Epinephrine in out-of-hospital cardiac arrest:A critical review

BACKGROUND:Epinephrine is recommended in advanced cardiac life support guidelines for use in adult cardiac arrest,and has been used in cardiopulmonary resuscitation since 1896.Yet,despite its long time use and incorporation into guidelines,epinephrine suffers from a paucity of evidence regarding its influence on survival.This critical review was conducted to address the knowledge deficit regarding epinephrine in out-of-hospital cardiac arrest and its effect on return of spontaneous circulation,survival to hospital discharge,and neurological performance.METHODS:The EMBASE and MEDLINE(through the Pubmed interface) databases,and the Cochrane library were searched with the key words "epinephrine", "cardiac arrest" and variations of these terms.Original research studies concerning epinephrine use in adult,out-of-hospital cardiac arrest were selected for further review.RESULTS:The search yielded nine eiigible studies based on inclusion criteria.This includes five prospective cohort studies,one retrospective cohort study,one survival analysis,one case control study,and one RCT The evidence clearly establishes an association between epinephrine and increased return of spontaneous circulation,the data were conflicting concerning survival to hospital discharge and neurological outcome.CONCLUSIONS:The results of this review exhibit the paucity of evidence regarding the use of epinephrine in out of hospital cardiac arrest.There is currently insufficient evidence to support or reject its administration during resuscitation.Larger sample,placebo controlled,double blind,randomized control trials need to be performed to definitively establish the effect of epinephrine on both survival to hospital discharge and the neurological outcomes of treated patients.

Application of Out-of-Hospital Extended Nursing in Brace Treatment of Patients with Idiopathic Scoliosis

Objective:To investigate the effect of out-of-hospital extended nursing on the compliance behaviors and therapeutic effect of brace treatment of patients with idiopathic scoliosis.Methods:54 patients with idiopathic scoliosis between February 2015 and December 2017 were randomly divided into control group and observation group.Patients in the control group received pelvic suspension traction,gymnastic exercises,and brace wear at discharge,on the basis of which patients in the observation group were added with extended care outside the hospital.The compliance behaviors and the changes of scoliosis angle(Cobb angle)of patients in the 2 groups were evaluated.Results:Compared with the control group,patients in the observation group had better compliance behaviors in completion status of functional exercise(χ2=5.594,P=0.018),brace wear(χ2=6.171,P=0.013),subsequent visit on time(χ2=9.247,P=0.002).Cobb angle was improved significantly in both groups at the last follow-up compared with that on admission,and the improvement was more significantly in the observation group(P<0.001).Conclusion:Through the implementation of out-of-hospital extended nursing,the compliance behaviors and clinical effect of brace treatment for idiopathic scoliosis patients are obviously improved,and this active nursing model is worth popularizing in clinic.

Brugada syndrome associated with out-of-hospital cardiac arrest: A case report

BACKGROUND Brugada syndrome(BrS)is an inherited disease characterized by an electrocardiogram(ECG)with a coved-type ST-segment elevation in the right precordial leads(V1-V3),which predisposes to sudden cardiac death(SCD)due to polymorphic ventricular tachycardia or ventricular fibrillation in the absence of structural heart disease.We report the case of a 29-year-old man with out-ofhospital cardiac arrest.BrS is associated with a high incidence of SCD in adults,and increasing the awareness of BrS and prompt recognition of the Brugada ECG pattern can be lifesaving.CASE SUMMARY A 29-year-old man suffered from out-of-hospital cardiac arrest,and after defibrillation,his ECG demonstrated a coved-type elevated ST segment in V1 and V2.These findings were compatible with type 1 Brugada pattern,and ECG of his brother showed a type 2 Brugada pattern.The diagnosis was BrS,NYHF IV,multiple organ dysfunction syndrome,sepsis,and hypoxic ischemic encephalopathy.The patient had no arrhythmia episodes after discharge throughout a follow-up period of 36 mo.CONCLUSION Increasing awareness of BrS and prompt recognition of the Brugada ECG pattern can be lifesaving.

