All non-traumatic OHCAs treated by our service between January 2004 and December 2009 were included. Capnography was routinely used in the study, and these data were retrospectively reviewed together with Utstein data and other clinical information. Results: Our service treated 918 OHCA patients, and capnography data were present in 575 patients. Capnography distinguished well between patients with or without return of spontaneous circulation (ROSC) for any initial rhythm and cause of the arrest (p < 0.001). Cardiac arrests with a respiratory cause had significantly higher levels of ETCO2 compared to primary cardiac causes (p < 0.001). Bystander CPR affected ETCO2–recordings, and the ETCO2 levels declined with time. Conclusions: Capnography is a useful tool to optimise and individualise ALS in cardiac arrested patients. Confounding factors including cause of cardiac arrest, initial rhythm, bystander CPR and time from cardiac arrest until quantitative capnography had an impact on the ETCO2 values, thereby complicating and limiting prognostic interpretation of capnography during ALS. Guideline 11.6 Equipment and Techniques in Adult Advanced Life Support 15. Kelly A-M. How useful are the Heart Foundation risk criteria for assessment of emergency department patients with chest pain? Emerg Med Aus 2012; Online first (February 14) Objective: To investigate the prognostic utility of Heart Foundation (Australia) risk stratification table in an ED chest pain population. Methods: A planned sub-study of a prospective observational study of adult patients with potentially cardiac chest pain who underwent evaluation for acute coronary syndrome (ACS) was conducted. Data collected included demographical, clinical, ECG, biomarker and outcome data. Outcome of interest was diagnostic utility of the classification system for ACS or myocardial infarction (MI) at index presentation and major adverse cardiac

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events (MACE) within 7 and 30 days. MACE included death, cardiac arrest, revascularization, cardiogenic shock, arrhythmia and prevalent (cause of presentation) and incident (occurring within the follow-up period) MI. Analysis was by descriptive and receiver–operator curve analyses. Results: Seven hundred and sixty-eight patients were studied; 109 had MI (14.2%, 95% confidence interval [CI] 11.9–16.8%). There were 88 MACE at 7 days (13.5%, 95% CI 11.1–16.4%) and 93 MACE at 30 days (14.4%%, 95% CI 11.9–17.3%). Diagnostic performance (c-statistic) of the National Heart Foundation risk classification for ACS, MI, 7 and 30 day MACE was 0.74 for each (95% CI 0.71–0.77). Although sensitivity of the high-risk classification for MI, 7 and 30 day MACE was high (99–100%), specificity was low (48–50%). Conclusion: The Heart Foundation risk classification shows only fair predictive performance for MI, 7 and 30 day MACE. With specificity of approximately 50%, the recommendation for coronary care admission for all high-risk patients is hard to justify. Guideline 14.1 ACS: Presentation with ACS 16. Knapik P, Rychlik W, Duda D. Relationship between blood, nasopharyngeal and urinary bladder temperature during intravascular cooling for therapeutic hypothermia after cardiac arrest. Resuscitation 2012; 83 (2): 208-12 Therapeutic hypothermia improves survival and neurological outcome in patients successfully resuscitated after cardiac arrest. Accurate temperature control during cooling is essential to prevent cooling-related side effects. Methods: Prospective observational study of 12 patients assessed during therapeutic hypothermia (32–34 °C) achieved by intravascular cooling following cardiac arrest. Simultaneous temperature measurements were taken using a Swan–Ganz catheter (blood temperature BLT), nasopharyngeal probe (nasopharyngeal temperature NPT) and the urinary bladder catheter (urinary bladder temperature UBT). A total of 1728 measurements (144 measurements per patient) were recorded over a 48-h period and analyzed. Blood temperature was considered as the reference measurement. Results: Temperature profiles obtained from BLT, NPT and UBT compared with the use of analysis of variance did not differ significantly. Pearson correlation revealed that the correlation between BLT and NPT as well as BLT and UBT was statistically significant (r = 0.96, p < 0.001 and r = 0.95, p < 0.001, respectively). Bland–Altman analysis proved that the agreement between all measurements was satisfactory and the differences were not clinically important. Conclusions: In 12 post-cardiac arrest patients undergoing intravascular cooling, both nasopharyngeal and urinary bladder temperature measurements were similar to blood temperatures measured using a pulmonary artery catheter. Guideline 11.8 Therapeutic Hypothermia after Cardiac Arrest 17. Lin L-Y, Lo M-T, Chiang W-C, Lin C, et al. A new way to analyze resuscitation quality by reviewing automatic external defibrillator data. Resuscitation 2012; 83 (2): 171-6 Aims: High quality cardiopulmonary resuscitation (CPR) plays an important role in survival of out-of-hospital cardiac arrests (OHCAs). We have developed an algorithm to automatically identify the quality of chest compressions from data retrieved from automatic external defibrillators (AEDs). Methods; Electrocardiographic (ECG) signals retrieved from AEDs were analyzed by a newly developed algorithm to identify fluctuations in CPR. The algorithm contained three steps. First, it decomposed the AED signals into several intrinsic mode fluctuations (IMFs) by empirical mode decomposition (EMD). Second, it identified the dominant IMFs that carried the chest compression signals and weighted the IMFs to both enhance the chest compression oscillations and filter the noise. Third, it calculated the autocorrelation function (ACF) of the reconstructed signals and tested their periodicity. Using this algorithm, several CPR quality indicators were automatically calculated minute-by-minute and compared with those derived by audio and visual review of AED data by experienced physicians. Results: A total of 77 (29 women,




48 men) OHCA patients were enrolled, and 351 one-min segments were analyzed. The results showed that the CPR quality parameters calculated from the algorithm were highly correlated with those from the manual review (all P < 0.001). The limits of agreement by Bland–Altman analysis were acceptable for chest compression number, total flow time, and no flow time, but not for CPR rate. We also demonstrated that only 41.8 ± 29.8% of time was spent in chest compressions and only 7.5 ± 16.8% was spent in adequate chest compressions. Conclusion: Our results demonstrated that several indicators of CPR quality can be precisely and automatically determined by analyzing the ECG signals from AEDs using EMD and autocorrelograms. Guideline 7 External Automated Defibrillation in Basic Life Support

18. Lowthian J, Curtis A, Jolley D, Stoelwinder J, McNeill J, Cameron P. Demand at the emergency department front door: 10-year trends in presentations. Med J Aust 2012; 196 (2): 128-32 Objectives: To measure the increase in volume and age-specific rates of presentations to public hospital emergency departments (EDs), as well as any changes in ED length of stay (LOS); and to describe trends in ED utilisation. Design, patients and setting: Population-based retrospective analysis of Department of Health public hospital ED data for metropolitan Melbourne for 1999–00 to 2008–09. Main outcome measures: Presentation numbers; presentation rates per 1000 person-years; ED LOS. Results: ED presentations increased from 550 662 in 1999–00 to 853 940 in 2008–09. This corresponded to a 32% rise in rate of presentation (95% CI, 29%–35%), an average annual increase of 3.6% (95% CI, 3.4%–3.8%) after adjustment for population changes. Almost 40% of all patients remained in the ED for ≥ 4 hours in 2008–09, with LOS increasing over time for patients who were more acutely unwell. The likelihood of presentation rose with increasing age, with people aged ≥ 85 years being 3.9 times as likely to present as those aged 35–59 years (95% CI, 3.8–4.0). The volume of older people presenting more than doubled over the decade. They were more likely to arrive by emergency ambulance and were more acutely unwell than 35–59 year olds, with 75% having an LOS ≥ 4 hours and 61% requiring admission in 2008–09. Conclusion: The rise in presentation numbers and presentation rates per 1000 person-years over 10 years was beyond that expected from demographic changes. Current models of emergency and primary care are failing to meet community needs at times of acute illness. Given these trends, the proposed 4-hour targets in 2012 may be unachievable unless there is significant redesign of the whole system. 19. Lundbye JB, Rai M, Ramu B, Hosseini-Khalili A, et al. Therapeutic hypothermia is associated with improved neurologic outcome and survival in cardiac arrest survivors of non-shockable rhythms. Resuscitation 2012; 83 (2): 202-7 Therapeutic hypothermia improves neurologic outcomes in patients resuscitated from cardiac arrest due to ventricular fibrillation. However, its role in patients with cardiac arrest due to non-shockable rhythms (pulseless electrical activity (PEA) and asystole) is unclear. We hypothesized that therapeutic hypothermia favorably impacts neurologic outcome and survival in patients resuscitated from cardiac arrest due to non-shockable rhythms. Methods: Retrospectively collected data on consecutive adult patients admitted to Hartford Hospital from 1/1/2004 to 11/1/2010 who survived a cardiac arrest due to PEA or asystole were analyzed. Patients who underwent therapeutic hypothermia (1/1/2007–11/1/2010) formed the hypothermia group while patients admitted prior to the institution of therapeutic hypothermia (1/1/2004–1/1/2007) at Hartford Hospital formed the control group. The primary end-point was measured using the Pittsburgh cerebral performance category (CPC) scale and patients were assessed for a good (CPC 1 and 2) or poor (CPC 3–5) neurological outcome prior to discharge from hospital. A

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secondary end-point was measured as survival at discharge from hospital. Results: Of 100 post-cardiac arrest patients included in the study, 15/52 (29%) patients in the hypothermia group had a good neurologic outcome as compared to 5/43 (10%) patients in the control group (P = 0.021). On multivariate analysis, the odds ratio for good neurologic outcome and survival at discharge from the hospital with therapeutic hypothermia as compared to control were 4.35 (95% CI 1.10–17.24, P = 0.04) and 5.65 (CI 1.66–19.23, P = 0.006) respectively. Conclusion: Therapeutic hypothermia is associated with favorable neurologic outcome and survival in patients resuscitated after cardiac arrest due to non-shockable rhythms. Guideline 11.8 Therapeutic Hypothermia after Cardiac Arrest 20. Nagao T, Kinoshita K, Sakurai A, Yamaguchi J, et al. Effects of Bag-mask versus Advanced Airway Ventilation for Patients Undergoing Prolonged Cardiopulmonary Resuscitation in Pre-hospital Setting. J Emerg Med 2012; 42 (2): 162-70 There is no evidence that the advanced airway ventilation (AAV) method improves patient outcome in the pre-hospital cardiac arrest setting. OBJECTIVE: The aim of this study was to estimate the effectiveness of AAV vs. bag-mask ventilation (BMV) for cardiopulmonary arrest (CPA) patients, when administered by a licensed emergency medical technician in the pre-hospital setting. METHODS: The study used the database of patients who suffered out-of-hospital cardiogenic CPA from 2006 to 2007 in our hospital. Patient records were searched for the method of pre-hospital airway management (BMV or AAV) and the patient's outcomes were compared between groups. The primary endpoint was a favorable neurological outcome; the secondary endpoints were rate of return of spontaneous circulation (ROSC) and rate of admission to the intensive care unit (ICU). RESULTS: A total of 355 CPA patients (156 BMV and 199 AAV) were retrospectively enrolled. There was no significant difference in demographics between the two groups. The transportation time exceeded 30 min in both groups. The overall ROSC rate and ICU admission rate were significantly higher in the AAV group (p = 0.0352 and p = 0.0089, respectively). The data showed that AAV (odds ratio 1.960; 95% confidence interval 1.015-3.785) resulted in a higher overall ROSC rate than BMV, but there were no significant differences in either the rate of pre-hospital ROSC or in favorable neurological outcome. CONCLUSION: AAV may yield advantages over BMV in the overall rate of ROSC in CPA patients, but both approaches for airway management in this study resulted in a comparably favorable neurological outcome. Earlier ROSC would be required for improved overall outcome. Guideline 11.6 Equipment and Techniques in Adult Advanced Life Support

