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Pubblicazioni recenti - cardiac arrest
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A Unique Interplay of Multiple Predisposing Factors Culminating in a Catastrophic QT Prolongation.
Cureus2020 Apr;12(4):e7757. doi: 10.7759/cureus.7757.
Vyas Vrinda, Khan Alisha, Kanagalingam Gowthami, Bhatta Luna,
Abstract
Implantable cardioverter-defibrillators (ICDs) are used in patients without a reversible cause for long QT syndrome (LQTS) and secondary prevention in patients with LQTS-associated sudden cardiac arrest. We present a female patient with multiple reversible factors for QT prolongation, including the use of antidepressants, antidiarrheals, antiemetics, and antihistamines; chronic malabsorption from bariatric surgery; probable Gitelman syndrome and urinary losses of electrolytes, causing QT prolongation which leads to polymorphic ventricular tachycardia and a successfully resuscitated cardiac arrest. Our patient also had history suggestive of probable congenital LQTS with multiple childhood syncopal episodes and a history of seizures in first-degree relatives, further justifying the placement of an ICD. Also, this case gives us an opportunity to delve into the risks of catastrophic QT prolongation in the morbidly obese population undergoing bariatric surgery.
Copyright © 2020, Vyas et al.
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Electrocardiography Interpretation Competency of Medical Interns: Experience from Two Ethiopian Medical Schools.
Emerg Med Int2020 ;2020():7695638. doi: 10.1155/2020/7695638.
Getachew Melaku, Beyene Temesgen, Kebede Sofia,
Abstract
Background:
Electrocardiography (ECG) is the graphical display of electrical potential differences of an electric field originating in the heart. Interpretation of ECG is a core clinical skill in the department of emergency medicine. The main aim of this survey was to assess competency of ECG interpretation among 2018 graduating class medical students in Addis Ababa University and Haramaya University. . A cross-sectional survey was conducted on medical interns at Addis Ababa University and Haramaya University. Data had been collected from October 01, 2018, to October 30, 2018, by using structured questionnaires. Data were entered, cleaned, edited, and analyzed by using SPSS version 25.0 statistical software. Descriptive statistics, cross-tabs, chi-squared test, Mann-Whitney test, and binary logistic regression were utilized.
Results:
Two-hundred and two graduating medical students were involved on this survey, out of which 61.3% (95% CI 56.3-66.3%) and 32.75% (95% CI 28.25-37.25) were able to correctly interpret the primary ECG parameters and the arrest rhythm of ECG abnormalities, respectively. The ability to detect from common emergency ECG abnormalities of anterioseptal ST segment elevation myocardial infraction, atrial fibrillation, and first-degree atrioventricular block was 42.6%, 39.1%, and 32.1%, respectively.
Conclusion:
This survey showed graduating medical students had low competency in ECG interpretations.
Copyright © 2020 Melaku Getachew et al.
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Delivery For Respiratory Compromise Among Pregnant Women With COVID-19.
Am J Obstet Gynecol2020 May;():. doi: S0002-9378(20)30567-6.
McLaren Rodney A, London Viktoriya, Atallah Fouad, McCalla Sandra, Haberman Shoshana, Fisher Nelli, Stein Janet L, Minkoff Howard L,
Abstract
OBJECTIVE:
While rapid recourse to delivery after failed CPR has been shown to improve outcomes of pregnant patients with cardiac arrest, it is not known whether delivery improves or compromises the outcome of COVID patients with respiratory failure. Our objective was to evaluate the safety and utility of delivery of COVID-19 infected pregnant women needing respiratory support.
STUDY DESIGN:
This is a retrospective observational study of COVID-19 infected pregnant women (PCR diagnosed), with severe disease (defined per prior publications.). A subset of these cases was previously presented, but without detail on the effect of delivery on disease (London, et al. "The Relationship Between Status at Presentation and Outcomes Among Pregnant Women with COVID-19" Am J Perinatol., in press). The study was exempted by IRB.