Effect of Airway Management and Impedance Threshold Device on Circulation, Survival and Neurological Outcome in Adult Out-Of-Hospital Cardiac Arrest

Purpose: This study was designed to study the effect of early use of the King Airway (KA) and impedance threshold device (ITD) in out-of-hospital cardiac arrest on ETCO2 as a surrogate measure of circulation, survival, and cerebral performance category (CPC) scores. After analysis of the first 9 month active period the KA was relegated to rescue airway status. Methods: This was a prospective pre-post study design. Patients >18 years with out-of-hospital cardiac caused arrest were included. Three periods were compared. In the first “non active” period conventional AHA 30/2 compression/ventilation ratio CPR was done with bag mask ventilation (BMV). No ITD was used. After advanced airway placement the compression/ventilation ratio was 10/1. In the second period continuous compressions were done. Primary airway management was a KA with an ITD. After placement of the KA the compression/ventilation ratio was 10/1. In the third period CPR reverted to 30/2 ratio with a two hand seal BMV with ITD. CPR ratio was 10/1 post endotracheal intubation (ETI) or KA. The KA was only recommended for failed BMV and ETI. Results: Survival to hospital discharge was similar in all three study periods. In Period 2 there was a strong trend to CPC scores >2. The study group hypothesized that the KA interfered with cerebral blood flow. For that reason the KA was abandoned as a primary airway. Comparing Period 1 to Period 3 there was a trend to improved survival in the bystander witnessed shockable rhythm (Utstein) subgroup, particularly if a metronome was used. ETCO2 was significantly increased in Period 2 and trended up in Period 3 when compared to Period 1. Advanced airway intervention had a highly significant negative association with survival. Conclusion: The introduction of an ITD into our system did not result in a statistically significant improvement in survival. The study groups were somewhat dissimilar. ETCO2 trended up. When comparing Period 1 to Period 3, the bundle of care was associated with a trend towards increased survival in the Utstein subgroup, particularly with a metronome set at 100. Multiple confounders make a definitive conclusion impossible. Advanced airways showed a significant association with poor survival outcomes. The KA was additionally associated with poor neurologic outcomes.

Association between the Consumption of Carbonated Beverages and Out-of-Hospital Cardiac Arrests of Cardiac Origin in Japan

Background: The consumption of carbonated beverages has been shown to increase the risk of developing metabolic syndrome. The associations between the consumption of carbonated beverages and left arterial dimension or left ventricular mass are believed to be likely related to the greater body weight of carbonated beverage drinkers relative to non-drinkers. Nonetheless, little is known about the association between the consumption of carbonated beverages and out-of-hospital cardiac arrests (OHCAs) in Japan. Methods: We compared the age-adjusted incidence of OHCAs to the expenditures on various beverages per person between 2005 and 2011 in the 47 prefectures of Japan. Patients who suffered from OHCAs of cardiac and non-cardiac origin were enrolled in All-Japan Utstein Registry of the Fire and Disaster Management Agency. The expenditures on various beverages per person in the 47 prefectures in Japan were obtained from data published by the Ministry of Health, Labour and Welfare of Japan. Results: There were 797,422 cases of OHCA in the All-Japan Utstein registry between 2005 and 2011, including 11,831 cases who did not receive resuscitation. Among these 785,591 cases of OHCA, 435,064 (55.4%) were classified as cardiac origin and 350,527 (44.6%) were non-cardiac origin. Non-cardiac origin included cerebrovascular disease, respiratory disease, malignant tumor, and exogenous disease (4.8%, 6.1%, 3.5%, and 18.9%, respectively). The expenditures on carbonated beverages were significantly associated with OHCAs of cardiac origin (r = 0.30, p = 0.04), but not non-cardiac origin (r = -0.03, p = 0.8). Expenditures on other beverages, including green tea, tea, coffee, cocoa, fruit or vegetable juice, fermented milk beverage, milk beverage, and mineral water, were not significantly associated with OHCAs of cardiac origin. Conclusion: Carbonated beverage consumption was significantly and positively associated with OHCAs of cardiac origin in Japan, indicating that beverage habits might play a role in OHCAs of cardiac origin.

