Various aspects of treatment in cardiac arrest prior to hospital arrival

Background and aims: Out-of-hospital cardiac arrest (OHCA) is a major public health issue, affecting almost 300,000 victims per year in Europe, who have an overall survival rate of about 10 per cent. In general, the current Emergency Medical Services (EMS) do not have the capacity to act quickly and effectively enough in regard to this vast group of patients. The objectives of the current work were: to study the importance of bystander cardiopulmonary resuscitation (CPR) from a national perspective; to determine the safety, feasibility and efficacy of trans-nasal evaporative cooling initiated during CPR; to investigate the effects of dual dispatch of fire-fighters and EMS on short- and long-term survival; to explore regional differences in response times and survival rates in relation to dual dispatch of fire-fighters and EMS in cases of OHCA. Methods and results: Study I. Observational study of 34,125 patients. From 1992 to 2005, bystander CPR significantly increased, especially when performed by laypersons, in witnessed (40% to 55%, p<0.0001) and unwitnessed (22% to 44%, p<0.0001) OHCA. Bystander CPR was associated with higher ventricular fibrillation (VF) rates (adjusted OR 1.73, 95% CI 1.62–1.86) and improved 30-day survival (adj. OR 2.20, 95% CI 1.68–2.90). Study II. Randomised trial concerning 200 cases of witnessed OHCA. Trans-nasal evaporative cooling was feasible in pre-hospital arrests. Eighteen device-related adverse events were reported, where one case of epistaxis was defined as serious. Time to target temperature of 34°C was shorter in the treatment group for both tympanic (102 vs. 282 minutes, p=0.03) and core (155 vs. 284 minutes, p=0.13) temperature. Study III. Intervention study (trained fire-fighters dispatched in cases of OHCA) using historical controls. When dispatched, fire-fighters were first on the scene and connected an automated external defibrillator (AED) in 41% of the cases. Thirty-day survival improved from 3.9% (control) to 7.6 % (intervention) (p=0.001, adjusted OR 2.8, 95% CI 1.6–4.9). Survival to 3 years increased from 2.4% to 6.5% respectively (p<0.001, adjusted OR 3.8, 95% CI 1.9–7.6). Study IV. Intervention study using historical controls, assessing the regional impact of Study III in areas with different population densities. Median response times shortened significantly in all subgroups, ranging from 0.8 (downtown) to 3.2 minutes (rural). The effect on 30-day survival rates varied depending on population density, with the lowest impact in rural areas. Conclusions: Bystander CPR, especially when performed by laypersons, increased in Sweden between 1992 and 2005 and is associated with increased VF and survival rates. Intra-arrest trans-nasal cooling in cases of OHCA is safe and feasible and it shortened the time interval required to cool patients. Implementation of a dual dispatch system (fire-fighters and EMS) in cases of OHCA was associated with increased 30-day- and 3-year survival. Shortened response times were seen in sparsely as well as in highly populated regions. The lowest impact of a dual dispatch system on survival was seen in rural areas

Future climate impacts of sodium-ion batteries

Sodium-ion batteries (SIBs) have emerged as an alternative to lithium-ion batteries (LIBs) due to their promising performance in terms of battery cycle lifetime, safety, operating in wider temperature range, as well as the abundant and low-cost of sodium resources. This study evaluated the climate impacts of three SIBs, and compared to two LIBs under four scenarios with considering potential changes in battery performance and background productions between 2020 and 2050. To ensure a fair comparison, all batteries were modeled in the 21,700 form, and a battery dimensioning model was developed to calculate the required amount of components for each battery. We found that equal to lower GHG emissions result from the use of SIBs compared to LIBs under optimal performance scenarios. From 2020 to 2050, the climate impacts of SIBs decreased by 43-57 %. The relative contribution of the battery manufacturing process decreases from 18-32 % to 2-4 % due to the increasingly share of clean energy in the electricity grid, while the relative contribution of key battery component materials increases over time, especially for cathode active materials. These results emphasize the significance of decarbonizing the electric grid, and suggest that future investment in SIBs is promising from an environmental point of view

Climate impact and energy efficiency from electricity generation through anaerobic digestion or direct combustion of short rotation coppice willow

Short rotation coppice willow is an energy crop used in Sweden to produce electricity and heat in combined heat and power plants. Recent laboratory-scale experiments have shown that SRC willow can also be used for biogas production in anaerobic digestion processes. Here, life cycle assessment is used to compare the climate impact and energy efficiency of electricity and heat generated by these measures. All energy inputs and greenhouse gas emissions, including soil organic carbon fluxes were included in the life cycle assessment. The climate impact was determined using time-dependent life cycle assessment methodology. Both systems showed a positive net energy balance, but the direct combustion system delivered ninefold more energy than the biogas system. Both systems had a cooling effect on the global mean surface temperature change. The cooling impact per hectare from the biogas system was ninefold higher due to the carbon returned to soil with the digestate. Compensating the lower energy production of the biogas system with external energy sources had a large impact on the result, effectively determining whether the biogas scenario had a net warming or cooling contribution to the global mean temperature change per kWh of electricity. In all cases, the contribution to global warming was lowered by the inclusion of willow in the energy system. The use of time-dependent climate impact methodology shows that extended use of short rotation coppice willow can contribute to counteract global warming