RESULTS:
Of 125 confirmed cases of COVID-19, twelve (9.6%) had severe disease (Table 1). Among the 12, three resolved spontaneously after transient respiratory support in hospital and were discharged home (one subsequently returned in preterm labor and delivered by cesarean two weeks later). Of the remaining nine who continued to need respiratory support, seven (77.8%) had iatrogenic preterm deliveries (six by cesarean delivery) for maternal respiratory distress (needing increasing levels of respiratory support without improved oxygen saturation), one had an early term delivery due to PROM, and one, now 30 weeks, has required intensive care with high-flow nasal cannula for three weeks. Of the eight patients delivering with maternal respiratory distress, seven did not require intubation, and one was intubated for emergent cesarean delivery, and remained on a ventilator for 19 days. Among the non-intubated, four had an improvement in oxygenation within two hours postpartum; two required less respiratory support, and two were taken completely off respiratory support. None of the other three required an increased level of respiratory support, and were off of all support between four and seven days postpartum.
CONCLUSION:
Delivery did not worsen the respiratory status of women with persistent oxygen desaturation and the need for increasing respiratory support. Among women not needing a ventilator, return of normal respiratory status after delivery occurred within hours to days. The one patient intubated intraoperatively took longer to recover. It is possible delivery may be less salutary when damage to the lungs are sufficient to warrant intubation. This series suggests that maternal respiratory distress should not be a contraindication to delivery.
Copyright © 2020 Elsevier Inc. All rights reserved.
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Tibial Intraosseous Administration of Epinephrine Is Effective in Restoring Return of Spontaneous Circulation in a Pediatric Normovolemic But Not Hypovolemic Cardiac Arrest Model.
Pediatr Emerg Care2020 May;():. doi: 10.1097/PEC.0000000000002127.
Yauger Young J, Johnson Michelle D, Mark Jordan, Le Tho, Woodruff Thomas, Silvey Stephanie, Revis James, Blouin Dawn, O?Sullivan Joseph, Brady Kerianne, Hensler Julie G, Johnson Don,
Abstract
OBJECTIVE:
We compared the efficacy of tibial intraosseous (TIO) administration of epinephrine in a pediatric normovolemic versus hypovolemic cardiac arrest model to determine the incidence of return of spontaneous circulation (ROSC) and plasma epinephrine concentrations over time.
METHODS:
This experimental study evaluated the pharmacokinetics of epinephrine and/or incidence of ROSC after TIO administration in either a normovolemic or hypovolemic pediatric swine model.
RESULTS:
All subjects in the TIO normovolemia cardiac arrest group experienced ROSC after TIO administration of epinephrine. In contrast, subjects experiencing hypovolemia and cardiac arrest were significantly less likely to experience ROSC when epinephrine was administered TIO versus intravenous (TIO hypovolemia: 14% [1/7] vs IV hypovolemia: 71% [5/7]; P = 0.031). The TIO hypovolemia group exhibited significantly lower plasma epinephrine concentrations versus IV hypovolemia at 60, 90, 120, and 150 seconds (P < 0.05). Although the maximum concentration of plasma epinephrine was similar, the TIO hypovolemia group exhibited significantly slower time to maximum concentration times versus TIO normovolemia subjects (P = 0.004).
CONCLUSIONS:
Tibial intraosseous administration of epinephrine reliably facilitated ROSC among normovolemic cardiac arrest pediatric patients, which is consistent with published reports. However, TIO administration of epinephrine was ineffective in restoring ROSC among subjects experiencing hypovolemia and cardiac arrest. Tibial intraosseous-administered epinephrine during hypovolemia and cardiac arrest may have resulted in a potential sequestration of epinephrine in the tibia. Central or peripheral intravascular access attempts should not be abandoned after successful TIO placement in the resuscitation of patients experiencing concurrent hypovolemia and cardiac arrest.
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Extracorporeal Hemoadsorption: An Option for COVID-19 Associated Cytokine Storm Syndrome.
Shock2020 May;():. doi: 10.1097/SHK.0000000000001568.