Are There Age-Related Differences in the In-Hospital Treatment of Victims from Out-of-Hospital Cardiac Arrest?

Objective: Hardly anything is known about reasons for age-related differences in surviving out-of-hospital cardiac arrest (OHCA) with worse surviving rates in elderly. Methods: 204 victims from OHCA who were admitted in our hospital between January 1st 2008 and December 31st 2013 were identified. According to their mean age (69.1 ± 14.2 years) we classified those patients (pts) who were younger than mean age minus standard deviation (SD) as young, and those victims from OHCA who were older than mean age plus SD as old. Results: Young victims from OHCA (n = 32 pts) presented more often with an initial shockable rhythm than the elderly (n = 38 pts) (50.0% vs. 21.1%;p = 0.014), received more often coronary angiography (71.9% vs. 18.4%;

Coronary Angiography in Patients with and without STEMI Following Out-of-Hospital Cardiac Arrest

Introduction: Little is known about discrepancies between patients who present with or without STEMI following out-of-hospital cardiac arrest (OHCA). Material and Methods: All patients with OHCA who were admitted to our hospital between January 1st 2008 and December 31st 2013 were classified according to their initial laboratory and electrocardiographic findings into STEMI, NSTEMI or no ACS. Results: Overall, 147 patients [32 STEMI (21.8%), 28 NSTEMI (19.0%) and 87 no ACS (59.2%)] were included with a mean age of 63.7 ± 13.3 years;there were 84 men (57.1%) and 63 (42.9%) women. Of these, 63 patients (51.7%) received coronary angiography [29 STEMI (90.6%), 9 NSTEMI (32.1%) and 38 no ACS (43.7%)] showing a high prevalence of coronary artery disease (CAD) [28 STEMI (96.6%), 9 NSTEMI (100.0%) and 26 no ACS (68.4%)] requiring percutaneous coronary intervention (PCI) in 52 cases [28 STEMI (96.6%), 8 NSTEMI (88.9%) and 16 no ACS (42.1%)]. Discussion: Coronary angiography immediately after hospital admission is feasible if all are prepared for potential further resuscitation efforts during cardiac catheterization. Primary focus on haemodynamic stabilisation may reduce the rates of coronary angiographies in patients following OHCA. Altogether, our data support the call for immediate coronary angiography in all patients following OHCA irrespective of their initial laboratory or electrocardiographic findings.

Perimortem caesarean section: A case report of an out-of-hospital arrest pregnant woman

Dear editor,In July 2015,a 39-year-old gravida 2,para 0 lady at 35 weeks’gestation was found collapsed at home and sent to the emergency department(ED)by ambulance.She had a background of chronic hypertension on antihypertensives and aspirin,but repeatedly refused inpatient treatment for her uncontrolled hypertension.

Decreased human leukocyte antigen-D-related expression on CD14^(+)monocytes in patients with out-of-hospital cardiac arrest provided target temperature management therapy:a prospective observational study

Background:Post–cardiac arrest syndrome involves systemic inflammation,which causes subsequent neurological impairments.We investigated the influence of targeted temperature management(TTM)therapy in patients with out-of-hospital cardiac arrest(OHCA)after return of spontaneous circulation(ROSC)by observing the changes in circulating CD14^(+)monocytes and the expression of human leukocyte antigen D–related(HLA-DR)and programmed cell death ligand 1(PD-L1)in CD14^(+)monocytes.Methods:Adult patients admitted to the emergency department of Beijing Chao-Yang Hospital after OHCA between January 2017 and March 2018 were included in this study.Thirty control subjects,10 patients with OHCA,and 37 patients with OHCA who received 72 hours of TTM therapy were enrolled.Peripheral blood samples of patients in the OHCA and TTM groups were collected on Days 1 and 3(D1 and D3)after ROSC and evaluated for HLA-DR and PD-L1 expression on CD14^(+)monocytes using flow cytometry.Results:Compared with control subjects,the percentage of circulating CD14^(+)monocytes,HLA-DR+/CD14^(+)monocyte ratios,and mean fluorescence intensity were significantly decreased in patients with OHCA.After ROSC,HLA-DR expression in CD14^(+)monocytes in the TTM group was lower than that in patients with OHCA.However,there were no significant differences in the percentage of PD-L1+/CD14^(+)monocytes or the mean fluorescence intensity between patients with OHCA and healthy volunteers.Conclusion:After ROSC,circulating CD14^(+)monocytes and HLA-DR+/CD14^(+)monocyte ratios decreased significantly in patients with OHCA.Human leukocyte antigen D–related expression in CD14^(+)monocytes was lower in patients treated with TTM.