21. Niles DE, Nishisaki A, Sutton RM, Nysaether J, et al. Comparison of relative and actual chest compression depths during cardiac arrest in children, adolescents, and young adults. Resuscitation 2012; 83 (3): 320-6 AIM: Cardiopulmonary resuscitation (CPR) guidelines recommend specific chest compression (CC) target depths for children. We quantitatively describe relative anterior-posterior diameter (APD) depth, actual depth, and force of CCs during real CPR events in children. METHODS: CC depth and force were recorded during real CPR events in children ≥ 8 years using FDA-approved CC sensor. Patient chest APD was measured at conclusion of each CPR event. CC data was stratified and analyzed according to age (pre-puberty, 8-14 years; post-puberty, 15+ years). Relative (% APD) and actual CC depth, corrected for mattress deflection, were assessed and compared with American Heart Association (AHA) 2005 and 2010 pediatric CPR guidelines. RESULTS: 35 events in 32 subjects included 16,158 CCs for data analysis: 16 pre-puberty (CCs=7484, age 11.9+/-2 years, APD 164.6+/-25.1 mm); 19 post-puberty (CCs=8674, age 18.0+/-2.7 years, APD 196.5+/-30.4 mm). After correction for mattress deflection, 92% of CC delivered to pre-puberty were <1/3 relative APD and 60% of CC were < 38 mm actual depth. Mean




actual CC depth (36.2+/-9.6 mm vs. 36.8+/-9.9 mm, p=0.64), mean relative APD (22.5%+/-7.0% vs. 19.5+/-6.7%, p=0.13), and mean CC force (30.7+/-7.6 kg vs. 33.6+/-9.4 kg, p=0.07) were not significantly less in pre-puberty vs. post-puberty. CONCLUSIONS: During in-hospital cardiac arrest of children ≥ 8 years, CCs delivered by resuscitation teams were frequently <1/3 relative APD and < 38 mm actual depth after mattress deflection correction, below pediatric and adult target guidelines. Mean CC actual depth and force were not significantly different in pre-puberty and post-puberty. Additional investigation to determine depth of CCs to optimize hemodynamics and outcomes is needed to inform future CPR guidelines. Guideline 12.2 Advanced Life Support for Infants and Children, Diagnosis and Initial Management

22. Ohta K, Nishi T, Tanaka Y, Takei Y, Enami M, Inaba H. Primary respiratory arrest recognised by emergency medical technicians and followed by cardiac arrest in Japan: Identification of a subgroup of EMT-witnessed cardiac arrests with an extremely poor outcome. Resuscitation 2012; Online first (February 6) Some unconscious patients are found to be in primary respiratory arrest (PRA) by emergency medical technicians (EMTs). In contrast to citizens, EMTs manage PRA with artificial ventilation but not with cardiopulmonary resuscitation (CPR). This study aimed to investigate the characteristics and outcomes of PRA prior to EMT arrival and compare these data with those of a PRA-related group: patients with out-of-hospital cardiac arrests (OHCAs). Methods: Baseline data were prospectively collected by fire departments for their adult (16 years or older) OHCA and PRA patients from April 2003 through March 2010. We extracted those who had PRA prior to EMT arrival. The EMT- and bystander-witnessed OHCA patients who underwent CPR were also extracted as control groups. Results: There were 178 cases of PRA prior to EMT arrival. The majority (164/178) of these individuals were in a deep coma and met the criteria for the initiation of bystander CPR. Approximately 61% (108/178) of these PRAs were followed by cardiac arrests, which were classified as EMT-witnessed OHCAs by the Utstein template. The EMTs manually ventilated the patients until the cardiac arrest occurred. The 1-Y survival of this subgroup was the lowest of the PRA and PRA-related OHCA subgroups and was significantly lower than that of bystander-witnessed OHCAs with bystander CPR, when trauma and terminal illness cases were excluded (adjusted odds ratio = 3.888 (1.103–24.827)). Conclusions: We identified a subgroup of PRAs with unexpectedly poor outcomes. The BLS guidelines for healthcare providers including EMTs should be re-evaluated by a large prospective study. 23. Osorio J, Dosdall DJ, Tabereaux PB, Robichaux RP, Jr. et al. Effect of chest compressions on ventricular activation. Am J Cardiol 2012; 109 (5): 670-4 External mechanical forces can cause ventricular capture and fibrillation (i.e., commotio cordis). In animals, we showed that chest compressions (CCs) can also cause the phenomenon. The aim of the present study was to determine whether ventricular capture by CCs occurs in humans. Electronic rhythm strips were analyzed in 31 cases of out-of-hospital cardiac arrest. The timing of the CCs was identified from the changes in thoracic impedance between the defibrillator pads. Ventricular capture was defined as QRS complexes of similar morphology occurring intermittently but synchronized with the CC artifact and impedance waveform. Only intermittent ventricular capture was identified to avoid misclassifying constant motion artifacts or intrinsic rhythm as ventricular capture. Of the 29 patients who received CCs for >=1 minute, minimal or stable motion artifact was present in 24. Intermittent ventricular capture was found in 7 of the 24 patients. In the patients with ventricular capture, the number of ventricular activations (from ventricular capture and native beats) was greater during the CCs than when the CCs was not being performed (18 +/- 8.9 vs 9.7 +/- 4.0 activations in 15 seconds, p = 0.01). However, in patients without ventricular capture, they were

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similar (6.8 +/- 8.2 vs 7.2 +/- 8.8 activations in 15 seconds, p = 0.47). Refibrillation occurred in 22 patients; it began during the CCs in 16 and closely following their initiation in 3. In conclusion, CCs during cardiopulmonary resuscitation can electrically stimulate the heart. Additional studies evaluating the effect of ventricular capture on cardiopulmonary resuscitation outcomes, its relation to refibrillation, and methods to prevent or time ventricular capture by CCs are warranted. Guideline 6 Compressions 24. Pappone MD, Vicedomini G, Manguso F, Baldi M, et al. Risk of Malignant Arrhythmias in Initially Symptomatic Patients With Wolff-Parkinson-White Syndrome: Results of a Prospective Long-Term Electrophysiological Follow-Up Study. Circulation 2012; 125 (5): 661-8 The available amount of detailed long-term data in patients with Wolff-Parkinson-White syndrome is limited, and no prospective electrophysiological studies looking at predictors of malignant arrhythmia are available. Methods and Results-: Among 8575 symptomatic Wolff-Parkinson-White patients with atrio-ventricular reentrant tachycardia referred for electrophysiological test, 369 (mean age, 23+/-12.5 years) declined catheter ablation and were followed up. The primary end point of the study was to evaluate over a 5-year follow-up the predictors and characteristics of patients who develop malignant arrhythmias. After a mean follow-up of 42.1+/-10 months, malignant arrhythmias developed in 29 patients (mean age, 13.9+/-5.6 years; 26 male), resulting in presyncope/syncope (25 patients), hemodynamic collapse (3 patients), or cardiac arrest caused by ventricular fibrillation (1 patient). Of the remaining 340 patients, 168 (mean age, 34.2+/-9.0 years) remained asymptomatic up to 5 years, and 172 (mean age, 13.6+/-5.1 years) had benign recurrence, including sustained atrio-ventricular reentrant tachycardia (132 patients) or atrial fibrillation (40 patients). Compared with the group with no malignant arrhythmias, the group with malignant arrhythmias showed shorter accessory-pathway effective refractory period (P<0.001) and more often exhibited multiple accessory pathways (P<0.001), and atrioventricular reentrant tachycardia triggering sustained pre-excited atrial fibrillation was more frequently inducible (P<0.001). Multivariable analysis demonstrated that short accessory-pathway effective refractory period (P<0.001) and atrioventricular reentrant tachycardia triggering sustained pre-excited atrial fibrillation (P<0.001) were independent predictors of malignant arrhythmias. Conclusions-: Symptomatic patients with Wolff-Parkinson-White syndrome generally have a good outcome, and predictors of malignant arrhythmias are similar to those reported for asymptomatic patients with ventricular pre-excitation. Guideline 11.9 Managing Acute Dysrhythmias 25. Ro YS, Shin SD, Song KJ, Park CB, et al. A comparison of outcomes of out-of-hospital cardiac arrest with non-cardiac etiology between emergency departments with low- and high-resuscitation case volume. Resuscitation 2012; Online first (February 22) It is unclear whether outcome after out-of-hospital cardiac arrest (OHCA) of non-cardiac etiology (NCE) is associated with the volume of patients with OHCA received annually at the emergency department (ED) where they receive treatment. This study evaluated whether the volume of patients treated is associated with better outcomes for non-cardiac OHCA patients. Methods: This study was performed in an emergency medical service (EMS) system with a single-tiered basic-to-intermediate service level and approximately 410 destination hospitals for eligible OHCA cases. A nationwide OHCA database (2006–2008), constructed from EMS run sheets, and a hospital medical record review were used. OHCA was defined as pulseless and unresponsive in the field. Included in the study were cases treated with OHCA whose etiology was non-cardiac. Excluded were cases with unknown hospital outcome. The cutoff number for a high volume (HV) versus a low volume (LV) of

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cardiopulmonary resuscitation (CPR) cases was calculated using a threshold model. The primary end points were survival to admission and survival to discharge. The adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) for the endpoints were calculated, adjusting for potential predictors. Results: There were 10,425 eligible patients (trauma 5735; drowning 98; poisoning 684; asphyxia 1413; and hanging 1605). The survival-to-admission and the survival-to-discharge rates of the study participants were 9.6% and 2.4%, respectively. The cutoff number for case volume was 38 per year. The rates of survival to admission and survival to discharge were significantly higher in the HV (18.6% and 5.1%, respectively) group when compared to the LV group (5.9% and 1.3%, respectively). For the treated, non-cardiac OHCA patients, the adjusted ORs in the HV group compared to the LV group were 2.16 for survival to admission (95% CI: 1.84–2.55) and 2.58 for survival to discharge (95% CI: 1.90–3.52). The survival-to-discharge rate was significantly higher in the HV group than in the LV group for each cause: trauma 2.1% vs. 0.6%, drowning 6.8% vs. 1.9%, poisoning 8.6% vs. 1.7%, asphyxia 13.5% vs. 3.8%, and hanging 5.2% vs. 1.3%, respectively. Conclusion: This national cohort study suggests that greater survival to admission as well as discharge for patients with OHCA of NCE is associated with greater annual volume of patients with OHCA treated at that hospital. Guideline 11.7 Post-Resuscitation Therapy in Adult Advanced Life Support 26. Sakles JC and Kalin L. The Effect of Stylet Choice on the Success Rate of Intubation Using the GlideScope Video Laryngoscope in the Emergency Department. Acad Emerg Med 2012; 19 (2): 235-8 The objective was to determine whether the using the GlideRite rigid stylet (GRS) compared with a standard malleable stylet (SMS) affects the success rate of intubation using the GlideScope in emergency intubations. Methods: This was a retrospective analysis of prospectively collected continuous quality improvement (CQI) data based on intubations performed in an academic emergency department (ED) over a 4-year period. Following each intubation the operator completed a data form regarding multiple aspects of the intubation, including the device used, type of stylet used, procedural complications, outcome of the intubation, difficult airway predictors (DAPs), and the operator’s postgraduate year (PGY). Intubation was considered successful if the GlideScope was used as the initial device and resulted in successful intubation of the trachea. Results: Over the 4-year study period, the GlideScope video laryngoscope (GVL) was used for 473 intubations. Of these, 322 (68%) used the GRS, while 151 (32%) used the SMS. When the GRS was used, operators were ultimately successful in 93.5% of cases (301 of 322), whereas when the SMS was used, operators were successful in 78.1% of cases (118 of 151; p < 0.0001). The first-attempt success rate for the GRS group was 82.9% (267 of 322) and for the SMS group was 67.5% (102 of 151; p < 0.001). The mean (± standard deviation [SD]) complication rate was 0.25 (±0.5) in the GRS group and was 0.47 (±0.7) in the SMS group (p = 0.0003). In the GRS group, 18% of patients (58 of 322) had oxygen desaturation, while in the SMS group, 31% of patients (46 of 151) had oxygen desaturation (p = 0.003). The mean number of DAPs was 2.0 (±1.5) in the GRS group and 2.0 (±1.5) in the SMS group (p = 0.65). The mean (±SD) PGY of the operator was 2.2 (±0.8) years in the GRS group and 2.2 (±0.8) years in the SMS group (p = 0.79). Conclusions: Both first-attempt and ultimate success rates were higher with GlideScope intubations in the ED when the rigid stylet was used compared to the malleable stylet. The number of complications and, in particular, the incidence of oxygen desaturation were lower in the GRS group than in the SMS group. The two stylet groups were similar regarding difficulty of the airway and experience level of the operator. Guideline 11.6 Equipment and Techniques in Adult Advanced Life Support 27. Schilleman K, Siew ML, Lopriore E, Morley CJ, Walther FJ and te Pas AB. Auditing resuscitation of preterm infants at birth by