Napp L Christian, Bauersachs Johann,
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Outcomes After In-Hospital Pediatric Recurrent Cardiac Arrests.
Pediatr Crit Care Med2020 May;():. doi: 10.1097/PCC.0000000000002427.
Brown Stephanie R, Brogan Thomas V, McMullan D Michael, Roberts Joan S,
Abstract
OBJECTIVES:
The objective of this study is to determine outcomes of recurrent cardiac arrest events in the general pediatric inpatient population.
DESIGN:
Retrospective cohort study of inpatients in a single institution.
SETTING:
A tertiary care free-standing children's hospital.
PATIENTS:
All patients less than 18 years old at Seattle Children's Hospital with recurrent cardiac arrest events occurring from January 1, 2010, to March 1, 2018, were included.
INTERVENTIONS:
None.
MEASUREMENTS AND MAIN RESULTS:
Overall survival to hospital discharge was 50% and all survivors had a good neurologic outcome, defined as Pediatric Cerebral Performance Category of 3 or less, or unchanged from baseline. Survival among patients who received extracorporeal life support was 43% and among those who received extracorporeal cardiopulmonary resuscitation, 33%. Initial arrest factors associated with survival included initial rhythm of ventricular tachycardia or ventricular fibrillation, shorter duration of cardiopulmonary resuscitation, and absence of multiple organ dysfunction. Additionally, nonsurvivors had more severe metabolic acidosis in the prearrest and postarrest period.
CONCLUSIONS:
Survival after pediatric in-hospital recurrent cardiac arrest is higher than previously reported. There is also evidence that initial rhythm other than ventricular tachycardia/ventricular fibrillation and longer duration of cardiopulmonary resuscitation as well as multiple organ dysfunction and more severe lactic acidosis in the peri-arrest period are associated with poor outcomes.
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Sudden Cardiac Arrest in an Asymptomatic Zinc Phosphide-Poisoned Patient: A Case Report.
Cardiovasc Toxicol2020 May;():. doi: 10.1007/s12012-020-09578-2.
Parhizgar Parinaz, Forouzanfar Reza, Hadeiy Seyed Kaveh, Zamani Nasim, Hassanian-Moghaddam Hossein,
Abstract
Zinc phosphide is a gray to black powder mainly used as a rodenticide. In contact with gastric fluid, it releases phosphine which is the main toxic material of this compound. Phosphine interferes with oxidative respiratory cycle of the cells, but is generally expected to manifest its toxicity with prodromal signs and symptoms including abdominal pain, nausea and vomiting, metabolic acidosis, and increased liver function tests. A 64-year-old man was referred to our center with the history of ingestion of three full table spoons of zinc phosphide powder with only a mild GI discomfort. Abdominal X-ray revealed radiopaque material in epigastric and abdominal right upper quadrant. Despite treatment with polyethylene glycol and completely normal vital signs and lab tests, he experienced sudden cardiac arrest 19 h after admission. Autopsy showed clues of focal myopathy and fibrosis with evidences of ischemia and congestion in cardiac tissue, pulmonary edema, shrunken bilateral kidneys, and nutmeg yellow liver. Toxicology panel confirmed the presence of phosphine and zinc phosphide in the gastric fluid. The patient deteriorated suddenly despite being completely symptom-free during the hours preceding cardiovascular arrest. Since the cardiopulmonary injury is the most rampant cause of early death, checking of the cardiac enzymes and cardiac monitoring could be beneficial for early detection and efficient management of these patients.
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Heterotopic Transplantation of Allogeneic Vertical Rectus Abdominis Myocutaneous Flaps in Miniature Swine.
J Surg Res2020 May;254():175-182. doi: S0022-4804(20)30246-8.