Life cycle assessment of an all-organic battery: Hotspots and opportunities for improvement

Organic batteries are emerging as a potential sustainable power source for future flexible devices. Using life cycle assessment, this study analyzed the environmental impacts from the synthesis process for an all-organic battery with conducting redox polymers as active materials for electrodes. Synthesis steps were modeled and analyzed in detail, based on actual laboratory processes data for electrodes, and industrial data for other battery components. Complete and transparent inventory data are presented and can be used in future environmental assessments. The organic battery studied is still at an early development stage, so environmental hotspots and potential improvements in the synthesis processes were examined. For selected environmental impact categories, the life cycle assessment results showed that synthesis of cathode backbone was the major contributor (47-63%) to the environmental impacts of the all-organic battery cell among different synthesis stages, because of a long synthesis route associated with high solvent usage. Solvents (e.g., dichloromethane), catalysts (e.g., copper oxide, Pd (PPh3)4), zinc, and waste treatment processes were important single contributors to the total impacts. The results reveal significant potential for improvement by optimizing the amount of solvents needed to synthesize battery electrodes. Changing treatment methods for laboratory waste solvents can also strongly influence the results

Energy performance of compressed biomethane gas production from co-digestion of Salix and dairy manure: factoring differences between Salix varieties

Biogas from anaerobic digestion is a versatile energy carrier that can be upgraded to compressed biomethane gas (CBG) as a renewable and sustainable alternative to natural gas. Organic residues and energy crops are predicted to be major sources of bioenergy production in the future. Pre-treatment can reduce the recalcitrance of lignocellulosic energy crops such as Salix to anaerobic digestion, making it a potential biogas feedstock. This lignocellulosic material can be co-digested with animal manure, which has the complementary effect of increasing volumetric biogas yield. Salix varieties exhibit variations in yield, composition and biomethane potential values, which can have a significant effect on the overall biogas production system. This study assessed the impact of Salix varietal differences on the overall mass and energy balance of a co-digestion system using steam pre-treated Salix biomass and dairy manure (DaM) to produce CBG as the final product. Six commercial Salix varieties cultivated under unfertilised and fertilised conditions were compared. Energy and mass flows along this total process chain, comprising Salix cultivation, steam pre-treatment, biogas production and biogas upgrading to CBG, were evaluated. Two scenarios were considered: a base scenario without heat recovery and a scenario with heat recovery. The results showed that Salix variety had a significant effect on energy output-input ratio (R), with R values in the base scenario of 1.57-1.88 and in the heat recovery scenario of 2.36-2.94. In both scenarios, unfertilised var. Tordis was the best energy performer, while the fertilised var. Jorr was the worst. Based on this energy performance, Salix could be a feasible feedstock for co-digestion with DaM, although its R value was at the lower end of the range reported previously for energy crops

Prospective life cycle assessment of a flexible all-organic battery

Strong interest from researchers and industry is accelerating development of flexible energy storage technologies for future flexible devices. It is critical to consider the environmental perspective in early development of new emerging technologies. In this study, cradle-to-factory gate prospective life cycle assessment (LCA) was performed on production of an all-organic battery with conductive redox polymers as electrode material. To gain a better understanding of the environmental performance of the all-organic battery, a flexible lithium-ion (Li-ion) battery with lithium titanate oxide and lithium cobalt oxide as electrode active materials was modeled as reference. Main environmental impacts of the all-organic battery were attributable to anode and cathode production, with electrode backbones being the main contributors. Solvents, catalysts, waste treatment, energy, and bromine were key individual contributors. Comparison with the flexible Li-ion battery indicated inferior environmental performance of the all-organic battery due to its relatively low specific energy (Wh/kg) and large amount of materials needed for production of its electrode backbones. Sensitivity analysis showed that changing scaling-up parameters and the production route of 3,4-ethylenedioxythiophene (a precursor of electrode backbones) strongly influenced the results. In order to lower the environmental impacts of the all-organic battery, future research should focus on designing a short production chain with lower material inputs of electrode backbones, increasing battery cycle life, and improving the specific energy of the battery. In addition, relevant recommendations were provided for prospective LCAs of upscaled systems

