2020 APHRS/HRS Expert Consensus Statement on the Investigation of Decedents with Sudden Unexplained Death and Patients with Sudden Cardiac Arrest, and of Their Families.

This international multidisciplinary document intends to provide clinicians with evidence-based practical patient-centered recommendations for evaluating patients and decedents with (aborted) sudden cardiac arrest and their families. The document includes a framework for the investigation of the family allowing steps to be taken, should an inherited condition be found, to minimize further events in affected relatives. Integral to the process is counseling of the patients and families, not only because of the emotionally charged subject, but because finding (or not finding) the cause of the arrest may influence management of family members. The formation of multidisciplinary teams is essential to provide a complete service to the patients and their families, and the varied expertise of the writing committee was formulated to reflect this need. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by Class of Recommendation and Level of Evidence. The recommendations were opened for public comment and reviewed by the relevant scientific and clinical document committees of the Asia Pacific Heart Rhythm Society (APHRS) and the Heart Rhythm Society (HRS); the document underwent external review and endorsement by the partner and collaborating societies. While the recommendations are for optimal care, it is recognized that not all resources will be available to all clinicians. Nevertheless, this document articulates the evaluation that the clinician should aspire to provide for patients with sudden cardiac arrest, decedents with sudden unexplained death, and their families

Prehospital randomised assessment of a mechanical compression device in out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised trial and economic evaluation

Background: Mechanical chest compression devices may help to maintain high-quality cardiopulmonary resuscitation (CPR), but little evidence exists for their effectiveness. We evaluated whether or not the introduction of Lund University Cardiopulmonary Assistance System-2 (LUCAS-2; Jolife AB, Lund, Sweden) mechanical CPR into front-line emergency response vehicles would improve survival from out-of-hospital cardiac arrest (OHCA). Objective: Evaluation of the LUCAS-2 device as a routine ambulance service treatment for OHCA. Design: Pragmatic, cluster randomised trial including adults with non-traumatic OHCA. Ambulance dispatch staff and those collecting the primary outcome were blind to treatment allocation. Blinding of the ambulance staff who delivered the interventions and reported initial response to treatment was not possible. We also conducted a health economic evaluation and a systematic review of all trials of out-of-hospital mechanical chest compression. Setting: Four UK ambulance services (West Midlands, North East England, Wales and South Central), comprising 91 urban and semiurban ambulance stations. Clusters were ambulance service vehicles, which were randomly assigned (approximately 1 : 2) to the LUCAS-2 device or manual CPR. Participants: Patients were included if they were in cardiac arrest in the out-of-hospital environment. Exclusions were patients with cardiac arrest as a result of trauma, with known or clinically apparent pregnancy, or aged < 18 years. Interventions: Patients received LUCAS-2 mechanical chest compression or manual chest compressions according to the first trial vehicle to arrive on scene. Main outcome measures: Survival at 30 days following cardiac arrest; survival without significant neurological impairment [Cerebral Performance Category (CPC) score of 1 or 2]. Results: We enrolled 4471 eligible patients (1652 assigned to the LUCAS-2 device and 2819 assigned to control) between 15 April 2010 and 10 June 2013. A total of 985 (60%) patients in the LUCAS-2 group received mechanical chest compression and 11 (< 1%) patients in the control group received LUCAS-2. In the intention-to-treat analysis, 30-day survival was similar in the LUCAS-2 (104/1652, 6.3%) and manual CPR groups [193/2819, 6.8%; adjusted odds ratio (OR) 0.86, 95% confidence interval (CI) 0.64 to 1.15]. Survival with a CPC score of 1 or 2 may have been worse in the LUCAS-2 group (adjusted OR 0.72, 95% CI 0.52 to 0.99). No serious adverse events were noted. The systematic review found no evidence of a survival advantage if mechanical chest compression was used. The health economic analysis showed that LUCAS-2 was dominated by manual chest compression. Limitations: There was substantial non-compliance in the LUCAS-2 arm. For 272 out of 1652 patients (16.5%), mechanical chest compression was not used for reasons that would not occur in clinical practice. We addressed this issue by using complier average causal effect analyses. We attempted to measure CPR quality during the resuscitation attempts of trial participants, but were unable to do so. Conclusions: There was no evidence of improvement in 30-day survival with LUCAS-2 compared with manual compressions. Our systematic review of recent randomised trials did not suggest that survival or survival without significant disability may be improved by the use of mechanical chest compression. Future work: The use of mechanical chest compression for in-hospital cardiac arrest, and in specific circumstances (e.g. transport), has not yet been evaluated

Machine learning and signal processing contributions to identify circulation states during out-of-hospital cardiac arrest