Waldner Matthias, Elgendy Tarek Y, Kim Deokyeol Y, Öksüz Sinan, Schweizer Riccardo, Zhang Wensheng, Minervini Marta I, Komatsu Chiaki, Plock Jan A, Gorantla Vijay S, Washington Kia M, Thomson Angus W, Solari Mario G,
Abstract
BACKGROUND:
Vascularized composite tissue allotransplantation (VCA) opens new possibilities for reconstruction of complex tissue defects, including upper extremity and facial transplantation. The main challenges in VCA transplantation are the side effects of long-term immunosuppression and chronic graft rejection. Translational preclinical animal models are crucial for VCA research to improve clinical outcomes and to study underlying immunologic mechanisms. Herein, we describe a novel, large animal, non-bone-bearing VCA model in inbred, swine leukocyte antigen-typed miniature swine.
METHODS:
Transplantation of vertical rectus abdominis myocutaneous (VRAM) flaps was performed between fully swine leukocyte antigen-mismatched miniature swine. The flaps were transferred to the posterolateral aspect of the neck of recipients and anastomosed to the common carotid artery and internal jugular vein. Different immunosuppressive drug regimens were used. Clinical graft evaluation was performed daily, and punch biopsies were taken for histology.
RESULTS:
Ten VRAM transplants were performed. The mean ischemia time was 89.4 min (SD ± 47), mean pedicle length 7.5 cm (SD ± 2), mean venous diameter 2.5 mm (SD ± 0.4), and mean arterial diameter 2.2 mm (SD ± 0.3). Follow-up demonstrated good correlation between clinical appearance and progression of graft rejection confirmed by histologic assessment. Complications were intraoperative cardiac arrest in one recipient and one flap loss due to venous compromise.
CONCLUSIONS:
VRAM transplantation in miniature swine is an appropriate preclinical VCA model, with the advantage of good clinical and histologic correlation during the course of rejection, as well as easy access to the graft. The availability of inbred, haplotyped animals allows studies across different major histocompatibility complex barriers in a non-bone-bearing VCA.
Copyright © 2020 Elsevier Inc. All rights reserved.
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Plasma adenosine and neurally mediated syncope: ready for clinical use.
Europace2020 May;():. doi: euaa070.
Brignole Michele, Groppelli Antonella, Brambilla Roberto, Caldara Gianluca L, Torresani Erminio, Parati Gianfranco, Solari Diana, Ungar Andrea, Rafanelli Martina, Deharo Jean Claude, Marlinge Marion, Chefour Mohamed, Guieu Regis,
Abstract
Either central or peripheral baroreceptor reflex abnormalities and/or alterations in neurohumoral mechanisms play a pivotal role in the genesis of neurally mediated syncope. Thus, improving our knowledge of the biochemical mechanisms underlying specific forms of neurally mediated syncope (more properly termed 'neurohumoral syncope') might allow the development of new therapies that are effective in this specific subgroup. A low-adenosine phenotype of neurohumoral syncope has recently been identified. Patients who suffer syncope without prodromes and have a normal heart display a purinergic profile which is the opposite of that observed in vasovagal syncope patients and is characterized by very low-adenosine plasma level values, low expression of A2A receptors and the predominance of the TC variant in the single nucleotide c.1364 C>T polymorphism of the A2A receptor gene. The typical mechanism of syncope is an idiopathic paroxysmal atrioventricular block or sinus bradycardia, most often followed by sinus arrest. Since patients with low plasma adenosine levels are highly susceptible to endogenous adenosine, chronic treatment of these patients with theophylline, a non-selective adenosine receptor antagonist, is expected to prevent syncopal recurrences. This hypothesis is supported by results from series of cases and from observational controlled studies.
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.
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Ventricular Fibrillation Caused by Primary Carnitine Deficiency.
J Emerg Med2020 May;():. doi: S0736-4679(20)30356-5.
Lu Chun-Chi, Chang Chia-Wen, Wu Yen-Hung, Lin Jhong-Chin,
Abstract
BACKGROUND:
Primary carnitine deficiency (PCD) is a rare but potentially life-threatening genetic disorder if left untreated. Although some patients remain asymptomatic lifelong, a few patients present with hepatic encephalopathy, hypoglycemia, cardiomyopathy, dysrhythmia, and even sudden death.
