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Development of the probability of return of spontaneous circulation in intervals without chest compressions during out-of-hospital cardiac arrest: an observational study
Kenneth Gundersen, Jan Kval?y, Jo Kramer-Johansen, Petter Steen, Trygve Eftest?l
BMC Medicine , 2009, DOI: 10.1186/1741-7015-7-6
Abstract: From an electrocardiogram database we identified all intervals without chest compressions that followed an interval with compressions, and where the patients had ventricular fibrillation or tachycardia. By calculating the mean-slope (a predictor of the return of spontaneous circulation) of the electrocardiogram for each 2-second window, and using a linear mixed-effects statistical model, we quantified the decline of mean-slope with time. Further, a mapping from mean-slope to probability of return of spontaneous circulation was obtained from a second dataset and using this we were able to estimate the expected development of the probability of return of spontaneous circulation for cases at different levels.From 911 intervals without chest compressions, 5138 analysis windows were identified. The results show that cases with the probability of return of spontaneous circulation values 0.35, 0.1 and 0.05, 3 seconds into an interval in the mean will have probability of return of spontaneous circulation values 0.26 (0.24–0.29), 0.077 (0.070–0.085) and 0.040(0.036–0.045), respectively, 27 seconds into the interval (95% confidence intervals in parenthesis).During pre-shock pauses in chest compressions mean probability of return of spontaneous circulation decreases in a steady manner for cases at all initial levels. Regardless of initial level there is a relative decrease in the probability of return of spontaneous circulation of about 23% from 3 to 27 seconds into such a pause.Recent evidence indicates that cardiopulmonary resuscitation (CPR) during both in- and out-of-hospital cardiac arrest is characterised by frequent and long interruptions in chest compressions [1,2]. This reduces vital organ perfusion [3], and in animal experiments, increased length of chest compression pause before shock correlates with reduced rates of return of spontaneous circulation (ROSC) and survival [4-6]. Edelson et al. [7] reported that successful defibrillation, defined as removal of ventricu
S-100B and neuron-specific enolase as predictors of neurological outcome in patients after cardiac arrest and return of spontaneous circulation: a systematic review
Koichiro Shinozaki, Shigeto Oda, Tomohito Sadahiro, Masataka Nakamura, Yo Hirayama, Ryuzo Abe, Yoshihisa Tateishi, Noriyuki Hattori, Tadanaga Shimada, Hiroyuki Hirasawa
Critical Care , 2009, DOI: 10.1186/cc7973
Abstract: A Medline search of literature published before August 2008 was performed using the following search terms: "NSE vs CA or CPR", "S100 vs CA or CPR". Publications examining the clinical usefulness of NSE or S-100B as a prognostic predictor in two outcome groups were reviewed. All publications met with inclusion criteria were classified into three groups with respect to the definitions of outcome; "dead or alive", "regained consciousness or remained comatose", and "return to independent daily life or not". The significance of differences between two outcome groups, cutoff values and predictive accuracy on each time points of blood sampling were investigated.A total of 54 papers were retrieved by the initial text search, and 24 were finally selected. In the three classified groups, most of the studies showed the significance of differences and concluded these biomarkers were useful for neurological predictor. However, in view of blood sampling points, the significance was not always detected. Nevertheless, only five studies involved uniform application of a blood sampling schedule with sampling intervals specified based on a set starting point. Specificity was not always set to 100%, therefore it is difficult to indiscriminately assess the cut-off values and its predictive accuracy of these biomarkers in this meta analysis.In such circumstances, the findings of the present study should aid future investigators in examining the clinical usefulness of these markers and determination of cut-off values.Identifying neurological prognostic factors after cardiopulmonary resuscitation (CPR) in patients with cardiac arrest (CA) as early and accurately as possible is urgently needed to determine therapeutic strategies after successful CPR and avoid medical futility. Many investigators have previously attempted to establish them [1,2].Epidemiological data on CA are generally accumulated according to the Utstein Templates [3-5], and retrospective analysis of these data allows, to