212 p. (eusk) 216 p. (eng.)Bat-bateko bihotz geldialdia (BBG) ustekabeko bihotz jardueraren etenaldi gisa definitzen da [9], non odol perfusioa ez baita iristenez burmuinera, ez beste ezinbesteko organoetara. BBGa ahalik eta azkarren tratatu behar da berpizte terapien bidez bat-bateko bihotz heriotza (BBH) ekiditeko [10, 11]. Ohikoena BBGa ospitalez kanpoko inguruneetan gertatzea da [12] eta kasu gehienetan ez da lekukorik egoten [13]. Horregatik, berpizte terapien aplikazio goiztiarra erronka mediku eta soziala da gaur egun

Observational Data to Improve Clinical Decision Making in Acute Care

The premise of Big Data in acute medicine is to make medicine more efficient and effective. However, the translation of large observational data to knowledge is difficult. This thesis explores and discusses the three main types of research questions which can be asked from large observational data:1. What is current clinical practice?2. What is best practice?3. What patients need to be prioritised?This thesis will focus on traumatic brain injury and in-hospital cardiac arrest.<br/

A prospective observational study to investigate the effect of prehospital airway management strategies on mortality and morbidity of patients who experience return of spontaneous circulation post cardiac arrest and are transferred directly to regional Heart Attack Centres by the Ambulance Service

Introduction The most appropriate airway management technique for use by paramedics in out-of-hospital cardiac arrest is yet to be determined and evidence relating to the influence of airway management strategy on outcome remains equivocal. In cases where return of spontaneous circulation (ROSC) occurs following out-of-hospital cardiac arrest, patients may undergo direct transfer to a specialist heart attack centre (HAC) where the post resuscitation 12 lead ECG demonstrates evidence of ST elevation myocardial infarction. To date, no studies have investigated the role of airway management strategy on outcomes in this sub-set of patients. The AMICABLE (Airway Management In Cardiac Arrest, Basic, Laryngeal mask airway, Endotracheal intubation) study therefore sought to investigate the influence of prehospital airway management strategy on outcomes in patients transferred by the ambulance service directly to a HAC post ROSC. Methods Adults with ROSC post out-of-hospital cardiac arrest who met local criteria for transfer to a HAC were identified prospectively. Ambulance records were reviewed to determine prehospital airway management approach and collect physiological and demographic data. HAC notes were obtained to determine in-hospital course and quantify neurological outcome via the Cerebral Performance Category (CPC) scale. Neurologically intact survivors were contacted post discharge to assess quality of life via the SF-36 health survey. Statistical analyses were performed via Chi-square, Mann Whitney U test, odds ratios, and binomial logistic regression. Results A total of 220 patients were recruited between August 2013 and August 2014, with complete outcome data available for 209. The age of patients ranged from 22-96 years and 71.3% were male (n=149). Airway management was undertaken using a supraglottic airway (SGA) in 72.7% of cases (n=152) with the remainder undergoing endotracheal intubation (ETI). There was no significant difference in the proportion of patients with good neurological outcome (CPC 1&2) between the SGA and ETI groups (p=.286). Similarly, binomial logistic regression incorporating factors known to influence outcome demonstrated no significant difference between the SGA and ETI groups (Adjusted OR 0.725, 95% CI 0.337-1.561). Clinical and demographic variables associated with good neurological outcome included the presence of a shockable rhythm (p<.001), exposure to angiography (p<.001), younger age (p<.001) and shorter time to ROSC (p<.001). Due to an inadequate response rate (25.4%, n=15) analysis of SF36 data was limited to descriptive statistics. Limitations The study only included patients who achieved ROSC and met the criteria for direct transfer to a HAC. Results are therefore not generalisable to more heterogenous resuscitation populations. Accuracy of clinical decision making and ECG interpretation were not assessed and therefore some patients included in the study may have been inappropriately transferred to a HAC. The low SF-36 survey response rate limited the level of neurological outcome analysis that could be undertaken. Conclusion In this study, there was no significant difference in the proportion of good neurological outcomes in patients managed with SGA versus ETI during cardiac arrest. Further research incorporating randomised controlled trials is required to provide more definitive evidence in relation to the optimal airway management strategy in out-of-hospital cardiac arrest

Inhaled xenon neuro- and cardioprotection following out-of-hospital cardiac arrest. A randomized, controlled trial