Impact of emergency percutaneous coronary intervention on outcomes of ST-segment elevation myocardial infarction patients complicated by out-of-hospital cardiac arrest

Background Cardiac arrest is one of the most serious complications of acute myocardial infarction （AMI）, especially in the out-of-hospital patients. There is no general consensus as to whether percutaneous coronary intervention （PCI） is effective in treating ST-segment elevation myocardial infarction （STEMI） patients complicated by out-of-hospital cardiac arrest （OHCA）. In our study, we evaluated the efficacy of PCI in treating STEMI patients complicated by OHCA through observing their clinical conditions in hospital; including total mortality, adverse cardiac events, stroke, acute renal failure, and gastrointestinal bleeding events. Methods A total of 1827 STEMI patients were enrolled in this study, where 81 were STEMI with OHCA. Between the patients with and without OHCA, and the OHCA patients with and without PCI, we compared the clinical characteristics during hospitalization, including total mortality and incidences of adverse cardiac events, and stroke. Results Compared to the patients without OHCA, the OHCA patients had significantly lower systolic blood pressure （P 〈0.05） and a faster heart rate （P〈0.05）, and a higher percentage of Killip class IV or Glasgow coma scale （GCS） 〈7 on admission （P 〈0.001）. And the in-hospital mortality was higher in the OHCA patients （55.6% vs. 2.4%, P 〈0.001）. Comparing the OHCA patients without PCI to the patients with PCI, there was no obvious difference of heart rate, blood pressure or the percentage of Killip class IV and GCS -〈7 on admission, but the incidences of cardiogenic shock, stroke were significantly lower in the with-PCI group during hospitalization （P 〈0.001, P 〈0.05）. And the in-hospital mortality of the OHCA patients receiving PCI was significantly lower （36.7% vs. 84.3%, P 〈0.001）. Conclusions During hospitalization, the incidence of adverse events and mortality are higher in the STEMI with OHCA patients, comparing with the STEMI without OHCA. Emergency PCI reduces the incidence of adverse events and decreases mortality during hospitalization, which is effective for treating STEMI with OHCA patients.

Early Changes in Circulatory T Helper Type 1, 2, and 17 Cells of Patients with Out-of-Hospital Cardiac Arrest after Successful Cardiopulmonary Resuscitation