Too cold may not be so cool: spontaneous hypothermia as a marker of poor outcome after cardiac arrest
Jakobea W?rner, Mauro Oddo
Critical Care , 2010, DOI: 10.1186/cc9270
Abstract: den Hartog and colleagues prospectively analyzed data from 105 consecutive comatose patients resuscitated from cardiac arrest (CA) and treated with therapeutic hypothermia (TH) over a 2-year period [1]. They observed that the percentage of patients with unfavourable outcome (including death, vegetative state and severe disability) was significantly higher in patients with spontaneous hypothermia (69%) than in those with a body temperature ≥35°C on admission to the ICU (50%, P = 0.05). Using multivariable analysis, and adjusting for age, initial arrest rhythm, and APACHE II and SOFA scores, the association between spontaneous hypothermia and outcome at 6 months was confirmed.In this single centre prospective cohort of more than 100 patients, spontaneous hypothermia remained significantly associated with long-term outcome, even when adjusted for APACHE II and SOFA scores. This indicates that low body temperature <35°C on admission after CA is a strong marker of neurological recovery.Previous studies have shown that spontaneous hypothermia is associated with increased mortality after severe trauma and haemorrhage [2]. TH has improved prognosis of hypoxic-ischemic encephalopathy [3], and might have an impact on our ability to predict final patient prognosis [4]. den Hartog and colleagues identify spontaneous hypothermia as a new prognostic marker of CA.However, in accordance with Utstein's style registry [5], arrest conditions (that is, witnessed versus un-witnessed arrest), initial arrest rhythm (that is, ventricular fibrillation versus non-ventricular fibrillation) and duration of circulatory arrest (that is, time from collapse to return of spontaneous circulation) are other well-known predictors of prognosis [6]. These parameters, and particularly time to return of spontaneous circulation, were not entered in the logistic regression; thus, it remains to be further established whether spontaneous hypothermia is an independent predictor of outcome. Furthermore, body te
Brain Stem Death as the Vital Determinant for Resumption of Spontaneous Circulation after Cardiac Arrest in Rats  [PDF]
Alice Y. W. Chang,Julie Y. H. Chan,Yao-Chung Chuang,Samuel H. H. Chan
PLOS ONE , 2012, DOI: 10.1371/journal.pone.0007744
Abstract: Spontaneous circulation returns to less than half of adult cardiac arrest victims who received in-hospital resuscitation. One clue for this disheartening outcome arises from the prognosis that asystole invariably takes place, after a time lag, on diagnosis of brain stem death. The designation of brain stem death as the point of no return further suggests that permanent impairment of the brain stem cardiovascular regulatory machinery precedes death. It follows that a crucial determinant for successful revival of an arrested heart is that spontaneous circulation must resume before brain stem death commences. Here, we evaluated the hypothesis that maintained functional integrity of the rostral ventrolateral medulla (RVLM), a neural substrate that is intimately related to brain stem death and central circulatory regulation, holds the key to the vital time-window between cardiac arrest and resumption of spontaneous circulation.
Relationship between time to target temperature and outcome in patients treated with therapeutic hypothermia after cardiac arrest
Moritz Haugk, Christoph Testori, Fritz Sterz, Maximilian Uranitsch, Michael Holzer, Wilhelm Behringer, Harald Herkner, the Time to Target Temperature Study Group
Critical Care , 2011, DOI: 10.1186/cc10116
Abstract: Temperature data between April 1995 and June 2008 were collected from 588 patients and analyzed in a retrospective cohort study by observers blinded to outcome. The time needed to achieve an esophageal temperature of less than 34°C was recorded. Survival and neurological outcomes were determined within six months after cardiac arrest.The median time from restoration of spontaneous circulation to reaching a temperature of less than 34°C was 209 minutes (interquartile range [IQR]: 130-302) in patients with favorable neurological outcomes compared to 158 min (IQR: 101-230) (P < 0.01) in patients with unfavorable neurological outcomes. The adjusted odds ratio for a favorable neurological outcome with a longer time to target temperature was 1.86 (95% CI 1.03 to 3.38, P = 0.04).In comatose cardiac arrest patients treated with therapeutic hypothermia after return of spontaneous circulation, a faster decline in body temperature to the 34°C target appears to predict an unfavorable neurologic outcome.For patients who have been successfully resuscitated after