CASE REPORT:
A 25-year-old woman with PCD collapsed suddenly while eating lunch. Bystander cardiopulmonary resuscitation (CPR) was performed for 8 min, with automated external defibrillation once before admission. Upon arrival at our emergency department (ED), she was unresponsive without a pulse or spontaneous breathing. The initial heart rhythm on the electrocardiogram monitor was ventricular fibrillation (VF). The medical staff continued CPR with defibrillation for sustained VF. Return of spontaneous circulation (ROSC) was achieved after a total resuscitation time of 14 min, with defibrillation twice after cardiac arrest. The heart rhythm after ROSC was atrial fibrillation, with a rapid ventricular rate initially and subsequent progression to sinus tachycardia with diffuse ST segment depression and a prolonged QT interval. Her low carnitine level was consistent with her underlying disease. Cardiac magnetic resonance imaging and sonography for detection of cardiomyopathy showed no significant findings. With carnitine supplementation for a few days, her plasma carnitine level returned to 30 ?M, with no recurrence of ventricular dysrhythmia. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: PCD is rare but could be life-threatening, and compiling detailed histories may help emergency physicians to determine the cause of sudden cardiac death after resuscitation. This information may be used to correct potential underlying problems and prevent recurrence of the condition after treatment.
Copyright © 2020 Elsevier Inc. All rights reserved.
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[One case successfully rescued acute poisoning caused by misadministration of large amount of glufosinate].
Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi2020 Apr;38(4):288-290. doi: 10.3760/cma.j.cn121094-20190412-00149.
Su C H, Jian X D, Zhang Q B, Liu Y G, Li H Y, Liu J Q,
Abstract
To report a case of acute glufosinate-ammonium poisoning cause respiratory cardiac arrest and grass amine poisoning cases of successful rescue. The clinical data of a case of acute glufosinate-ammonium poisoning admitted to a third-class a hospital in April 2018 were analyzed and summarized. The patient was poisoned by oral administration of a large amount of glufosinate-ammonium. Respiratory and cardiac arrest occurred during treatment and resuscitation was successful Later, the nervous system showed impaired function, The patients were treated with complete gastrointestinal cleansing, hemoperfusion, and the protection of important organs. For a large number of patients with oral glufosinate-ammonium poisoning, we should pay close attention to the damage of nervous system while taking active and conventional detoxification treatment.
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Successful Outcome Following Intravenous Lipid Emulsion Rescue Therapy in a Patient with Cardiac Arrest Due to Amitriptyline Overdose.
Am J Case Rep2020 May;21():e922206. doi: 10.12659/AJCR.922206.
Angel-Isaza Ana María, Bustamante-Cristancho Luis Alfonso, Uribe-B Francisco L,
Abstract
BACKGROUND The management of patients with tricyclic antidepressant drug overdose can be a challenge for the emergency department physician. Tricyclic antidepressants block alpha-adrenergic receptors and the anticholinergic effects may lead to cardiotoxicity, resulting in arrhythmias and hypotension that can lead to patient mortality. This report is of a case of a 28-year-old woman who presented with cardiac arrest due to amitriptyline overdose and who responded to intravenous lipid emulsion (ILE) therapy. CASE REPORT A 28-year-old woman was admitted to the emergency department with amitriptyline overdose. She suffered a cardiac arrest followed by cardiovascular and neurological complications. Hypotension and lack of a pulse did not respond to treatment with high-dose sodium, but she stabilized following treatment with ILE. The prompt response from the emergency team guaranteed rapid intervention that may have influenced the successful results. CONCLUSIONS Despite the frequency and severity of poisoning with tricyclic antidepressants, there is little consensus among physicians regarding patient management. This case showed the successful use of ILE as rescue therapy in a patient in cardiac arrest following amitriptyline overdose. However, the successful outcome obtained in this case is not a recommendation for the use of ILE as a first-line treatment for the management of patients with tricyclic antidepressant drug overdose. Controlled clinical studies are required to evaluate the safety and efficacy of ILE in the management of tricyclic antidepressant drug overdose.