recording video and physiological parameters. Resuscitation 2012; Online first (February 6) Objective: To evaluate compliance with neonatal resuscitation guidelines during resuscitation of preterm infants by video recording of delivery room management and monitoring physiologic parameters. Methods: The delivery room management of preterm infants at birth was recorded by an independent researcher. Physiological parameters (airway pressures, gas flow, tidal volume, heart rate and oxygen saturation) were measured, use of supplemental oxygen was noted and a video of the resuscitation was recorded. All signals were digitised and recorded using specially designed software. The delivery room management was then evaluated and compared with the local resuscitation guidelines. Results: Thirty-four infants were included with a mean (SD) gestational age of 30.6 (3.2) weeks and birth weight of 1292 (570) g. Time from birth to initial evaluation was longer than recommended (65 (15) s). Respiratory support was started at 70 (23) s. In 7/34 infants (21%), interventions were performed according to guidelines. In 25/34 infants (74%), one or more respiratory interventions were not performed according to guidelines. In 10/34 infants (29%), one or more non-respiratory interventions (mainly related to the prevention of heat loss) were not performed according to guidelines. The presence and adequacy of spontaneous breathing was difficult to judge clinically. In almost all occasions (96%) the information from the respiratory function monitor was not used. Conclusions: Neonatal caregivers often deviate from resuscitation guidelines. Respiratory function monitoring parameters were often not used during resuscitation. A difficult part of neonatal resuscitation is subjectively assessing spontaneous breathing. Section 13: Neonatal guidelines 28. Shanmugasundaram M, Valles A, Kellum MJ, Ewy GA, Indik JH. Analysis of amplitude spectral area and slope to predict defibrillation in out of hospital cardiac arrest due to ventricular fibrillation (VF) according to VF type: Recurrent versus shock-resistant. Resuscitation 2012; Online first (February 18) In out-of-hospital cardiac arrest (OHCA) due to ventricular fibrillation (VF), VF may recur during resuscitation (recurrent VF) or fail to defibrillate (shock-resistant VF). While retrospective studies have suggested that amplitude spectral area (AMSA) and slope predict defibrillation, it is unknown whether the predictive power is influenced by VF type. We hypothesized that in witnessed OHCA with initial rhythm of VF that the utility for AMSA and slope to predict defibrillation would differ between shock-resistant and recurrent VF. Methods: AMSA and slope were measured immediately prior to each shock. For second or later shocks, VF was classified as recurrent or shock-resistant. Cardiac arrest was classified according to whether the majority of shocks were for recurrent VF or shock-resistant VF. Results: 44 patients received 98 shocks for recurrent VF and 96 shocks for shock-resistant VF; 24 patients achieved ROSC in the field. AMSA and slope were higher in recurrent VF compared to shock-resistant VF (AMSA: 28.8 ± 13.1 vs 15.2 ± 8.6 mV Hz, P < 0.001, and slope: 2.9 ± 1.4 vs 1.4 ± 1.0 mV s−1, P = 0.001). Recurrent VF was more likely to defibrillate than shock-resistant VF (P < 0.001). AMSA and slope predicted defibrillation in shock-resistant VF (P < 0.001 for both AMSA and slope) but not in recurrent VF. Recurrent VF predominated in 79% of patients that achieved ROSC compared to 55% that did not (P = 0.10). Conclusions: In witnessed OHCA with VF as initial rhythm, recurrent VF is associated with higher values of AMSA and slope and is likely to re-defibrillate. However, when VF is shock-resistant, AMSA and slope are highly predictive of defibrillation. Guideline 11.4 Electrical Therapy for Adult Advanced Life Support 29. Shin SD, Ahn KO, Song KJ, Park CB, Lee EJ. Out-of-hospital airway management and cardiac arrest outcomes: A propensity score matched analysis. Resuscitation 2012; 83 (3): 313-9

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It is unclear whether advanced airway management during ambulance transport is associated with improved out-of-hospital cardiac arrest (OHCA) outcomes compared with bag-valve mask ventilation (BVM). This study aimed to determine whether EMT-intermediate ETI or LMA is associated with improved OHCA outcomes in Korea. METHODS: We used a Korean national OHCA cohort database composed of hospital and ambulance data. We included all EMS-treated by level 1 EMTs (EMT-intermediate level) and OHCA with presumed cardiac etiology for the period January 2006-December 2008. We excluded cases not receiving continued resuscitation in the emergency department (ED), treated by level 2 EMT, as well as those without available hospital outcome data. The primary exposure was airway management technique during ambulance transport (endotracheal tube (ETI), laryngeal mask airway (LMA) or bag-valve-mask ventilation with an oropharyngeal airway). The primary outcomes were survival to admission and survival to hospital discharge. We compared outcomes between each airway management group using multivariable logistic regression, adjusting for sex, age, witnessed, prehospital defibrillation, bystander cardiopulmonary resuscitation (CPR), call to ambulance arrival time to the scene, call to ambulance arrival time to ED, initial ECG, metropolitan (defined as population>1 million), and level of ED (higher versus lower level). We repeated the analysis using propensity-score matched subsets. RESULTS: Of 54,496 patients with OHCA, we included 5278 (9.7%). Overall survival to admission and to discharge was 20.2% and 6.9%, respectively. ETI and LMA were performed in 250 (4.7%) and 391 (7.4%), respectively. In the full multivariable models using total patients, adjusted survival to admission and discharge were similar for ETI and BVM: OR 0.91 (0.66-1.27) and 1.00 (0.60-1.66), respectively. Adjusted survival to admission and discharge were significantly lower in LMA than BVM: OR 0.72 (0.54-0.95) and 0.52 (0.32-0.85), respectively. In the full multivariable models using propensity matched samples, adjusted survival to admission and discharge were similar for ETI and BVM; OR 1.32 (0.81-2.16) and 1.44 (0.66-3.15), respectively. Adjusted survival to admission was similar for LMA and BVM: OR 0.72 (0.50-1.02). However, survival to discharge was significantly lower for LMA than BVM: OR 0.45 (0.25-0.82). CONCLUSIONS: In Korea, EMT-I placed LMA during ambulance transport was associated with worsened OHCA survival to discharge than BVM. Outcomes were similar between EMT-I endotracheal intubation and bag-valve-mask ventilation. Guideline 11.6 Equipment and Techniques in Adult Advanced Life Support

30. Smolina K, Wright FL, Rayner M, Goldacre MJ. Determinants of the decline in mortality from acute myocardial infarction in England between 2002 and 2010: linked national database study. BMJ 2012; 344 (d8059) Objective: To report trends in event and case fatality rates for acute myocardial infarction and examine the relative contributions of changes in these rates to changes in total mortality from acute myocardial infarction by sex, age, and geographical region between 2002 and 2010. Design: Population based study using person linked routine hospital and mortality data. Setting: England. Participants: 840 175 people of all ages who were admitted to hospital for acute myocardial infarction or died suddenly from acute myocardial infarction. Main outcome measures: Acute myocardial infarction event, 30 day case fatality, and total mortality rates. Results: From 2002 to 2010 in England, the age standardised total mortality rate fell by about half, whereas the age standardised event and case fatality rates both declined by about one third. In men, the acute myocardial infarction event, case fatality, and total mortality rates declined at an average annual rate of, respectively, 4.8% (95% confidence interval 3.0% to 6.5%), 3.6% (3.4% to 3.7%), and 8.6% (5.4% to 11.6%). In women, the corresponding figures were 4.5% (1.7% to 7.1%), 4.2% (4.0% to 4.3%), and 9.1% (4.5% to 13.6%). Overall, the relative contributions of the reductions in event and case fatality rates to the decline in acute myocardial infarction mortality rate were, respectively, 57% and 43% in men and 52% and 48% in women; however, the relative contributions differed by age, sex, and geographical region. Conclusions; Just over half of the decline in deaths from acute myocardial



infarction during the 2000s in England can be attributed to a decline in event rate and just less than half to improved survival at 30 days. Both prevention of acute myocardial infarction and acute medical treatment have contributed to the decline in deaths from acute myocardial infarction over the past decade. 31. Storm C, Nee J, Roser M, Jarres A and Hasper D. Mild hypothermia treatment in patients resuscitated from non-shockable cardiac arrest. Emerg Med J 2012; 29 (2): 100-3 Objective: Therapeutic hypothermia has proved effective in improving outcome in patients after cardiac arrest due to ventricular fibrillation (VF). The benefit in patients with non-VF cardiac arrest is still not defined. Methods: This prospective observational study was conducted in a university hospital setting with historical controls. Between 2002 and 2010 387 consecutive patients have been admitted to the intensive care unit (ICU) after cardiac arrest (control n=186; hypothermia n=201). Of those, in 175 patients the initial rhythm was identified as non-shockable (asystole, pulseless electrical activity) rhythm (control n=88; hypothermia n=87). Neurological outcome was assessed at ICU discharge according to the Pittsburgh cerebral performance category (CPC). A follow-up was completed for all patients after 90 days, a Kaplan-Meier analysis and Cox regression was performed. Results: Hypothermia treatment was not associated with significantly improved neurological outcome in patients resuscitated from non-VF cardiac arrest (CPC 1‚ 2: hypothermia 27.59% vs control 18.20%, p=0.175). 90-Day Kaplan-Meier analysis revealed no significant benefit for the hypothermia group (log rank test p=0.82), and Cox regression showed no statistically significant improvement. Conclusions: In this cohort patients undergoing hypothermia treatment after non-shockable cardiac arrest do not benefit significantly concerning neurological outcome. Hypothermia treatment needs to be evaluated in a large multicentre trial of cardiac arrest patients found initially to be in non-shockable rhythms to clarify whether cooling may also be beneficial for other rhythms than VF. Guideline 11.8 Therapeutic Hypothermia after Cardiac Arrest 32. Strote JA, Maynard C, Olsufka M, Nichol G, et al. Comparison of Role of Early (Less Than Six Hours) to Later (More Than Six Hours) or No Cardiac Catheterization After Resuscitation From Out-of-Hospital Cardiac Arrest. Am J Cardiol 2012; 109 (4): 451-4 Despite reports of patients with resuscitated sudden cardiac arrest (rSCA) receiving acute cardiac catheterization, the efficacy of this strategy is largely unknown. We hypothesized that acute cardiac catheterization of patients with rSCA would improve survival to hospital discharge. A retrospective cohort of 240 patients with out-of-hospital rSCA caused by ventricular tachycardia or fibrillation was identified from 11 institutions in Seattle, Washington from 1999 through 2002. Patients were grouped into those receiving acute catheterization within 6 hours (<=6-hour group, n = 61) and those with deferred catheterization at >6 hours or no catheterization during the index hospitalization (>6-hour group, n = 179). Attention was directed to survival to hospital discharge, neurologic status, extent of coronary artery disease, presenting electrocardiographic findings, and symptoms before arrest. Propensity-score methods were used to adjust for the likelihood of receiving acute catheterization. Survival was greater in patients who underwent acute catheterization (72% in the <=6-hour group vs 49% in the >6-hour group, p = 0.001). Percutaneous coronary intervention was performed in 38 of 61 patients (62%) in the <=6-hour group and 13 of 170 patients (7%) in the >6-hour group (p <0.0001). Neurologic status was similar in the 2 groups. A significantly larger percentage of patients in the acute catheterization group had symptoms before cardiac arrest and had ST-segment elevation on electrocardiogram after resuscitation. Age, bystander cardiopulmonary resuscitation, daytime presentation, history of percutaneous coronary intervention or stroke, and acute ST-segment elevation were positively associated with receiving cardiac catheterization. In conclusion, in this series of patients who sustained out-of-hospital