cardiac arrest, therapeutic mild hypothermia increases the rate of a favorable outcome in comparison with standard life support. Randomized controlled trials, however, have not shown evidence of whether the time to target temperature correlates with neurological outcome [1-4]. Registries about the practical use of therapeutic hypothermia have also not found a significant association between the timing of therapeutic hypothermia and final outcome [5-7]. We expected a strong relationship between the time to target temperature (<34°C) and neurological outcome. Furthermore, we hypothesized that earlier achievement of target temperature would not necessarily improve outcome.The study was designed as a single-center retrospective cohort study on temperature data extracted from patients' charts by observers blinded to outcome. The protocol and consent procedures were approved by the ethics committee of the Medical University of
Serum Cortisol Levels as a Predictor of Neurologic Survival inSuccessfully Resuscitated Victims of Cardiopulmonary Arrest
Nader Tavakoli,Ali Bidari,Samad Shams Vahdati
Journal of Cardiovascular and Thoracic Research , 2012,
Abstract: Introduction: Out-of-hospital cardiac arrest (OHCA) is the most stressful lifetime event for the victims and an important issue for the emergency physicians. The status of the hypothalamic pituitary- adrenal axis (HPA) function in successfully resuscitated victims of cardiopulmonary arrest has been recently of an interest for the researchers. Methods: In a prospective cohort study, 50 successfully resuscitated OHCA victims’ serum cortisol levels were measured 5 minutes and 1 hour after return of spontaneous circulation (ROSC). The data were analyzed comparing the one-week neurologic survival. Results: Fifty blood samples were obtained for serum cortisol levels after 5 minutes of ROSC. Fourteen patients (28%) pronounced death during one hour after CPR. Blood sample from living 36 patients after one hour post-CPR were obtained for second cortisol assay. Eleven patients (22%) were neurologically survived after one week. Seven patients (14%) were discharged finally from hospital with good neurologic recovery. The serum cortisol levels in both the neurologically surviving and the non-surviving after 5 minutes of ROSC patients were 63.4 ±13.6 and 43.2±25.5(microg/ml), (mean±S.D., respectively) and after 1 hour of ROSC patients’ serum cortisol levels were 64.9±13.1 and 47.3±27.1(microg/ml), (mean±S.D., respectively). The difference was significantly higher in neurologically survived group in both 5 minutes and 1 hour after ROSC (P= 0.015 and 0.013 respectively). Conclusion: serum cortisol levels after 5 minutes and one hour of ROSC in victims of cardiopulmonary arrest are significantly higher in neurologically survived than non-survived patients.
Successful resuscitation of out of hospital cardiac arrest patients in the emergency department  [cached]
Shou-Yen Chen,Shih-Hao Wang,Yi-Ming Weng,Yu-Che Chang
Signa Vitae , 2011,
Abstract: Background. We examined factors associated with the successful resuscitation, in the emergency department (ED), of adult, out-of-hospital cardiac arrest (OHCA) patients.Methods. The study cohort consisted of adult patients (over 18 years of age) who presented to the ED in 2009 with a diagnosis of cardiac arrest. Data were retrieved from the institutional database. Results. A total of 122 adult, non-traumatic, OHCA patients were enrolled in the study. There were no significant differences between the sustained return of spontaneous circulation (ROSC) and non-sustained ROSC groups in initial body temperature (P = 0.420), time to successful intubation (P = 0.524), time to first intravenous epinephrine injection (P = 0.108), blood sugar levels (P = 0.122), hematocrit (P = 0.977), cardiac enzymes (P = 0.116) and serum sodium level (P = 0.429). Leukocytosis (P = 0.047) and cardiac rhythm of pulseless ventricular tachycardia/ ventricular fibrillation and pulseless electrical activity (P = 0.022), were significantly associated with sustained ROSC. In contrast, patients with more severe acidosis (P = 0.003) and hyperkalemia (P < 0.001) had a reduced likelihood of achieving sustained ROSC. After multiple variable logistic regression analysis adjusting for variables, the correlation between sustained ROSC and leukocytosis and hyperkalemia remained high (leukocytosis, P = 0.007, odds ratio [OR] 3.655, 95% CI 1.422-9.395; hyperkalemia, P = 0.001, OR 0.169, 95% CI 0.057-0.500)Conclusion. Patients suffering an OHCA were appropriately resuscitated after arriving at the ED. Successful resuscitation in adult OHCA victims was determined by the patient's status, in particular their white blood cell count and potassium level.