Background： Immune disorder is an important feature of patients with out-of-hospital cardiac arrest （OHCA） after the return of spontaneous circulation （ROSC）. We investigated the expression of circulatory T helper type （Th）1, Th2, and Th 17 cells to explore the early immune alteration in OHCA patients after ROSC. Methods： During July-September 2016 and March-September 2017, 65 consecutive OHCA patients with ROSC 〉 12 h and 30 healthy individuals were enrolled in this study. Clinical and 28-day survival data were collected. Peripheral blood samples were analyzed to evaluate the expression of Th1/Th2/Th 17 cells by flow cytometry from OHCA patients after ROSC on days l and 3 and from healthy individuals. Results： Compared with healthy individuals, T lymphocyte counts and Thl cell counts decreased on days 1 and 3 after ROSC （1464 [1198, 2152] vs. 779 [481, 1140] vs. 581 [324, 1118/μl,χ^2= 30.342, P 〈 0.001; 154 [90, 246] vs. 39 [19, 78] vs. 24 [12, 53]μl, χ^2 = 42.880, P〈 0.001）, and Th2 and Th17 cell counts decreased on day 3 （17.0 [10.8, 24.0] vs. 9.0 [3.0, 15.5]μl, Z= -3.228, P= 0.001; 4.7 [2.7, 9.1] vs. 2.7 [1.0, 6.5]μl, Z = -2.294, P = 0.022）. No change in CD4＋/CD3＋ lymphocyte ratio was seen on day 1 or day 3 （57.9 [49.4, 63.0] vs. 55.4 [46.5, 66.5] vs. 55.4 [50.2, 67.0]%, χ^2 = 0.171, P = 0.918）. Th1/CD4＋ lymphocyte ratio decreased on days 1 and 3 （19.0 [14.0, 24.9] vs. 9.3 [4.6, 13.9] vs. 9.5 [4.9, 13.6]%, χ^2= 25.754, P 〈 0.001）, and Th2/CD4＋ lymphocyte ratio increased on day 1 and decreased on day 3 （1.9 [1.2, 2.5] vs. 2.5 [1.6, 4.0] vs. 1.9 [1.6, 3.81%,χ^2= 6.913, P = 0.032）. Thl/Th2 cell ratio also decreased on both clays （9.4 [7.3, 13.5] vs. 3.1 [1.9, 5.6] vs. 4.2 [2.8, 5.9], χ^2 = 44.262, P 〈 0.001 ）. Despite an upward trend in the median of Th 17/CD4＋ lymphocyte ratio in OHCA patients, there was no significant difference compared with healthy individuals （0.9 [0.4, 1.2] vs. 0.7 [0.4, 1.2] vs. 0.6 [0.3, 1.01%, χ^2= 2.620, P = 0.270）. The dynamic expression of Th1/Th2/Th 17 cells on days 1 and 3 were simultaneously analyzed in 28/53 OHCA patients who survived 〉3 days; patients were divided into survivors （n = 10） and nonsurvivors （n = 18） based on 28-day survival. No significant differences in Th1/Th2/Th 17 cell counts, ratios in CD4＋ lymphocytes, and Th1/Th2 cell ratio were seen between survivors and nonsurvivors on both days （all P 〉 0.05）. There was no difference over time in both survivors and nonsurvivors （all P 〉 0.05）. Conclusion： Downregulated T lymphocyte counts, including Th1/Th2/Th17 subsets and Th1/Th2 cell ratio imbalance, occur in the early period after ROSC, that may be involved in immune dysfunction in OHCA patients.

Outcome of bystander cardiopulmonary resuscitation after out-of-hospital cardiac arrest in Beijing

Aim:We aimed to investigate the association between bystander cardiopulmonary resuscitation(CPR)and survival of patients with out-of-hospital cardiac arrests(OHCA)in Beiing.Methods:This observational study analyzed adult patients with OHCA treated by the Beiing emergency medical service(EMS)from January 2013 to December 2017.Data were collected in a Utstein style with a 1-year follow-up and a primary outcome 01 survival to hospital discharge.Secondary outcomes were return of spontaneous circulation(ROSC),survival to admission,favorable neurological outcome at hospital discharge,and survival and favorable neurological outcomes of up to 1 year.Results:A total of 5016 patients with OHCA from Beiing's urban area were recorded by EMS,wherein 765 patients(15.25%)underwent bystander CPR.The data were propensity score-matched forage,sex,location,witness,aetiology,initial rhythm,and call to EMS arrival to compare the difference between the occurrence and nonoccurrence of bystander CPR.The survival upon the discharge of patients who experienced bystander CPR was superior to that of patients who did not receive bystander CPR(3.7%vs 1.2%,respectively;P<0.001).Moreover,patients with OHCA resuscitated with bystander CPR achieved better outcomes of ROSC,survival to admission,favorable neurological outcome at hospital discharge,survival and favorable neurological outcome after 1 year compared with those who were not resuscitated with bystander CPR.Conclusion:Survival and neu rological outcome of patients who underwent bystander CPR was better than those who underwent nonbystander CPR in Beiing.However,the rate of bystander CPR was low.