cardiac arrest, acute catheterization (<6 hours of presentation) was associated with improved survival. Guideline 11.7 Post-Resuscitation Therapy in Adult Advanced Life Support 33. Verbeek PR, Ryan D, Turner L, Craig AM. Serial Prehospital 12-Lead Electrocardiograms Increase Identification of ST-segment Elevation Myocardial Infarction. Prehosp Emerg Care 2012; 16 (1): 109-14 Many prehospital protocols require acquisition of a single 12-lead electrocardiogram (ECG) when assessing a patient for ST-segment elevation myocardial infarction (STEMI). However, it is known that ECG evidence of STEMI can evolve over time. Objectives. To determine how often the first and, if necessary, second or third prehospital ECGs identified STEMI, and the time intervals associated with acquiring these ECGs and arrival at the emergency department (ED). Methods. We retrospectively analyzed 325 consecutive prehospital STEMIs identified between June 2008 and May 2009 in a large third-service emergency medical services (EMS) system. If the first ECG did not identify STEMI, protocol required a second ECG just before transport and, if necessary, a third ECG before entering the receiving ED. Paramedics who identified STEMI at any time bypassed participating local EDs, taking patients directly to the percutaneous coronary intervention (PCI) center. Paramedics used computerized ECG interpretation with STEMI diagnosis defined as an “acute MI” report by GE/Marquette 12-SL software in ZOLL E-series defibrillator/cardiac monitors (ZOLL Medical, Chelmsford, MA). We recorded the time of each ECG, and the ordinal number of the diagnostic ECG. We then determined the number of cases and frequency of STEMI diagnosis on the first, second, or third ECG. We also measured the interval between ECGs and the interval from the initial positive ECG to arrival at the ED. Results. STEMI was identified on the first prehospital ECG in 275 cases, on the second ECG in 30 cases, and on the third ECG in 20 cases (cumulative percentages of 84.6%, 93.8%, and 100%, respectively). For STEMIs identified on the second or third ECG, 90% were identified within 25 minutes after the first ECG. The median times from identification of STEMI to arrival at the ED were 17.5 minutes, 11.0 minutes, and 0.7 minutes for STEMIs identified on the first, second, and third ECGs, respectively. Conclusions. A single prehospital ECG would have identified only 84.6% of STEMI patients. This suggests caution using a single prehospital ECG to rule out STEMI. Three serial ECGs acquired over 25 minutes is feasible and may be valuable in maximizing prehospital diagnostic yield, particularly where emergent access to PCI exists. Guideline 14.1 ACS: Presentation with ACS 34. Yost D, Phillips RH, Gonzales L, Lick CJ, et al. Assessment of CPR interruptions from transthoracic impedance during use of the LUCAS mechanical chest compression system. Resuscitation 2012; Online first (February 3) Quality of cardiopulmonary resuscitation (CPR) is a key determinant of outcome following out-of-hospital cardiac arrest (OHCA). Recent evidence shows manual chest compressions are typically too shallow, interruptions are frequent and prolonged, and incomplete release between compressions is common. Mechanical chest compression systems have been developed as adjuncts for CPR but interruption of CPR during their use is not well documented. Aim: Analyze interruptions of CPR during application and use of the LUCAS™ chest compression system. Methods: 54 LUCAS 1 devices operated on compressed air, deployed in 3 major US emergency medical services systems, were used to treat patients with OHCA. Electrocardiogram and transthoracic impedance data from defibrillator/monitors were analyzed to evaluate timing of CPR. Separately, providers estimated their CPR interruption time during application of LUCAS, for comparison to measured application time. Results: In the 32 cases analyzed, compressions were paused a median of 32.5 s (IQR 25–61) to apply LUCAS. Providers’ estimates correlated poorly with measured pause length; pauses were often more than twice as long as estimated. The average device compression rate was




104/min (SD 4) and the average compression fraction (percent of time compressions were occurring) during mechanical CPR was 0.88 (SD 0.09). Conclusions; Interruptions in chest compressions to apply LUCAS can be <20 s but are often much longer, and users do not perceive pause time accurately. Therefore, we recommend better training on application technique, and implementation of systems using impedance data to give users objective feedback on their mechanical chest compression device use.

Reviews ___________________________________________________________________________________________ 35. Atkins DL and Berger S. Improving Outcomes from Out-of-Hospital Cardiac Arrest in Young Children and Adolescents. Ped Cardiol 2012; 33 (3): 474-83 Out-of-hospital cardiac arrest (OHCA) is an unusual but devastating occurrence in a young person. Years of life-lost are substantial and long-term health care costs of survivors can be high. However, there have been noteworthy improvements in cardiopulmonary resuscitation (CPR) standards, out-of hospital care, and postcardiac arrest therapies that have resulted in a several-fold improvement in resuscitation outcomes. Recent interest and research in resuscitation of children has the promise of generating improvements in the outcomes of these patients. Integrated and coordinated care in the out-of-hospital and hospital settings are required. This article will review the epidemiology of OHCA, the 2010 CPR guidelines, and developments in public access defibrillation for children. 36. Azadi N, Niemann JT, Thomas JL. Coronary Imaging and Intervention During Cardiovascular Collapse: Use of the LUCAS Mechanical CPR Device in the Cardiac Catheterization Laboratory. J Inv Cardiol 2012; 24 (2): 79-83 The management of cardiac arrest during coronary angiography and intervention presents substantial challenges. Patients presenting with ST-segment elevation myocardial infarction or following resuscitation from cardiac arrest are at greatest risk and may represent a significant portion of patients in some centers. Timely and effective cardiopulmonary resuscitation (CPR), with manual chest compressions is the primary mode of support though novel circulatory assist devices may have some role. To this end, the use of mechanical compression devices provides multiple patient- and provider-level benefits. This series provides a description of the use of the LUCAS mechanical CPR device and examples of coronary imaging and intervention during mechanical CPR. 37. de Oliveira FC, Feitosa-Filho GS, Ritt LEF. Use of beta-blockers for the treatment of cardiac arrest due to ventricular fibrillation/pulseless ventricular tachycardia: A systematic review. Resuscitation 2012; Online first Advanced Life Support guidelines recommend the use of epinephrine during Cardiopulmonary Resuscitation (CPR), as to increase coronary blood flow and perfusion pressure through its alpha-adrenergic peripheral vasoconstriction, allowing minimal rises in coronary perfusion pressure to make defibrillation possible. Contrasting to these alpha-adrenergic effects, epinephrine's beta-stimulation may have deleterious effects through an increase in myocardial oxygen consumption and a reduction of subendocardial perfusion, leading to postresuscitation cardiac dysfunction. Objective: The present paper consists of a systematic review of the literature regarding the use of beta-blockade in cardiac arrest due to ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT). Methods: Studies were identified through MEDLINE electronic


databases research and were included those regarding the use of beta-blockade during CPR. Results: Beta-blockade has been extensively studied in animal models of CPR. These studies not only suggest that beta-blockade could reduce myocardial oxygen requirements and the number of shocks necessary for defibrillation, but also improve postresuscitation myocardial function, diminish arrhythmia recurrences and prolong survival. A few case reports described successful beta-blockade use in patients, along with two prospective human studies, suggesting that it could be safe and effectively used during cardiac arrest in humans. Conclusion Even though the existing literature points toward a beneficial effect of beta-blockade in patients presenting with cardiac arrest due to VF/pulseless VT, high quality human trials are still lacking to answer this question definitely. Guideline 11.5 Medications in Adult Advanced Life Support 38. Deo R and Albert C. Epidemiology and Genetics of Sudden Cardiac Death. Circulation 2012; 125 (4): 620-37 Sudden cardiac death (SCD) generally refers to an unexpected death from a cardiovascular cause in a person with or without preexisting heart disease. The specificity of this definition varies depending on whether the event was witnessed; however, most studies include cases that are associated with a witnessed collapse, death occurring within 1 hour of an acute change in clinical status, or an unexpected death that occurred within the previous 24 hours. Further, sudden cardiac arrest describes SCD cases with resuscitation records or aborted SCD cases in which the individual survived the cardiac arrest. The incidence of SCD in the United States ranges between 180 000 and 450 000 cases annually. These estimates vary owing to differences in SCD definitions and surveillance methods for case ascertainment. In recent prospective studies using multiple sources in the United States, Netherlands, Ireland, and China, SCD rates range from 50 to 100 per 100 000 in the general population. Despite the need for multiple sources of surveillance to provide a more accurate estimate of SCD incidence, it is clear that the overall burden in the population remains high. Although improvements in primary and secondary prevention have resulted in substantial declines in overall coronary heart disease (CHD) mortality over the past 30 years, SCD rates specifically have declined to a lesser extent. SCD still accounts for >50% of all CHD deaths and 15% to 20% of all deaths. For some segments of the population, rates are not decreasing and may actually be increasing. As a result, SCD prevention represents a major opportunity to further reduce mortality from CHD. Despite major advances in cardiopulmonary resuscitation and postresuscitation care, survival to hospital discharge after cardiac arrest in major metropolitan centers remains poor. Survival to hospital discharge was recently estimated to be only 7.9% among out-of-hospital cardiac arrests that were treated by emergency medical services personnel. In addition, the majority of SCDs occur at home, often where the event is unwitnessed. As a result, automated external defibrillators, which improve resuscitation rates for witnessed arrests, may have limited effectiveness on reducing overall mortality from SCD. Therefore, substantial reductions in SCD incidence will require effective primary preventive interventions. Since the majority of SCDs occur in the general population, an in-depth understanding of the epidemiology of SCD may lead to possible low-risk interventions that could be applied broadly to populations. In addition, recent data emerging related to the genetics of SCD may eventually aid in the identification of high-risk subsets within the general population or provide new molecular targets for intervention. 39. Katz VL. Peri-mortem cesarean delivery: its role in maternal mortality. Sem Perinatol 2012; 36 (1): 68-72 Since Roman times, physicians have been instructed to perform postmortem cesarean deliveries to aid in funeral rites, baptism, and in the very slim chance that a live fetus might still be within the deceased mother's womb. Physicians being called to a dying mother’s bedside disliked this procedure. As births moved to hospitals, and modern obstetrics evolved, the causes of maternal death changed from sepsis, hemorrhage, and dehydration to a greater incidence of sudden cardiac arrest from medication errors or embolism. Thus, the likelihood of delivering a viable