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Clinical assessment of perfusion techniques during surgical repair of coarctation of aorta with aortic arch hypoplasia in neonates: a pilot prospective randomized study.
Semin Thorac Cardiovasc Surg2020 May;():. doi: S1043-0679(20)30130-1.
Kulyabin Y Y, Bogachev-Prokophiev A V, Soynov I A, Omelchenko A Y, Zubritskiy A V, Gorbatykh Y N,
Abstract
OBJECTIVE:
We aimed to compare the safety and efficacy of three perfusion methods primarily used in aortic arch reconstruction in infants, namely, deep hypothermic circulatory arrest, selective antegrade cerebral perfusion, and double arterial cannulation.
METHODS:
Forty-five infants with aortic arch obstruction and biventricular anatomy were enrolled in this pilot prospective study (ClinicalTrials.gov registration number: NCT02835703). Patients were randomly assigned into three groups according to the perfusion strategy (deep hypothermic circulatory arrest, n=15; selective antegrade cerebral perfusion, n=15; double arterial cannulation, n=15). The primary composite endpoint was the incidence of adverse events in the early postoperative period (acute kidney injury [KDIGO criteria], new brain MRI findings, and in-hospital mortality). The secondary endpoints were intensive care unit length of stay, vasoactive-inotropic score index, and cardiopulmonary bypass duration. All patients underwent aortic arch reconstruction under cardiopulmonary bypass and were monitored with near infrared spectroscopy during surgery.
RESULTS:
No significant differences in the baseline characteristics and cardiopulmonary bypass duration were observed among the groups. The incidence of unfavorable events was lower in the double arterial cannulation group (p=0.041). Acute kidney injury was observed in 8, 6, and 5 patients from the deep hypothermic circulatory arrest, selective antegrade cerebral perfusion, and double arterial cannulation groups, respectively (p=0.64). Twelve patients from the deep hypothermic circulatory arrest group had new brain MRI findings (p=0.019). There were 5 in-hospital deaths with no significant difference among the groups (p=0.70). The "head" and "lumbar" values on near infrared spectroscopy during aortic arch reconstruction were significantly higher in the selective antegrade cerebral perfusion and double arterial cannulation groups than in the deep hypothermic circulatory arrest group. Patients in the double arterial cannulation group had a significantly lower vasoactive-inotropic score index 24 hours postoperatively than the deep hypothermic circulatory arrest group (p=0.03). Vasoactive-inotropic score index >12 was found to be a risk factor for acute kidney injury and early mortality.
CONCLUSIONS:
Continuous regional perfusion during aortic arch reconstruction decreases the risk of new brain MRI findings in infants and the need for postoperative inotropic support. Although values of near infrared spectroscopy during the procedure were significantly higher with continuous perfusion strategies, these methods do not reduce the acute kidney injury incidence compared to that with deep hypothermic circulatory arrest. Double arterial cannulation significantly reduces the need for inotropic support.
Copyright © 2020 Elsevier Ltd. All rights reserved.
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Socioeconomic differences in coronary procedures and survival after out-of-hospital cardiac arrest: A nationwide Danish study.
Resuscitation2020 May;():. doi: S0300-9572(20)30201-X.
Møller Sidsel, Wissenberg Mads, Kragholm Kristian, Folke Fredrik, Hansen Carolina Malta, Ringgren Kristian B, Andersen Julie, Barcella Carlo, Lippert Freddy, Køber Lars, Gislason Gunnar, Gerds Thomas Alexander, Torp-Pedersen Christian,
Abstract
AIM:
It remains unclear whether socioeconomic differences exist in post-resuscitation care in out-of-hospital cardiac arrests (OHCA). We aimed to examine socioeconomic differences in coronary procedures and survival after OHCA.