Effect of Trans-Nasal Evaporative Intra-arrest Cooling on Functional Neurologic Outcome in Out-of-Hospital Cardiac Arrest : The PRINCESS Randomized Clinical Trial

© 2019 American Medical Association. All rights reserved.Importance: Therapeutic hypothermia may increase survival with good neurologic outcome after cardiac arrest. Trans-nasal evaporative cooling is a method used to induce cooling, primarily of the brain, during cardiopulmonary resuscitation (ie, intra-arrest). Objective: To determine whether prehospital trans-nasal evaporative intra-arrest cooling improves survival with good neurologic outcome compared with cooling initiated after hospital arrival. Design, Setting, and Participants: The PRINCESS trial was an investigator-initiated, randomized, clinical, international multicenter study with blinded assessment of the outcome, performed by emergency medical services in 7 European countries from July 2010 to January 2018, with final follow-up on April 29, 2018. In total, 677 patients with bystander-witnessed out-of-hospital cardiac arrest were enrolled. Interventions: Patients were randomly assigned to receive trans-nasal evaporative intra-arrest cooling (n = 343) or standard care (n = 334). Patients admitted to the hospital in both groups received systemic therapeutic hypothermia at 32°C to 34°C for 24 hours. Main Outcomes and Measures: The primary outcome was survival with good neurologic outcome, defined as Cerebral Performance Category (CPC) 1-2, at 90 days. Secondary outcomes were survival at 90 days and time to reach core body temperature less than 34°C. Results: Among the 677 randomized patients (median age, 65 years; 172 [25%] women), 671 completed the trial. Median time to core temperature less than 34°C was 105 minutes in the intervention group vs 182 minutes in the control group (P < .001). The number of patients with CPC 1-2 at 90 days was 56 of 337 (16.6%) in the intervention cooling group vs 45 of 334 (13.5%) in the control group (difference, 3.1% [95% CI, -2.3% to 8.5%]; relative risk [RR], 1.23 [95% CI, 0.86-1.72]; P = .25). In the intervention group, 60 of 337 patients (17.8%) were alive at 90 days vs 52 of 334 (15.6%) in the control group (difference, 2.2% [95% CI, -3.4% to 7.9%]; RR, 1.14 [95% CI, 0.81-1.57]; P = .44). Minor nosebleed was the most common device-related adverse event, reported in 45 of 337 patients (13%) in the intervention group. The adverse event rate within 7 days was similar between groups. Conclusions and Relevance: Among patients with out-of-hospital cardiac arrest, trans-nasal evaporative intra-arrest cooling compared with usual care did not result in a statistically significant improvement in survival with good neurologic outcome at 90 days. Trial Registration: ClinicalTrials.gov Identifier: NCT01400373.Peer reviewedFinal Accepted Versio

Time to intra-arrest therapeutic hypothermia in out-of-hospital cardiac arrest patients and its association with neurologic outcome: a propensity matched sub-analysis of the PRINCESS trial

© 2020, The Author(s). Purpose: To study the association between early initiation of intra-arrest therapeutic hypothermia and neurologic outcome in out-of-hospital cardiac arrest. Methods: A prespecified sub-analysis of the PRINCESS trial (NCT01400373) that randomized 677 bystander-witnessed cardiac arrests to transnasal evaporative intra-arrest cooling initiated by emergency medical services or cooling started after hospital arrival. Early cooling (intervention) was defined as intra-arrest cooling initiated \u3c 20 min from collapse (i.e., ≤ median time to cooling in PRINCESS). Propensity score matching established comparable control patients. Primary outcome was favorable neurologic outcome, Cerebral Performance Category (CPC) 1–2 at 90 days. Complete recovery (CPC 1) was among secondary outcomes. Results: In total, 300 patients were analyzed and the proportion with CPC 1–2 at 90 days was 35/150 (23.3%) in the intervention group versus 24/150 (16%) in the control group, odds ratio (OR) 1.92, 95% confidence interval (CI) 0.95–3.85, p =.07. In patients with shockable rhythm, CPC 1–2 was 29/57 (50.9%) versus 17/57 (29.8%), OR 3.25, 95%, CI 1.06–9.97, p =.04. The proportion with CPC 1 at 90 days was 31/150 (20.7%) in the intervention group and 17/150 (11.3%) in controls, OR 2.27, 95% CI 1.12–4.62, p =.02. In patients with shockable rhythms, the proportion with CPC 1 was 27/57 (47.4%) versus 12/57 (21.1%), OR 5.33, 95% CI 1.55–18.3, p =.008. Conclusions: In the whole study population, intra-arrest cooling initiated \u3c 20 min from collapse compared to cooling initiated at hospital was not associated with improved favorable neurologic outcome. In the subgroup with shockable rhythms, early cooling was associated with improved favorable outcome and complete recovery