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Epinephrine for Non-Shockable In-hospital Cardiac Arrest — Time is of the Essence

29 Jun, 14 | by Alistair Lindsay

Guidelines recommend epinephrine as the primary medical intervention for cardiac arrest. However, no randomized trial data are available to support this recommendation. In this observational study from the American Heart Association’s Get With The Guidelines – Resuscitation multi-center registry of in-hospital cardiac arrest, the authors sought to determine if timing of epinephrine administration in the setting of non-shockable (i.e. pulseless electrical activity or asystole) in-hospital cardiac arrest is associated with patient outcomes. Among 25,095 patients with non-shockable in-hospital cardiac arrest, the median time to first epinephrine was 3 minutes (IQR 1-5 minutes). When analyzed at 3 minute intervals, there was a stepwise decrease in survival to discharge with increasing time to epinephrine. As compared to 1-3 minutes, the adjusted odds ratios were 0.91 (95% confidence interval [CI] 0.82 – 1.00; p = 0.055) for 4-6 minutes, 0.74 (95% CI 0.63 – 0.88; p < 0.001) for 7-9 minutes, and 0.63 (95% CI 0.52 – 0.76) for > 9 minutes. The authors also performed sensitivity analyses to ensure the primary analysis was not confounded by overall delays in initiation of resuscitation independent of time to epinephrine, by the selection of 3 minute increments for categorization of epinephrine administration, or by missing covariates. The results of the sensitivity analyses were similar to those of the primary analysis. more…

Pre-hospital cooling with saline infusion does not improve cardiac arrest outcomes

13 Apr, 14 | by Alistair Lindsay

Prior randomized trials have established hypothermia as a promising therapy to improve outcomes of cardiac arrest.  It has been suggested that the benefit of hypothermia may be increased through early initiation of cooling in the field prior to hospital arrival.  In this trial, 1,364 patients with out-of-hospital cardiac arrest were randomized to usual care or pre-hospital cooling with infusion of cold normal saline immediately after return of spontaneous circulation. The intervention was associated with a reduction in core temperature, but no change in clinical outcomes. Among patients with arrest in the setting of ventricular fibrillation, there were no differences between patients treated with cold saline vs control in survival to discharge (62.7% vs. 64.3%, P.69) or neurologic recovery (57.5% vs. 61.9%, P=.69). Similarly, among patients without ventricular fibrillation, the proportion of patients surviving to discharge (19.2% vs 16.3%, P=.30) or with neurological recovery (14.4% vs. 13.4%, P=.30) did not differ between the intervention and control groups. more…

Target cooling temperatures in cardiac arrest – should we just focus on avoiding fever instead?

2 Feb, 14 | by Alistair Lindsay

Prior trials of out-of-hospital cardiac arrest of presumed cardiac etiology have demonstrated improved survival and neurologic function when patients are treated with therapeutic hypothermia. Questions remain as to the optimal target temperature for therapeutic hypothermia. In this international study of patients with out-of-hospital cardiac arrest, 950 patients were randomly assigned to therapeutic hypothermia at a target temperature of either 33°C or 36°C. Treating physicians were aware of the patient’s assignment and all therapies to achieve targets were at the treating center’s discretion. Mean follow-up was 256 days and the primary outcome was death with secondary outcomes including assessments of neurological recovery. No benefit was observed with treatment to target temperature of 33°C. Compared to patients treated to 36°C, patients treated to 33°C had similar mortality (hazard ratio, 1.06; 95% CI, 0.89 to 1.28; P=0.51) and neurologic recovery (risk ratio, 1.02; 95% CI, 0.88 to 1.16; P=0.78) Pre-specified sub-group analyses also failed to demonstrate statistically significant differences between the two target temperatures. more…

Epinephrine Use and Cardiac Arrest Survival

5 Apr, 12 | by Alistair Lindsay

Whist epinephrine (adrenaline) is commonly used during cardiopulmonary resuscitation (CPR), both in and out of hospital, its effectiveness is poorly established.  Although some animal studies have suggested a short term benefit due to increased cerebral and coronary perfusion, an increase in myocardial oxygen consumption and ventricular arrhythmias has also been documented.  The purpose of this analysis was to determine how the use of epinephrine in CPR performed before hospital arrival (out-of-hospital arrest) was associated with immediate and 1-month survival. more…

Cardiac arrest in marathon runners investigated

29 Jan, 12 | by Alistair Lindsay

Despite the increasingly sedentary nature of society, one participation sport that is thriving is long-distance running with approximately 2 million people participating in marathon or half-marathons in the United States annually. Tragically, this increase in participants has led to an increase in reports of race-related cardiac arrests and in this study by Kim et al the incidence and outcomes of cardiac arrests associated with long-distance running were explored.   more…

Improving CPR outcomes – querying the role of a “rapid response” team

15 Feb, 09 | by Alistair Lindsay

Following cardiac arrest, delays in treatment are associated with poor neurological outcomes and lower survival rates.  A rapid response team – also known as a medical emergency team – is a multidisciplinary team designed to diagnose, evaluate and treat non intensive-care patients showing signs of clinical deterioration, the aim being to decrease the chances of a subsequent cardiac arrest.  Chan et al. investigated the rates of hospital-wide cardiac arrest codes and deaths before and after the introduction of a rapid response team at Saint Luke’s Hospital, Kansas City. more…

Breaking the rules – when to terminate cardiac arrest

17 Jan, 09 | by Alistair Lindsay

Reported rates of survival following cardiac arrest range from 0.2% to 23%, with a median of 6.4% in the United States.  The majority of patients who survive an out of hospital cardiac arrest (OHCA) are resusucitated at the scene of the arrest.  For those who cannot be immediately resuscitated, deciding whether to terminate resuscitation efforts can prove extremely challenging for emergency service personnel. more…

No additional benefit from thrombolysis during out-of-hospital cardiac arrest

17 Jan, 09 | by Alistair Lindsay

Myocardial infarction and pulmonary embolism account for approximately 70% of out of hospital cardiac arrests. Cardiac arrest itself activates systemic coagulation hence thrombolytic therapy delivered during cardiopulmonary resuscitation can dissolve intravascular blood clots and has beneficial effects on microcirculatory reperfusion, improving survival and neurological recovery. more…

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