Cardiac arrest leads often to death or permanent neurological damage, despite prompt advanced life support and resuscitation. Ischaemia-reperfusion injury persists, although circulation and cardiac function has been restored. The most vulnerable organs for hypoxemia and reperfusion injury are the brain and heart. The only proven intervention against ongoing ischaemia-reperfusion injury is targeted temperature management to core temperature of 33–36 C for 24 hours after cardiac arrest. Still, at least on average third of the succesfully from ventricular fibrillation-generated cardiac arrest resuscitated patients die, particularly to hypoxic-ischaemic brain injury. The noble gas xenon is an anaesthetic gas, which has been demonstrated in preclinical animal models to attenuate posthypoxic brain and myocardial injury. Xenon has many properties of ”an ideal anaesthetic”, but being so scarce and laborous to extract makes it expensive. In this clinical trial, the standard-of-care after out-of-hospital cardiac arrest, targeted temperature management to 33 °C for 24 hours, was compared to hypothermia supplemented with inhaled xenon for 24 hours. Both study groups consisted of 55 cardiac arrest victims and the postarrest care was identical in both groups and in accordance with current international guidelines. Cerebral hypoxic-ischaemic injury was assessed with brain diffusion tensor magnetic resonance imaging after rewarming. Fractional anistrophy (FA) value corresponds to the microintegrity of brain white matter tracts and is diminished after injury. Cardiac troponin-T is a marker of cardiomyocyte injury, which was serially assessed during 72 hours following resuscitation. The main findings of this study were, that combining inhaled xenon and therapeutic hypothermia in cardiac arrest patients was safe and feasible. The combination of xenon and hypothermia significantly attenuated brain white matter injury illustrated with higher FA-values. After adjustements for age, sex, study site, primary coronary percutaneous intevention (PCI) and noradrenaline dose, Troponin-T values were lower at 72 hours post OHCA in the xenon group corresponding to an mitigating effect in myocardial injury. These results translate to significant neuro- and cardioprotection against ongoing ischaemia-reperfusion injury by xenon inhalation combined with hypothermia. The overall mortality in this study was 30,9 %. The study was underpowered to demonstrate differences in outcome or functional neurological recovery.Sydänpysähdys johtaa viiveettä aloitetusta elvytyksestä huolimatta usein potilaan kuolemaan tai vakavaan neurologiseen vammautumiseen. Hapenpuutteen ja reperfuusion aiheuttama kudosvaurio jatkuu, vaikka verenkierto ja sydämen toiminta onnistutaan elvytystoimin palauttamaan. Erityisen alttiita hapenpuutteelle ja reperfuusiovauriolle ovat aivot ja sydän. Ainoa tehokkaaksi todettu reperfuusiovaurion hoito on potilaan jäähdyttäminen 33 – 36 C lämpötilaan vuorokaudeksi elvytyksen jälkeen. Hoidosta huolimatta noin kolmannes onnistuneesti kammiovärinästä elvytetyistä potilaista kuolee, tavallisimmin hapenpuuteaivovaurion seurauksiin. Jalokaasu ksenon on anestesiakaasu, jonka on tämän lisäksi lukuisissä prekliinisissä eläintutkimuksissa todettu vähentävän hermo- ja sydänlihaskudoksen vauriota hapenpuutteen jälkeen. Ksenon-anestesialla on monia ihanteellisen anestesian piirteitä, mutta sen käytettävyyttä rajoittaa kaasun harvinaisuus ja työläs puhdistamisprosessi, minkä takia ksenon on kallista. Tässä tutkimuksessa verrattiin vakiintunutta sydänpysähdyspotilaan jatkohoitoa teho-osastolla – vuorokauden jäähdytyshoitoa – jäähdytyshoitoon ja samanaikaiseen ksenon-kaasun hengittämiseen yhteensä 110:llä onnistuneesti kammiovärinästä elvytetyillä potilailla. Näiden kahden tutkimusryhmän potilaita (55 potilasta kummassakin ryhmässä) hoidettiin muuten samankaltaisesti noudattaen viimeisimpiä kansainvälisiä suosituksia sydänpysähdyksestä elvytettyjen jatkohoidossa. Keskushermoston hapenpuutevauriota arvioitiin potilaan normaaliin lämpötilaan lämmittämisen jälkeen aivojen magneettitutkimuksen diffuusiotensorikuvauksen fraktioidun anisotrofia (FA) -arvon perusteella, jonka pieneneminen viittaa aivojen valkean aineen vaurioon ja mikrointegraation hajoamiseen. Sydänpysähdyksen jälkeistä sydänvauriota arvioitiin sydänlihassoluvaurion merkkiaineen troponiini-T:n muutosten perusteella. Tutkimuksen perusteella ksenonin ja jäähdytyshoidon yhdistelmä oli turvallista ja hengitys ja verenkierto olivat hoidon aikana vakaita myös juuri elvytetyillä sydänpysähdyspotilailla, joilla valtaosalla oli merkittävä sepelvaltimotauti. Ksenon-yhdistelmähoito vähensi merkitsevästi aivojen valkean aineen vauriota magneettikuvauksen FA-arvoja verrattaessa. Myös sydänlihaksen vauriomerkkiaineen, troponiini-T:n arvot vähenivät elvytystä seuranneen 72 tunnin kuluessa merkitsevästi, sopien pienempään sydänlihasvaurioon yhdistelmähoitoa saaneessa tutkimusryhmässä. Nämä tulokset viittaavat ksenonin merkittävään neuro- ja kardioprotektiiviseen vaikutukseen käynnissä olevan hapenpuute-reperfuusiovaurion rajoittamisessa. Tutkimuspotilaiden kuolleisuus oli 30,9 %. Hoitoryhmien koko oli liian pieni merkitsevän eron havainnointiin henkiinjäämisessä tai toiminnallisessa neurologisessa selviytymisessä