METHODS:
OHCA patients ?30 years of cardiac cause with a hospital admission from the Danish Cardiac Arrest Registry, 2001-2014, were divided according to quartiles of household income (lowest, low, high, highest). Associations of income, coronary procedures and 30-day survival were examined by age-standardized incidence rates and incidence rate ratios (IRR), and by logistic regression.
RESULTS:
A total of 6,105 patients were included. Higher-income patients were younger, males and had less comorbidity-burden. Higher-income patients had higher incidence rates for coronary angiographies both day 0-1 and day 2-7 after OHCA (day 0-1: highest: IRR 1.79, 95%CI 1.46-2.21; high: IRR 1.28, 95%CI 1.10-1.51; low: IRR 1.05, 95%CI 0.90-1.23), compared to lowest. Fifty-four percentage of the patients undergoing a coronary angiography received percutaneous-coronary-intervention or coronary-artery-bypass-grafting with no difference among three of the four groups, but lower IRR in low-income patients (IRR 0.74, 95%CI 0.61-0.89) compared to lowest. Higher-income patients had also higher odds for 30-day survival compared to lowest, both in patients with (highest: OR 1.61, 95%CI 1.12-2.32; high: OR 1.13, 95%CI 0.80-1.60; low: OR 1.14, 95%CI 0.81-1.61) and without (highest: OR 2.54, 95%CI 1.83-3.53; high: OR 1.41, 95%CI 1.06-1.87; low: OR 1.12, 95%CI 0.86-1.47) coronary angiography day 0-1.
CONCLUSION:
Higher patient-income was found associated with more performed coronary angiographies after OHCA, and higher odds for 30-day survival.
Copyright © 2020 Elsevier B.V. All rights reserved.
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Continuous Electroencephalography Monitoring in Critically Ill Infants and Children.
Pediatr Neurol2020 Apr;():. doi: S0887-8994(20)30139-9.
Griffith Jennifer L, Tomko Stuart T, Guerriero Réjean M,
Abstract
Continuous video electroencephalography (CEEG) monitoring of critically ill infants and children has expanded rapidly in recent years. Indications for CEEG include evaluation of patients with altered mental status, characterization of paroxysmal events, and detection of electrographic seizures, including monitoring of patients with limited neurological examination or conditions that put them at high risk for electrographic seizures (e.g., cardiac arrest or extracorporeal membrane oxygenation cannulation). Depending on the inclusion criteria and clinical characteristics of the population studied, the percentage of pediatric patients with electrographic seizures varies from 7% to 46% and with electrographic status epilepticus from 1% to 23%. There is also evidence that epileptiform and background CEEG patterns may provide important information about prognosis in certain clinical populations. Quantitative EEG techniques are emerging as a tool to enhance the value of CEEG to provide real-time bedside data for management and prognosis. Continued research is needed to understand the clinical value of seizure detection and identification of other CEEG patterns on the outcomes of critically ill infants and children.
Copyright © 2020 Elsevier Inc. All rights reserved.
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Serum GFAP and UCH-L1 for the prediction of neurological outcome in comatose cardiac arrest patients.
Resuscitation2020 May;():. doi: S0300-9572(20)30195-7.
Ebner Florian, Moseby-Knappe Marion, Mattsson-Carlgren Niklas, Lilja Gisela, Dragancea Irina, Undén Johan, Friberg Hans, Erlinge David, Kjaergaard Jesper, Hassager Christian, Wise Matt P, Kuiper Michael, Stammet Pascal, Wanscher Michael, Horn Janneke, Ullén Susann, Cronberg Tobias, Nielsen Niklas,
Abstract
OBJECTIVE:
Neurological outcome prediction is crucial early after cardiac arrest. Serum biomarkers released from brain cells after hypoxic-ischemic injury may aid in outcome prediction. The only serum biomarker presently recommended in the European Resuscitation Council prognostication guidelines is neuron-specific enolase (NSE), but NSE has limitations. In this study, we therefore analysed the outcome predictive accuracy of the serum biomarkers glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase-L1 (UCH-L1) in patients after cardiac arrest.