Improved neurologically intact survival with the use of an automated, load-distributing band chest compression device for cardiac arrest presenting to the emergency department
Marcus Hock Ong, Stephanie Fook-Chong, Annitha Annathurai, Shiang Ang, Ling Tiah, Kok Yong, Zhi Koh, Susan Yap, Papia Sultana
Critical Care , 2012, DOI: 10.1186/cc11456
Abstract: We conducted a phased, prospective cohort evaluation with intention-to-treat analysis of adults with non-traumatic cardiac arrest. At these two urban EDs, systems were changed from manual CPR to LDB-CPR. Primary outcome was survival to hospital discharge, with secondary outcome measures of return of spontaneous circulation, survival to hospital admission and neurological outcome at discharge.A total of 1,011 patients were included in the study, with 459 in the manual CPR phase (January 01, 2004, to August 24, 2007) and 552 patients in the LDB-CPR phase (August 16, 2007, to December 31, 2009). In the LDB phase, the LDB device was applied in 454 patients (82.3%). Patients in the manual CPR and LDB-CPR phases were comparable for mean age, gender and ethnicity. The mean duration from collapse to arrival at ED (min) for manual CPR and LDB-CPR phases was 34:03 (SD16:59) and 33:18 (SD14:57) respectively. The rate of survival to hospital discharge tended to be higher in the LDB-CPR phase (LDB 3.3% vs Manual 1.3%; adjusted OR, 1.42; 95% CI, 0.47, 4.29). There were more survivors in LDB group with cerebral performance category 1 (good) (Manual 1 vs LDB 12, P = 0.01). Overall performance category 1 (good) was Manual 1 vs LDB 10, P = 0.06.A resuscitation strategy using LDB-CPR in an ED environment was associated with improved neurologically intact survival on discharge in adults with prolonged, non-traumatic cardiac arrest.Sudden cardiac arrest is a global concern. This can be an out-of-hospital cardiac arrests (OHCA), or cardiac arrest in a patient attending the Emergency Department (ED) or an in-hospital patient. The incidence of out-of-hospital cardiac arrest (OHCA) in USA has been estimated at 1.89/1,000 person-years and at 5.98/1,000 person-years in patients with any clinically recognized heart disease [1]. Published survival rates for OHCA in North America range from 3.0% to 16.3% [2].The problem with standard cardiopulmonary resuscitation (STD-CPR) is that it provides on
Circulation Flows: Cooling Flows with Bubble Return  [PDF]
William G. Mathews,Fabrizio Brighenti,David A. Buote,Aaron D. Lewis
Physics , 2003, DOI: 10.1086/377596
Abstract: The failure of the XMM-Newton and Chandra X-ray telescopes to detect cooling gas in elliptical galaxies and clusters of galaxies has led many to adopt the position that the gas is not cooling at all and that heating by an active nucleus in the central E or cD galaxy is sufficient to offset radiative cooling. In this paper we explore an idealized limiting example of this point of view in which hot, buoyant bubbles formed near the center return the inflowing, radiatively cooling gas to distant regions in the flow. We show that idealized steady state, centrally heated non-cooling flows can indeed be constructed. In addition, the emission-weighted temperature profiles in these circulating flows resemble those of normal cooling flows. However, these solutions are valid only (1) for a range of bubble parameters for which there is no independent justification, (2) for a limited spatial region in the cooling flow and (3) for a limited period of time after which cooling seems inevitable. Our exploration of non-cooling flows is set in the context of galaxy/group flows.
The Role of Oxygen in Cardiac Arrest Resuscitation  [cached]
Signa Vitae , 2010,
Abstract: The heart is incapable of storing significant oxygen or substrates and thus is entirely dependent on a continuous delivery of flow in order to support its high metabolic state. Following cardiac arrest, myocardial tissue oxygen tension falls rapidly and aerobic production of ATP ceases. Without re-oxygenation of the ischemic myocardium, return of spontaneous circulation (ROSC) cannot be achieved. The oxygen paradox which has been described regarding other ischemia-reperfusion conditions seems to have application in cardiac arrest. It is clear that some level of oxygenation is necessary to achieve ROSC, however post ROSC there appears to be increased toxicity associated with hyperoxia. The optimal conditions for re-oxygenation in the setting of cardiac arrest remain ill defined at present.
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