neonate at the time of a mother's death increased. Additionally, as cardiopulmonary resuscitation (CPR) became widespread, physicians realized that during pregnancy, with the term gravid woman lying on her back, chest compressions cannot deliver sufficient cardiac output to accomplish resuscitation. Paradoxically, after a postmortem cesarean delivery is performed, effective CPR was seen to occur. Mothers were revived. Thus, the procedure was renamed the peri-mortem cesarean. Because brain damage begins at 5 minutes of anoxia, the procedure should be initiated at 4 minutes (the 4-minute rule) to deliver the healthiest fetus. If a mother has a resuscitatable cause of death, then her life may be saved as well by a prompt and timely cesarean delivery during CPR. Sadly, too often, we are paralyzed by the horror of the maternal cardiac arrest, and instinctively, we try CPR for too long before turning to the peri-mortem delivery. The quick procedure though may actually improve the situation for the mother, and certainly will save the child. 40. Kim Y-M, Yim H-W, Jeong S-H, Klem ML,Callaway CW. Does therapeutic hypothermia benefit adult cardiac arrest patients presenting with non-shockable initial rhythms?: A systematic review and meta-analysis of randomized and non-randomized studies. Resuscitation 2012; 83 (2): 188-96 The benefit of therapeutic hypothermia (TH) for comatose adult patients with return of spontaneous circulation after cardiac arrest (CA) with non-shockable initial rhythms is uncertain. We evaluated whether TH reduces mortality and improves neurological outcome in comatose adults resuscitated from non-shockable CA. Methods: We searched PubMed, EMBASE, CENTRAL, and BIOSIS through March 2010, to identify studies using TH after non-shockable CA. Randomized and non-randomized studies (RS and NRS) comparing survival or neurological outcome in TH and standard care or normothermia were selected. We corresponded with authors to clarify data missing from published articles. Individual and pooled statistics were calculated as risk ratios (RRs) with 95% confidence interval (CI). Both fixed- and random-effects models were used for both meta-analyses. Findings: Two RS and twelve NRS were included in the meta-analysis and separately analyzed. The pooled RR for 6-month mortality of two RS was 0.85 (95% CI 0.65–1.11). The pooled RR for in-hospital mortality for 10 NRS was 0.84 (95% CI 0.78–0.92) and for poor neurological outcome on discharge was 0.95 (95% CI 0.90–1.01) in random-effects model. In subgroup analysis for the NRS with out-of-hospital CA, the pooled RR for in-hospital mortality was 0.86 (95% CI 0.76–0.99) and for the poor neurological outcome on discharge was 0.96 (95% CI 0.90–1.02). For the prospective NRS, the pooled RR for in-hospital mortality was 0.76 (95% CI 0.65–0.89) and for the poor neurological outcome on discharge was 0.96 (95% CI 0.90–1.02). Most of studies had substantial risks of bias and overall quality of evidence was very low. Interpretation: TH is associated with reduced in-hospital mortality for adults patients resuscitated from non-shockable CA. However, most of the studies had substantial risks of bias and quality of evidence was very low. Further high quality randomized clinical trials would confirm the actual benefit of TH in this population. Guideline 11.8 Therapeutic Hypothermia after Cardiac Arrest 41. Lang ES, Spaite DW, Oliver ZJ, Gotschall CS, et al. A National Model for Developing, Implementing, and Evaluating Evidence-based Guidelines for Prehospital Care. Acad Emerg Med 2012; 19 (2): 201-9 In 2007, the Institute of Medicine’s (IOM’s) Committee on the Future of Emergency Care recommended that a multidisciplinary panel establish a model for developing evidence-based protocols for the treatment of emergency medical systems (EMS) patients. In response, the National EMS Advisory Council (NEMSAC) and the Federal Interagency Committee on EMS (FICEMS) convened a panel of multidisciplinary experts to review current strategies for developing evidence-based guidelines (EBGs) and to propose a model for developing such guidelines for the



prehospital milieu. This paper describes the eight-step model endorsed by FICEMS, NEMSAC, and a panel of EMS and evidence-based medicine experts. According to the model, prehospital EBG development would begin with the input of evidence from various external sources. Potential EBG topics would be suggested following a preliminary evidentiary review; those topics with sufficient extant foundational evidence would be selected for development. Next, the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology would be used to determine a quality-of-evidence rating and a strength of recommendation related to the patient care guidelines. More specific, contextualized patient care protocols would then be generated and disseminated to the EMS community. After educating EMS professionals using targeted teaching materials, the protocols would be implemented in local EMS systems. Finally, effectiveness and uptake would be measured with integrated quality improvement and outcomes monitoring systems. The constituencies and experts involved in the model development process concluded that the use of such transparent, objective, and scientifically rigorous guidelines could significantly increase the quality of EMS care in the future. 42. Lerner EB, Rea T, Bobrow B, Acker J, et al. Emergency Medical Service Dispatch Cardiopulmonary Resuscitation Prearrival Instructions to Improve Survival From Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation 2012; 125 (4): 648-55 Efforts to improve survival from OHCA should be aimed at strengthening each link in the Chain of Survival. When a bystander calls the community emergency response number to request medical aid, the call creates an opportunity to improve both identification of OHCA and provision of bystander CPR. This telephone interaction is the initial interface between citizens at the scene and professional emergency responders and can serve as the catalyst for recognition of cardiac arrest and initiation of bystander CPR through formal interrogation of the caller and “just-in-time” education. Just-in-time education in the form of telephone CPR instructions, referred to as CPR prearrival instructions, can provide callers with step-by-step instructions on how to perform CPR. Unfortunately, prearrival instructions are not available to all callers who access the emergency response number. It is difficult to estimate the exact number of lives that could be saved by offering CPR prearrival instructions, but it has been shown that CPR prearrival instructions can potentially double the proportion of arrest patients who receive bystander CPR and in turn help communities achieve bystander CPR in the majority of arrest patients who collapse before EMS arrival. The survival effectiveness of CPR guided by prearrival instructions appears to approach that of CPR provided by previously trained bystanders. Therefore, based on the estimate that annually nearly 200 000 of the 300 000 OHCAs that occur in the United States do not receive bystander CPR, more comprehensive implementation of CPR prearrival instructions has the potential to save thousands of additional lives each year. This scientific statement reviews the process of providing CPR prearrival instructions, identifies these instructions as integral to the Chain of Survival, and describes the framework for programmatic best practices for providing CPR prearrival instructions. The statement also emphasizes the importance of monitoring dispatcher performance and providing regular feedback. Specifically, this scientific statement makes 4 main recommendations: 1. Callers to community emergency response numbers (eg, 911) should be formally and systematically questioned to determine whether the patient might have had a cardiac arrest. When a potential cardiac arrest patient is identified, CPR prearrival instructions should be immediately


provided to assist bystanders if CPR is not already ongoing. 2. CPR prearrival instructions should be provided in a confident and assertive manner and should include straightforward chest compression–only instructions to achieve early bystander Hands-Only CPR for the adult who suddenly collapses. 3. Individual dispatcher and organizational-level performance can be measured by using a modest set of metrics that can be ascertained through review of the audio dispatch recording. 4. These metrics should be incorporated into an integrated quality assurance program that includes cooperation and collaboration of EMS and hospital stakeholders. The program should provide feedback at the individual and organizational level. 43. Myerburg RJ and Junttila MJ. Sudden Cardiac Death Caused by Coronary Heart Disease. Circulation 2012; 125 (8): 1043-52 An association between the anatomic pathology and pathophysiology of coronary atherosclerosis and sudden cardiac death (SCD) has been long recognized. At the end of the 15th century, Da Vinci described a personally witnessed SCD that he attributed to a “parched and shrunk and withered … artery that feeds the heart” at autopsy, and in 1812, Warren, commenting on the significance of Heberden's description of angina pectoris, reported a patient who died suddenly a short time after presenting with an anginal pattern of chest pain. However, insights into the magnitude and mechanisms of SCD as a consequence of the presence and extent of coronary atherosclerosis, its underlying vascular pathophysiology, the myocardial electrophysiology, and the role of ischemic cardiomyopathy began to unravel only during the past 50 years. Despite a rapidly developing base of knowledge about the tachyarrhythmic manifestations of acute coronary syndromes and chronic ischemic cardiomyopathy, especially during the past 25 years, that resulted from extensive clinical, investigative, and interventional advances, important challenges remain for the prediction and prevention of SCD caused by coronary heart disease (CHD).. 44. Reade MC, Davies SR, Morley PT, Dennett J and Jacobs IC. Review article: Management of cyanide poisoning. Emerg Med Aus 2012; Online first (February 21) Cyanide poisoning is uncommon, but generates interest because of the presumed utility of an antidote immediately available in those areas with a high risk of cyanide exposure. As part of its regular review of guidelines, the Australian Resuscitation Council conducted a systematic review of the human evidence for the use of various proposed cyanide antidotes, and a narrative review of the relevant pharmacological and animal studies. There have been no relevant comparative or placebo-controlled human trials. Nine case series were identified. Treatment with hydroxocobalamin was reported in a total of 361 cases. No serious adverse effects of hydroxocobalamin were reported, and many patients with otherwise presumably fatal poisoning survived. Sodium thiosulphate use was reported in two case series, similarly with no adverse effects. Treatment with a combination of sodium nitrite, amyl nitrite and sodium thiosulphate was reported in 74 patients, with results indistinguishable from those of hydroxocobalamin and sodium thiosulphate. No case series using dicobalt edetate or 4-dimethylaminophenol were identified, but successful use in single cases has been reported. Hydroxocobalamin and sodium thiosulphate differ from alternatives in having negligible adverse effects, and on the basis of current evidence are the antidotes of choice. The indications for the use of an antidote, the requirements for supportive care and a recommended approach for workplaces where there is a risk of cyanide poisoning are presented.


Guideline 9.5.1 Emergency Management of a Victim who has Been Poisoned

45. Susantitaphong P, Alfayez M, Cohen-Bucay A, Balk EM and Jaber BL. Therapeutic hypothermia and prevention of acute kidney injury: A meta-analysis of randomized controlled trials. Resuscitation 2012; 83 (2): 159-67 Therapeutic hypothermia has been shown to reduce neurological morbidity and mortality in the setting of out-of-hospital cardiac arrest and may be beneficial following brain injury and cardiopulmonary bypass. We conducted a systematic review to ascertain the effect of therapeutic hypothermia on development of acute kidney injury (AKI) and mortality. Methods: We searched for randomized controlled trials in MEDLINE through February 2011. We included trials comparing hypothermia to normothermia that reported kidney-related outcomes including, development of AKI, dialysis requirement, changes in serum creatinine, and mortality. We performed Peto fixed-effect and random-effects model meta-analyses, and meta-regressions. Results; Nineteen trials reporting on 2218 patients were included; in the normothermia group, the weighted rate of AKI was 4.2%, dialysis requirement 3.7%, and mortality 10.8%. By meta-analysis, hypothermia was not associated with a lower odds of AKI (odds ratio [OR] 1.01, 95% confidence interval [CI] 0.68, 1.51; P = 0.95) or dialysis requirement (OR 0.81; 95% CI 0.30, 2.19; P = 0.68); however, by meta-regression, a lower target cooling temperature was associated with a lower odds of AKI (P = 0.01). Hypothermia was associated with lower mortality (OR 0.69; 95% CI 0.51, 0.92; P = 0.01). Conclusions; In trials that ascertained kidney endpoints, therapeutic hypothermia prevented neither the development of AKI nor dialysis requirement, but was associated with lower mortality. Different definitions and rates of AKI, differences in mortality rates, and concerns about the optimal target cooling temperature preclude definitive conclusions. Guideline 11.8 Therapeutic Hypothermia after Cardiac Arrest

Animal, manikin & cadaver models ___________________________________________________________________________________________ 46. Field RA, Soar J, Davies RP, Akhtar N and Perkins GD. The impact of chest compression rates on quality of chest compressions - A manikin study. Resuscitation 2012; 83 (3): 360-4 PURPOSE: Chest compressions are often performed at a variable rate during cardiopulmonary resuscitation (CPR). The effect of compression rate on other chest compression quality variables (compression depth, duty-cycle, leaning, performance decay over time) is unknown. This randomised controlled cross-over manikin study examined the effect of different compression rates on the other chest compression quality variables. METHODS: Twenty healthcare professionals performed 2 min of continuous compressions on an instrumented manikin at rates of 80, 100, 120, 140 and 160 min (-1) in a random order. An electronic metronome was used to guide compression rate. Compression data were analysed by repeated measures ANOVA and are presented as mean (SD). Non-parametric data was analysed by Friedman test. RESULTS: At faster compression rates there were significant improvements in the number of compressions delivered (160(2) at 80 min (-1) vs. 312(13) compressions at 160 min (-1), P<0.001); and compression duty-cycle (43(6)% at 80 min(-1) vs. 50(7)% at 160 min(-1), P<0.001). This was at the cost of a significant reduction in compression depth (39.5(10) mm at 80 min (-1) vs. 34.5(11) mm at 160 min(-1), P<0.001); and earlier decay in compression quality (median decay point 120 s at 80 min(-1) vs. 40 s at 160 min (-1), P<0.001). Additionally not all participants achieved the target rate (100% at 80 min (-1) vs. 70% at 160 min (-1)). Rates above 120 min (-1) had the greatest impact on reducing chest compression