Cardiac arrest, stony heart, and cardiopulmonary resuscitation: An updated revisit

The post-resuscitation period is recognized as the main predictor of cardiopul-monary resuscitation(CPR)outcomes.The first description of post-resuscitation syndrome and stony heart was published over 50 years ago.Major manifestations may include but are not limited to,persistent precipitating pathology,systemic ischemia/reperfusion response,post-cardiac arrest brain injury,and finally,post-cardiac arrest myocardial dysfunction(PAMD)after successful resuscitation.Why do some patients initially survive successful resuscitation,and others do not?Also,why does the myocardium response vary after resuscitation?These ques-tions have kept scientists busy for several decades since the first successful resuscitation was described.By modifying the conventional modalities of resu-scitation together with new promising agents,rescuers will be able to salvage the jeopardized post-resuscitation myocardium and prevent its progression to a dismal,stony heart.Community awareness and staff education are crucial for shortening the resuscitation time and improving short-and long-term outcomes.Awareness of these components before and early after the restoration of circulation will enhance the resuscitation outcomes.This review extensively addresses the underlying pathophysiology,management,and outcomes of post-resuscitation syndrome.The pattern,management,and outcome of PAMD and post-cardiac arrest shock are different based on many factors,including in-hospital cardiac arrest vs out-of-hospital cardiac arrest(OHCA),witnessed vs unwitnessed cardiac arrest,the underlying cause of arrest,the duration,and protocol used for CPR.Although restoring spontaneous circulation is a vital sign,it should not be the end of the game or lone primary outcome;it calls for better understanding and aggressive multi-disciplinary interventions and care.The development of stony heart post-CPR and OHCA remain the main challenges in emergency and critical care medicine.

Out of hospital cardiac arrest resuscitation outcome in North India—CARO study

BACKGROUND: To evaluate the outcome of cardiopulmonary resuscitation(CPR) in out-ofhospital cardiac arrests(OHCA) in India and factors infl uencing the outcome.METHODS: The outcome and related factors like demographics, aspects of the OHCA event, return of spontaneous circulation(ROSC) and survival to discharge, among the 80 adult patients presenting to emergency department experiencing OHCA considered for resuscitation between January 2014 to April 2015, were analyzed, according to the guidelines of the Utstein consensus conference.RESULTS: The survival rate to hospital admission was 32.5%, the survival rate to hospital discharge was 8.8% and with good cerebral performance category(CPC1) neurological status was 3.8%. Majority of OHCA was seen in elderly individuals between 51 to 60 years, predominately in males. Majority of OHCA were witnessed arrests(56.5%) with 1.3% bystander CPR rate, 92.5% arrests occurred at home, 96% presented with initial non-shockable rhythm and 92.5% with presumed cardiac etiology but survival was better in those who experienced OHCA at public place, in witnessed arrests, in patients who had shockable presenting rhythm and in those where CPR duration was ≤20 minutes.CONCLUSION: Witnessed arrests, early initiation of CPR by bystanders, CPR duration ≤20 minutes, initial presenting shockable rhythm, OHCA with non-cardiac etiology are associated with a good outcome. To improve the outcome of CPR and the low survival rates after an OHCA event in India, focused strategies should be designed to set up an emergency medical system(EMS), to boost the rates of bystander CPR and education of the lay public in basic CPR.

Benefits of using an endotracheal tube introducer as an adjunct to a Macintosh laryngoscope for endotracheal intubation performed by inexperienced doctors during mechanical CPR:A randomized prospective crossover study

Dear editor, Out-of-hospital cardiac arrest survival rates vary between 7% and 46% and are lower than those for inhospital cardiac arrests (IHCA).[1,2] Therefore, efforts are being made to increase survival rates for out-ofhospital cardiac arrests (OHCA). According to advanced cardiac life support (ACLS) guidelines, out-of-hospital cardiac arrest survival rates may be increased by performing cardiopulmonary resuscitation (CPR) with minimal interruptions.[3] According to the latest ACLS, does the patient need an advanced airway.