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quality. CONCLUSIONS: For Guidelines 2005 trained rescuers, a chest compression rate of 100-120 min(-1) for 2 min is feasible whilst maintaining adequate chest compression quality in terms of depth, duty-cycle, leaning, and decay in compression performance. Further studies are needed to assess the impact of the Guidelines 2010 recommendation for deeper and faster chest compressions. Guideline 6 Compressions 47. Gazmuri RJ, Ayoub IM, Radhakrishnan J, Motl J and Upadhyaya MP. Clinically plausible hyperventilation does not exert adverse hemodynamic effects during CPR but markedly reduces end-tidal PCO2. Resuscitation 2012; 83 (2): 259-64 Aims: Ventilation at high respiratory rates is considered detrimental during CPR because it may increase intrathoracic pressure limiting venous return and forward blood flow generation. We examined whether ventilation at high, yet clinically plausible, tidal volumes could also be detrimental, and further examined effects on end-tidal pCO2 (PETCO2). Methods: Sixteen domestic pigs were randomized to one of four ventilatory patterns representing two levels of respiratory rate (min−1) and two levels of tidal volume (ml/kg); i.e., 10/6, 10/18, 33/6, and 33/18 during chest compression after 8 min of untreated VF. Results: Data (mmHg, mean ± SD) are presented in the order listed above. Ventilation at 33/18 prompted higher airway pressures (p < 0.05) and persistent expiratory airway flow (p < 0.05) before breath delivery demonstrating air trapping. The right atrial pressure during chest decompression showed a statistically insignificant increase with increasing minute-volume (7 ± 4, 10 ± 3, 12 ± 1, and 13 ± 3; p = 0.055); however, neither the coronary perfusion pressure (23 ± 1, 17 ± 6, 18 ± 6, and 21 ± 2; NS) nor the cerebral perfusion pressure (32 ± 3, 23 ± 8, 30 ± 12, and 31 ± 3; NS) was statistically different. Yet, increasing minute-volume reduced the PETCO2 demonstrating a high dependency on tidal volumes delivered at currently recommended respiratory rates. Conclusions: Increasing respiratory rate and tidal volume up to a minute-volume 10-fold higher than currently recommended had no adverse hemodynamic effects during CPR but reduced PETCO2 suggesting that ventilation at controlled rate and volume could enhance the precision with which PETCO2 reflects CPR quality, predicts return of circulation, and serve to guide optimization of resuscitation interventions. Guideline 11.6 Equipment and Techniques in Adult Advanced Life Support (Animal study)

48. Holla M. Value of a rigid collar in addition to head blocks: a proof of principle study. Emerg Med J 2012; 29 (2): 104-7 Background: All trauma patients with a cervical spinal column injury or with a mechanism of injury with the potential to cause cervical spinal injury should be immobilised until a spinal injury is excluded. Immobilisation of the entire patient with a rigid cervical collar, backboard, head blocks with tape or straps is recommended by the Advanced Trauma Life Support guidelines. However there is insufficient evidence to support these guidelines. Objective: To analyse the effects on the range of motion of the addition of a rigid collar to head blocks strapped on a backboard. Method: The active range of motion of the cervical spine was determined by computerised digital dual inclinometry, in 10 healthy volunteers with a rigid collar, head blocks strapped on a padded spine board and a combination of both. Maximal opening of the mouth with all types of immobiliser in place was also measured. Results The addition of a rigid collar to head blocks strapped on a spine board did not result in extra immobilisation of the cervical spine. Opening of the mouth was significantly reduced in patients with a rigid collar. Conclusion: Based on this proof of principle study and other previous evidence of adverse effects of rigid collars, the addition of a rigid collar to head blocks is considered unnecessary and potentially dangerous. Therefore the use of this combination of cervical spine immobilisers must be reconsidered. Guideline 9.1.6 Management of Suspected Spinal Injury



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49. Hong DY, Park SO, Lee KR, Baek KJ, Shin DH. A different rescuer changing strategy between 30:2 cardiopulmonary resuscitation and hands-only cardiopulmonary resuscitation that considers rescuer factors: A randomised cross-over simulation study with a time-dependent analysis. Resuscitation 2012; 83 (3): 353-9 AIM: To compare the time-dependent changes in the quality of chest compressions in 30:2 cardiopulmonary resuscitation (CPR) and hands-only cardiopulmonary resuscitation (HO-CPR) and to evaluate how individual rescuer factors affect the quality of chest compressions over time for both CPR techniques. METHODS: Total 1028 adult hospital and university workers participated in CPR training programs including sessions of 30:2 CPR and HO-CPR. Tests of both CPR methods were performed in a random order using a manikin with Skill-ReporterTM. Data were collected from 863 subjects. The time-dependent changes in chest compressions quality and the effects of individual rescuer factors (age, gender, body mass index (BMI), prior CPR training and experience) were analysed using the general linear model for a repeated-measures procedure. RESULTS: In HO-CPR, the mean proportion of correct compressions depth (MPCD) decreased significantly throughout the time sectors following 20-40 s (74.4-50.4% in 100-120 s) compared to 30:2 CPR (83.4-76.3% in 100-120 s) (p<0.0001). A significant decline of MPCD (MPCD<70%) was initially observed at 40-60 s in HO-CPR, however, this pattern was not observed in 30:2 CPR. Individual rescuer factors minimally affected the time-dependent change in MPCD during 30:2 CPR. For HO-CPR, all rescuer factors except for male or obese/overweight (BMI>=25) were associated with a significant declines of MPCD, and these decline were usually observed from 40 to 60 s. CONCLUSION: Switching rescuers at an interval of 2-min is reasonable for 30:2 CPR. However, for HO-CPR switching rescuers every 1-min may be preferable except when rescuers are male or obese/overweight (BMI≥25). Guideline 6 Compressions 50. Ilper H, Kunz T, Pfleger H, Schalk R, et al. Comparative quality analysis of hands-off time in simulated basic and advanced life support following European Resuscitation Council 2000 and 2005 guidelines. Emerg Med J 2012; 29 (2): 95-9 Aim: To compare hands-off time (HOT) in simulated advanced life support (ALS) following European Resuscitation Council (ERC) 2005 guidelines and ERC 2000 and to provide quantitative data on workflow. Subjects and Methods: Observations with 18 professional paramedics, performing 39 megacodes (mega-code training; MCT) were videotaped during ALS re-certification. Teams were randomly assigned to train according to ERC 2000 or ERC 2005. HOT, hands-off intervals (HOI) and other variables describing interventions and workflow were analysed. Results: In group ERC 2000 17±3 HOI appeared with a mean duration of 17.5±10.8 s (mean ± SD). Overall HOT was 382±47 s, equivalent to a mean hands-off fraction (HOF) of 0.45±0.05. 15±5 ventilation-free intervals (VFI) were observed, with a mean duration of 21±10 s. In contrast after ERC 2005 variables resulted in 18±3 HOI with a mean duration of 10.0±4.0 s (p<0.001 vs ERC 2000), overall HOT 196±33 s (HOF 0.23±0.04; p<0.001), 24±12 VFI with duration of 24±7 s (p<0.05). The first HOI lasted for 60.4±33.1 s in ERC 2000 and 17.6±4.3 s in ERC 2005 (p<0.001). In ERC 2000 6.1±2.6 interruptions for two bag/mask ventilations (BMV) lasted for 5.4±0.8 s, whereas in ERC 2005 9.6±3.1 interruptions for two BMV took 6.5±2.2 s (p<0.001). In both groups HOI were used thoroughly for basic life support/ALS-based interventions. Conclusion: The application of ERC guidelines of 2005 markedly reduced the first HOI and mean duration of HOI at the cost of delayed secure airway management and ECG analysis in this MCT model. Guideline 11.1.1 Cardiopulmonary Resuscitation for Advanced Life Support Providers


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51. Komasawa N, Ueki R, Yamamoto N, Atagi K, et al Comparison of air-Q and Soft Seal laryngeal mask for airway management by novice doctors during infant chest compression: A manikin study. Resuscitation 2012; 83 (3): 365-8 Recent resuscitation guidelines for infant cardiopulmonary resuscitation (CPR) emphasise that rescuers should minimise the interruption of chest compressions. To that end, supraglottic devices such as laryngeal mask airways (LMAs) are suggested as a backup for airway management during infant CPR. We therefore compared the utility of the air-Q LMA (air-Q) with that of the Soft Seal LMA (Soft Seal) for infant CPR in an infant manikin. METHODS: Twenty-four novice doctors in the anaesthesia department performed insertion and ventilation with air-Q and Soft Seal on an infant manikin with or without chest compression. RESULTS: Two doctors failed to insert the Soft Seal without chest compression, while nine failed during chest compression (P<0.05). However, only one doctor failed to insert the air-Q without chest compression, and two doctors failed during chest compression. Insertion time was not significantly increased with chest compression using either device. Insertion time during chest compression was significantly shorter for the air-Q than for the Soft Seal (P<0.05). The visual analogue scale (VAS) was used to evaluate difficulty of use (0 mm (extremely easy) to 100 mm (extremely difficult)). VAS scores did not change significantly by the addition of chest compression with either device; however, VAS scores during chest compression were significantly higher with Soft Seal than with the air-Q device. CONCLUSION: We conclude that novice doctors find the air-Q easier to use than Soft Seal for emergency airway management during chest compression in infants, in an infant manikin. Guideline 13.5 Tracheal Intubation and Ventilation of the Newly Born Infant

52. Kurz MC, Dante SA and Puckett BJ. Estimating the impact of off-balancing forces upon cardiopulmonary resuscitation during ambulance transport. Resuscitation 2012; Feb 1 Survival from out-of-hospital cardiac arrest (OOH-CA) remains poor, especially when patients are transported with CPR in progress. Previous investigations suggest that CPR quality erodes during transport due to the austere environment. We sought to determine how frequently ambulance personnel are exposed to off-balancing forces during transport of OOH-CA patients and to estimate the potential impact on CPR and coronary perfusion pressure (CPP). Methods: An onboard monitoring system was utilized to record acceleration data during the transport of 50 OOH-CA patients. Acceleration vectors were calculated for every second of drive time (speed >0 m/s). A model was constructed to estimate the potential impact of these vectors upon CPR and CPP. These data were then compared to a case-control cohort of 102 matched non-urgent transports. Results: A total of 5.8 h of drive time was analyzed in the cardiac arrest cohort. Mean transport time was 8 min 53 s with a mean drive time of 6 min 58 s. Critical acceleration threshold was exceeded 60% of transport time (202.42 min, mean 4.05 min/transport) yielding a potential hands-off ratio of 0.42 with a CPP < 15 mmHg 62% of drive time. Ambulance speed was inversely related to the magnitude of off-balancing forces. Comparison to 14.1 h of control cohort yielded similar off-balancing forces and relationships despite lower speeds and no “lights and siren” use. Conclusion: Critical acceleration forces occur frequently during transport of OOH-CA patients and may directly effect CPR quality and thereby CPP. These force vectors are stronger and more frequent at slower speeds, comprising the majority of ambulance drive time. Reducing speed or transporting OOH-CA patients without lights and sirens does little to mitigate these forces. 53. Li Y, Ristagno G, Guan J, Barbut D, et al. Preserved heart rate variability during therapeutic hypothermia correlated to 96 hrs neurological outcomes and survival in a pig model of cardiac arrest. Crit Care Med 2012; 40 (2): 580-6 Therapeutic hypothermia initiated with cardiopulmonary resuscitation improves neurologic outcomes and survival after prolonged cardiac arrest.



However, the potential mechanism by which hypothermia improves neurologic outcomes remains unclear. In the current study, we investigated the effect of rapid head cooling on 96-hr neurologic outcomes and survival by heart rate variability analysis in a pig model of prolonged cardiac arrest. DESIGN: Prospective randomized controlled animal study. SETTING: University-affiliated research laboratory. SUBJECTS: Yorkshire-X domestic pigs (Sus scrofa). INTERVENTIONS: A protocol of 10 mins of untreated ventricular fibrillation followed by 5 mins of cardiopulmonary resuscitation in a pig model of cardiac arrest was used in this study. Sixteen male domestic pigs weighing between 39 and 45 kg were randomized into two groups, hypothermia (n = 8) and control (n = 8). For the hypothermia group, intranasal-induced head cooling was initiated with cardiopulmonary resuscitation and persisted for 4 hrs after resuscitation. For the control group, cardiopulmonary resuscitation was started with normothermia. MEASUREMENTS AND MAIN RESULTS: Time and frequency domain heart rate variability was calculated in 5-min sections of electrocardiographic recordings at baseline and 4 hrs after resuscitation. Neurologic outcomes were evaluated every 24 hrs during the 96-hr postresuscitation observation period. No differences in the baseline measurement and resuscitation outcome were observed between the groups. However, the 96-hr cerebral performance categories of the hypothermic group were significantly lower than control (1.0 +/- 0.0 vs. 4.0 +/- 1.9, p = .003). Four hrs after resuscitation, mean RR interval, heart rate variability triangular index, and normalized very-low-frequency power were restored to baseline in the hypothermia group. Square root of the mean squared differences of successive RR intervals and SD of instantaneous RR intervals were significantly improved in the cooled animals compared with controls. A significant correlation between 4-hr heart rate variability and 96-hr cerebral performance category was observed in this study. CONCLUSION: Selective head cooling maintains a certain level of autonomic nervous system function in this pig model of cardiac arrest. The preserved heart rate variability during postresuscitation hypothermia was associated with favorable 96-hr neurologic recovery and survival. Guideline 11.8 Therapeutic Hypothermia after Cardiac Arrest 54. Preece MHW, Hill A, Horswill MS and Watson MO. Supporting the detection of patient deterioration: Observation chart design affects the recognition of abnormal vital signs. Resuscitation 2012; Online first (February 18) Aim: To evaluate the effect of observation chart design on the ability of health professionals and novice chart users to recognise patient deterioration. Methods: Participants were 45 health professionals (doctors and nurses) and 46 novices. Each participant completed 48 trials in which they viewed realistic patient observations recorded on six hospital observation charts of differing design quality. Each chart design was used on eight trials, four times with normal data and four times with abnormal data. On each trial, the participant's task was to identify any abnormal observation or else to indicate that all observations were normal (based on normal physiological ranges given in the instructions). The main outcome measures were participants’ error rates and response times for detecting abnormal observations on each of the six charts. Results: There was a significant effect of chart type on error rates (p < 0.001), but health professionals made the same number of errors as novices (p = 0.43). Chart type also had a significant effect on response times (p < 0.001). Health professionals responded faster overall than novices (p = 0.006); however, a significant interaction between chart type and participant group (p = 0.02) indicated that the health professionals’ advantage was confined to the two most rudimentary charts. No significant differences were found between doctors and nurses on either measure. Conclusions: Our findings suggest that observation chart design has a substantial impact on the decision accuracy and response times of both health professionals and novices in recognising abnormal patient observations. 55. Pryor RR, Seitz JR, Morley J, Suyama J, et al. Estimating Core Temperature with External Devices After Exertional Heat Stress in



Thermal Protective Clothing. Prehosp Emerg Care 2012; 16 (1): 136-41 Background. Temperature measurement is important for emergency medical services (EMS) providers when identifying and treating heat illness or infection. Direct measures of body core temperature (Tc) are often expensive (ingestible capsules) or impractical (rectal probes) in the field. Multiple devices for estimating core temperature (Tc) have been adopted by EMS providers, with little understanding of the agreement between these devices and Tc. Objective. To examine the agreement between the results of five external thermometers and Tc after subjects experienced physical exertion while wearing protective clothing. Methods. Fifty firefighters completed treadmill walking in thermal protective clothing in a hot environment. Measurements of core, temporal, tympanic, forehead, and skin temperatures were obtained during a 20-minute recovery period simulating emergency incident rehabilitation. Results. The mean bias of external thermometers ranged from −1.31° C to −3.28 °C when compared with Tc and exceeded the predetermined clinical cutoff of ± 0.5 °C from Tc. The 95% limits of agreement ranged from 2.75 °C to 5.00 °C. Conclusions. External measuring devices failed to accurately predict Tc in hyperthermic individuals following exertion. Confidence intervals around the bias were too large to allow for reasonable estimation of Tc. EMS providers should exercise caution when using any of these temperature estimation techniques.

Case studies, letters & editorials ___________________________________________________________________________________________ 56. Blakeway E, Jabbour RJ, Baksi J, Peters NS and Touquet R. ECGs: Colour-coding for initial training. Resuscitation 2012; Online first (Feb 2): Sir, We describe the use of the four primary colours: green, yellow, blue, red to define the four distinct electrical windows of the 12-Lead ECG: inferior, lateral, anterior, right to facilitate initial training for reading ECGs. The rhythm strip (usually lead II) is most commonly viewed first after confirmation of the patient details. Additionally, when recording an ECG, the left leg lead (which is the positive electrode for leads aVF, II and III) is always coloured Green by convention (Europe, not USA). Therefore Green is the colour for all three inferior leads (II, III, aVF). The left arm ECG lead (which is the positive electrode for aVL and lead I) is always yellow. Hence the four lateral leads (I, aVL, V5, V6) are Yellow. Similarly the right arm ECG lead (positive electrode for aVR) is always Red, so the right-ward leads (aVR, V1) are Red. The remaining fourth primary colour, Blue is used for the anterior Leads V2-4; especially important as this is the prognostically most significant territory for an MI. Consequently, Blue is viewed before Red: .Green, yellow, blue, red. ECG paper could even be printed colour-coded for clarity and understanding (Fig 1) Colour-coding the chest leads themselves would promote correct placement: Red V1 to the right of the sternum (4th inter-costal space), Blue V2-4 running from the left of the sternum, with Yellow V5-6 being more lateral (Fig. 1). The groupings correlate broadly to the blood supply of the heart walls, hence the logic of understanding the basic anatomy of the coronary arterial supply (Fig. 1). Which coronary arteries are diseased typically determines which groupings of leads/colours are affected: • Inferior: Green - II, III, aVF • Lateral: Yellow - I aVL, V5, V6 • Anterior +/- septum Blue V2 - V4, extending to Red V1. • Right: Red - aVR, V1


It is easier to detect differences by comparing and contrasting four coloured groupings – as opposed to 12 individual ECG leads, especially for ST segment changes associated with acute coronary syndrome – typically raised in infarction and depressed in ischaemia, the opposite being the case for posterior changes. Ischaemia is a frequent cause of cardiac arrest and arrhythmia requiring timely recognition. ‘Reciprocal Changes’ can develop in other leads from those demonstrating infarction, which is of help in substantiating infarction. It is useful for such logical understanding to keep basic coronary anatomy in mind. The right coronary artery (RCA) and circumflex artery (horizontal division of the left coronary artery), both run in the atrio-ventricular groove, the former anteriorly, the latter posteriorly. The left anterior descending artery (LAD) (the vertical division of the left coronary artery) and the posterior descending artery (PDA) both run in the inter-ventricular groove, the former anteriorly and the latter posteriorly (Fig. 1). As with history taking and clinical examination, pattern recognition – here of the 12-Lead ECG – is paramount. By systematically and sequentially comparing and contrasting four distinct ECG groupings: Green, Yellow, Blue, Red – as opposed to 12 individual leads – colour by colour, we suggest detection of abnormalities is simpler. Colour-coding of the chest leads, Red V1, Blue V2-4, Yellow V5-6 would also help secure correct placement.


57. Cohen SI and Ellis ER. Death and Near Death from Cardiac Arrest during the Boston Marathon. Pacing Clin Electrophysiol 2012; 35 (2): 241-4 The Boston Marathon has been run for 115 years during which there were three sudden cardiac arrests. The most recent was a near death avoided by rapid cardiopulmonary resuscitation (CPR) and defibrillation. Awareness of the dangers of participating in a marathon, the risk


factors associated with sudden death during competition, and the life-saving importance of rapid CPR and defibrillation are essential for participants and event organizers. Available records and reports of the three known cases of cardiac arrest during the Boston Marathon were examined. These cases were identified by representatives of the Boston Athletic Association, which has organized each marathon since its inception. Pertinent literature was reviewed and new information was obtained during interviews of witnesses and rescuers. The data were analyzed in search of shared risk factors for cardiac arrest, death, and the optimal requirements for survival. In 115 years, there were two cardiac deaths and one near death from cardiac arrest. A history of coronary artery disease, advanced age, and prolonged race time are risk factors for sudden cardiac arrest. Rapid application of CPR and defibrillation are essential for survival. Prevention or reduction of life-threatening cardiac incidents during marathon races might be achieved if participants of advanced age or with a history of coronary artery disease seek medical clearance prior to entering an event. Those with coronary risk factors should have a discussion with their physician. Availability of trained personnel and defibrillators are important considerations in marathon planning. 58. Lucas JM, Cocchi MN, Salciccioli J, Stanbridge JA, et al. Neurologic recovery after therapeutic hypothermia in patients with post-cardiac arrest myoclonus. Resuscitation 2012; 83 (2): 265-9 Early myoclonus in comatose survivors of cardiac arrest, even when it is not myoclonic status epilepticus (MSE), is considered a sign of severe global brain ischemia and has been associated with high rates of mortality and poor neurologic outcomes. We report on three survivors of primary circulatory cardiac arrests who had good neurologic outcomes (two patients with a CPC score = 1 and one patient with a CPC score = 2) after mild therapeutic hypothermia, despite exhibiting massive myoclonus within the first 4 h after return of spontaneous circulation. The concept that early myoclonus heralds a uniformly poor prognosis may need to be reconsidered in the era of post-cardiac arrest mild therapeutic hypothermia. [Case study] 59. Salzman M and Friedman J. Bystander cardiopulmonary resuscitation-induced splenic laceration and hepatosplenic hematoma. Am J Emerg Med 2012; 30 (2): 388 Splenic laceration is an uncommon complication of cardiopulmonary resuscitation (CPR). We report a case of bystander CPR-induced splenic laceration with hepatosplenic hematoma complicating management of a patient with cardiovascular collapse because of acute myocardial infarction. Bystander CPR has been shown to improve survival rates in patients who experience witnessed cardiovascular collapse. However, cardiopulmonary resuscitation is not without complications. We report the case of bystander CPR-induced splenic laceration with subsequent hepatosplenic hematoma complicating the management of acute myocardial infarction. [Case study] 60. Soar J and Parry J. Animations for teaching the recognition of cardiac arrest. Resuscitation 2012; 83 (2): e31 Rescuers often fail to recognize cardiac arrest. This causes a delay in starting cardiopulmonary resuscitation (CPR) and this decreases the victim’s chances of survival. A common reason for not starting CPR is the presence of a period of agonal breathing (gasping) after the heart stops. This is often mistaken for normal breathing. Training rescuers to recognize the signs of cardiac arrest using inanimate manikins is difficult. The use of video clips from actual arrests raises ethical issues about consent, and trainees may also find these real videos disturbing. Actors role playing cardiac arrest victims are not always realistic. Animation offers an alternative approach to teaching the recognition of cardiac arrest.


A project by second and third year students at the Bristol School of Animation, University of the West of England in which students worked individually or in teams resulted in four short video clips that can be viewed at: http://www.youtube.com/user/ResusCouncilUK#p/u These videos show different approaches to animation, and in our view show that short animations have a potentially useful role in training rescuers to recognize cardiac arrest. 61. Strapazzon G, Beikircher W, Procter E, Brugger H. Electrical Heart Activity Recorded During Prolonged Avalanche Burial. Circulation 2012; 125 (4): 646-7 A man in his mid-thirties triggered an avalanche at an elevation of 2750 m (9022 ft) while ski touring and sustained complete avalanche burial for 253 minutes before being located with an avalanche transceiver device, probed, and extricated by a rescue team. The burial depth (ie, depth of the head) was 30 cm (1 ft). The victim was in a supine position with a patent airway and a clearly visible air space in front of the mouth and nose with a size of 15×15×5 cm (0.5×0.5×0.2 ft) and frozen inner surface, which was not reported to the emergency physician on site. The victim had a Glasgow Coma Scale of 3 (E1V1M1), no vital signs, and no obvious traumatic fatal injuries. Extrication proceeded without reading the core body temperature or ECG. Because of severe weather conditions and the impending risk for the rescue team, the emergency physician withheld an on-site attempt of resuscitation. The victim was evacuated down to the valley by helicopter and declared dead. It was revealed that the victim was equipped with a multifunction sport watch and transmitter chest belt. The recorded dataset included heart rate, cutaneous temperature, and elevation, and was downloaded and saved according to the operating manual of the device. We present here the first recording of cardiac activity ever obtained during complete and prolonged avalanche burial in a human. During ascent, heart rate (mean, 146±12 bpm; range, 96–164 bpm) showed values reflective of physical effort. On rest at the peak, heart rate was abnormally high (mean, 113±13 bpm; range, 88–154 bpm) because of the elevation. Over the course of burial, 5 distinct phases of cardiac activity are apparent: (i) 0 to 18 minutes: highly variable frequency in heart rate with a mean of 83±25 bpm (range, 28–144 bpm); (ii) 18 to 35 minutes: sustained rate of 154±0 bpm; (iii) 35 to 70 minutes: sustained bradycardia with a mean of 51±14 bpm (range, 46–154 bpm); (iv) 70 to 253 minutes: sustained tachycardia with a mean of 176±13 bpm (range, 72–180 bpm) with variability occurring in the final minutes; and (v) 253 minutes: cardiac arrest on extrication of the avalanche victim. [case study]

Education & ethics in resuscitation ___________________________________________________________________________________________ 62. Beckers SK, Biermann H, Sopka S, Skorning M, et al Younker J. Influence of pre-course assessment using an emotionally activating stimulus with feedback: A pilot study in teaching Basic Life Support. Resuscitation 2012; 83 (2): 219-26 Cardiopulmonary resuscitation (CPR) mastery continues to challenge medical professionals. The purpose of this study was to determine if an

http://www.youtube.com/user/ResusCouncilUK#p/u


emotional stimulus in combination with peer or expert feedback during pre-course assessment effects future performance in a single rescuer simulated cardiac arrest. Methods: First-year medical students (n = 218) without previous medical knowledge were randomly assigned to one of the study groups and asked to take part in a pre-course assessment: Group 1: after applying an emotionally activating stimulus an expert (instructor) gave feedback on CPR performance (Ex). Group 2: after applying the same stimulus feedback was provided by a peer from the same group (Pe); Group 3: standard without feedback (S). Following pre-course assessment, all subjects received a standardized BLS-course, were tested after 1 week and 6 months later using single-rescuer-scenario, and were surveyed using standardized questionnaires (6-point-likert-scales: 1 = completely agree, 6 = completely disagree). Results: Participants exposed to stimulus demonstrated superior performance concerning compression depth after 6 months independent of feedback-method (Ex: 65.85% [p = 0.0003]; Pe: 57.50% [p = 0.0076] vs. 21.43%). The expert- more than the peer-group was emotionally more activated in initial testing, Ex: 3.26 ± 1.35 [p ≤ 0.0001]; Pe: 3.73 ± 1.53 [p = 0.0319]; S: 4.25 ± 1.37) and more inspired to think about CPR (Ex: 2.03 ± 1.37 [p = 0.0119]; Pe: 2.07 ± 1.14 [p = 0.0204]; S: 2.60 ± 1.55). After 6 months this activation effect was still detectable in the expert-group (p = 0.0114). Conclusions: The emotional stimulus approach to BLS-training seems to impact the ability to provide adequate compression depth up to 6 months after training. Furthermore, pre-course assessment helped to keep the participants involved beyond initial training. 63. Fischer H, Strunk G, Neuhold S, et al. The effectiveness of ERC advanced life support (ALS) provider courses for the retention of ALS knowledge. Resuscitation 2012; 83 (2): 227-31 Purpose: Out-of-hospital emergency physicians in Austria need mandatory emergency physician training, followed by biennial refresher courses. Currently, both standardized ERC advanced life support (ALS) provider courses and conventional refresher courses are offered. This study aimed to compare the retention of ALS-knowledge of out-of-hospital emergency physicians depending on whether they had or had not participated in an ERC-ALS provider course since 2005. Methods: Participants (n = 807) from 19 refresher courses for out-of-hospital emergency physicians answered eight multiple-choice questions (MCQ) about ALS based on the 2005 ERC guidelines. The pass score was 75% correct answers. A multivariate logistic regression analyzed differences in passing scores between those who had previously participated in an ERC-ALS provider course and those who had not. Age, gender, regularity of working as an out-of-hospital emergency physician and the self-reported number of real resuscitation efforts within the last 6 months were entered as control variables. Results: Out-of-hospital emergency physicians who had previously attended an ERC-ALS provider course had a significantly higher chance of passing the MCQ test (OR = 1.60, p = 0.015). Younger age (OR = 0.95, p < 0.001), regular work as an out-of-hospital emergency physician (OR = 2.66, p < 0.001) and a higher number of self-reported resuscitations within the last 6 months (OR = 1.08, p = 0.002) were also significant predictors of passing the test. Conclusion: Out-of-hospital emergency physicians that had attended an ERC-ALS provider course since 2005 had a higher retention of ALS knowledge compared to non-ERC-ALS course participants. 64. Johansson J, Blomberg H, Svennblad B, Wernroth L, et al. Prehospital Trauma Life Support (PHTLS) Training of Ambulance Caregivers and Impact on Survival of Trauma Victims. Resuscitation 2012; Online first The Prehospital Trauma Life Support (PHTLS) course has been widely implemented and approximately half a million prehospital caregivers in over 50 countries have taken this course. Still, the effect on injury outcome remains to be established. The objective of this study was to investigate the association between PHTLS training of ambulance crew members and the mortality in trauma patients. Methods: A population-


based observational study of 2830 injured patients, who either died or were hospitalized for more than 24 hours, was performed during gradual implementation of PHTLS in Uppsala County in Sweden between 1998 and 2004. Prehospital patient records were linked to hospital-discharge records, cause-of-death records, and information on PHTLS training and the educational level of ambulance crews. The main outcome measure was death, on scene or in hospital. Results: Adjusting for multiple potential confounders, PHTLS training appeared to be associated with a reduction in mortality, but the precision of this estimate was poor (odds ratio, 0.71; 95% confidence interval, 0.42-1.19). The mortality risk was 4.7% (36/763) without PHTLS training and 4.5% (94/2067) with PHTLS training. The predicted absolute risk reduction is estimated to correspond to 0.5 lives saved annually per 100 000 population with PHTLS fully implemented. Conclusions: PHTLS training of ambulance crew members may be associated with reduced mortality in trauma patients, but the precision in this estimate was low due to the overall low mortality. While there may be a relative risk reduction, the predicted absolute risk reduction in this population was low. 65. Kardong-Edgren S, Oermann MH and Odom-Maryon T. Findings from a nursing student CPR study: implications for staff development educators. J Nurs Staff Dev 2012; 28 (1): 9-15 This article reports a secondary data analysis of a year-long study with 606 nursing students involving brief monthly CPR practice with voice-activated manikins versus no practice. Findings indicate that even with monthly practice and accurate voice-activated manikin feedback, some students could not perform CPR correctly. Implications of these findings for staff educators are discussed. 66. Pierick TA, Van Waning N, Patel SS and Atkins DL. Self-instructional CPR training for parents of high risk infants. Resuscitation 2012; Online first (February 18) Objective: Premature infants (PRE) and infants with congenital heart disease (CHD) are at high risk for respiratory or cardiac arrest in their first year. Bystander cardiopulmonary resuscitation (CPR) is a major predictor of resuscitation outcome. The purpose of this study was to assess the usefulness of a self-instructional DVD kit (Infant CPRAnytime™) for families of high-risk infants. We hypothesized that comfort level of performing CPR would increase, parents would share the kit with others, and review it during the year. Methods: Parents of PRE (<35 weeks or <2500 g) or CHD infants received a self-instructional CPR kit. One parent completed a questionnaire, reviewed the DVD, and practiced CPR before discharge. They were asked to share the kit with other care providers, practice CPR every 3 months, and complete questionnaires at 4 and 12 months. Results: We enrolled 311 subjects: 238 PRE and 73 CHD. Comfort level performing CPR increased from 2.8 at baseline to 3.5 at 12 months (p = 0.023). The kit was shared with 3.1 additional persons and reviewed by the parent 1.8 times over 12 months. Eight emergency rescue events were reported: choking (3) and CPR (5). All events requiring CPR were in infants with CHD. Six infants survived with reported good or stable neurologic status. Conclusions: Self-instructional tools provide an excellent method of CPR training for parents of high risk infants. Caregiver comfort increased over 12 months and parents continued to review the kit during the first year. An additional 3.1 persons used the kit for CPR training. 67. Stuart M. CPR policies and the patient's best interests. Resuscitation 2012; 83 (2): 168-70 Standard hospital CPR policies in many countries require CPR to be attempted on all patients having a cardiac arrest unless a Not-for-CPR order is in place. It has recently been shown that this approach is legally inappropriate in New Zealand. It appears that this argument may also potentially apply in other common law countries given the role that 'best interests' has in these jurisdictions in providing treatment to patients


lacking decision-making capacity. Not-for-CPR orders provide an important and transparent mechanism for making advanced decisions regarding resuscitation. However, advanced planning is not always possible and it is legally inappropriate to require CPR to be performed when it is not in the patient's best interests. Notwithstanding the difficult practical balance that exists at the time of arrest between initiating CPR without delay or interruption for it to be effective for those whom CPR is in their best interests, and recognising as quickly as possible those patients for who CPR is not appropriate, it is argued that policies should be modified to allow clinicians to consider whether CPR is appropriate at time of arrest. Such a change may require ALS training to include a stronger emphasis on early recognition of patients for whom CPR is not in their best interests. 68. Zebuhr C, Sutton RM, Morrison W, Niles D, et al. Evaluation of quantitative debriefing after pediatric cardiac arrest. Resuscitation 2012; Online first (February 2) Aim: Our primary objective was to describe and determine the feasibility of implementing a care environment targeted pediatric post-cardiac arrest debriefing program. A secondary objective was to evaluate the usefulness of debriefing content items. We hypothesized that a care environment targeted post-cardiac arrest debriefing program would be feasible, well-received, and result in improved self-reported knowledge, confidence and performance of pediatric providers. Methods: Physician-led multidisciplinary pediatric post-cardiac arrest debriefings were conducted using data from CPR recording defibrillators/central monitors followed by a semi-quantitative survey. Eight debriefing content elements divided, a priori, into physical skill (PS) related and cognitive skill (CS) related categories were evaluated on a 5-point Likert scale to determine those most useful (5-point Likert scale: 1 = very useful/5 = not useful). Summary scores evaluated the impact on providers’ knowledge, confidence, and performance. Results: Between June 2010 and May 2011, 6 debriefings were completed. Thirty-four of 50 (68%) front line care providers attended the debriefings and completed surveys. All eight content elements were rated between useful to very useful (Median 1; IQR 1–2). PS items scored higher than CS items to improve knowledge (Median: 2 (IQR 1–3) vs. 1 (IQR 0–2); p < 0.02) and performance (Median: 2 (IQR 1–3) vs. 1 (IQR 0-1); p < 0.01). Conclusions: A novel care environment targeted pediatric post-cardiac arrest pediatric debriefing program is feasible and useful for providers regardless of their participation in the resuscitation. Physical skill related elements were rated more useful than cognitive skill related elements for knowledge and performance

And.. ___________________________________________________________________________________________ Biscuit H and Bruce B. Neuro-protective Effect of Alcohol in Dealings With Idiocy. Online first, 2 Jan 2012. In social outings involving idiots, alcohol was found to protect neurons against apoptosis in smarter individuals. The delay in sensory relay caused by alcohol consumption is the likely mechanism for this phenomenon. Whilst neurons were still lost in the experimental group, the rate of loss was significantly lower than in controls or placebo alcohol free beer intervention groups. Exposed control groups lost 4 AND (arbitrary


neuronal density) more than their respective alcohol test cohort. Results were significant to >0.0001. The authors stipulate that beer may save brain cells under severe intellectual-vacuum stress. Full paper at: http://lifeinthefastlane.com/wp-content/uploads/2012/02/Neuroprotective-alcohol.pdf?9d7bd4

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http://lifeinthefastlane.com/wp-content/uploads/2012/02/Neuroprotective-alcohol.pdf?9d7bd4


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