METHODS:
Serum GFAP and UCH-L1 were collected at 24, 48 and 72hours after cardiac arrest. The primary outcome was neurological function at 6-month follow-up assessed by the cerebral performance category scale (CPC), dichotomized into good (CPC1-2) and poor (CPC3-5). Prognostic accuracies were tested with receiver-operating characteristics by calculating the area under the receiver-operating curve (AUROC) and compared to the AUROC of NSE.
RESULTS:
717 patients were included in the study. GFAP and UCH-L1 discriminated between good and poor neurological outcome at all time-points when used alone (AUROC GFAP 0.88-0.89; UCH-L1 0.85-0.87) or in combination (AUROC 0.90-0.91). The combined model was superior to GFAP and UCH-L1 separately and NSE (AUROC 0.75-0.85) at all time-points. At specificities ?95%, the combined model predicted poor outcome with a higher sensitivity than NSE at 24hours and with similar sensitivities at 48 and 72hours.
CONCLUSION:
GFAP and UCH-L1 predicted poor neurological outcome with high accuracy. Their combination may be of special interest for early prognostication after cardiac arrest where it performed significantly better than the currently recommended biomarker NSE.
Copyright © 2020. Published by Elsevier B.V.
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Validation of the Suppression Ratio from a Simplified EEG Montage During Targeted Temperature Management After Cardiac Arrest.
Resuscitation2020 May;():. doi: S0300-9572(20)30193-3.
Riker Richard R, Craig Alexa, Eubank Louis, May Teresa, Seder David B,
Abstract
AIM:
The Suppression Ratio (SR) estimates the percent of the electroencephalography (EEG) epoch with very low voltage, and is associated with neurological outcome after cardiac arrest. We aimed to compare the SR generated by two monitoring devices and determine the association between SR and patterns on amplitude integrated EEG (aEEG) and full conventional EEG (cEEG).
METHODS:
Consecutive adult patients treated with TTM after cardiac arrest were enrolled. We compared the SR from the Medtronic Vista monitor (MSR) to the SR generated from the full montage cEEG with Persyst Magic-Marker software (PSR). A blinded neurologist, board certified in epilepsy, scored the 4-channel aEEG pattern and the cEEG background using standardized terminology. Values for SR were compared to aEEG and cEEG categories using Kruskal-Wallis ANOVA, and to each other using Altman-Bland methodology.
RESULTS:
23 adults treated with TTM had a mean core temperature of 33.8°C at the time of SR and EEG background analysis. The MSR was 0% during continuous cEEG background, 23% when cEEG was discontinuous, and 64% during cEEG burst suppression (p=0.01). The MSR was 0% during aEEG continuous patterns, 34% during aEEG burst suppression, and 46% during flat aEEG (p<0.001). The MSR and PSR were highly correlated (0.88, p<0.0001), with minimal bias (0.3%) and excellent 95% limits of agreement (-2.9 to 2.4%).
CONCLUSION:
The Suppression Ratio from the Medtronic Vista monitor is highly correlated with the full montage SR from Persyst software. The MSR values are valid, changing with different aEEG patterns and cEEG background categories.
Copyright © 2020 Elsevier B.V. All rights reserved.
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SCAI cardiogenic shock classification after out of hospital cardiac arrest and association with outcome??
Catheter Cardiovasc Interv2020 May;():. doi: 10.1002/ccd.28984.
Pareek Nilesh, Dworakowski Rafal, Webb Ian, Barash Jemma, Emezu Gift, Melikian Narbeh, Hill Jonathan, Shah Ajay, MacCarthy Philip, Byrne Jonathan,
Abstract
OBJECTIVES:
We aimed to validate the Society for Cardiovascular Angiography and Interventions (SCAI) classification to evaluate association with outcome in a real-world population and effect of invasive therapies.
BACKGROUND:
Cardiogenic shock is common after Out of Hospital Cardiac Arrest (OOHCA) but is often multifactorial and challenging to stratify.
METHODS:
The SCAI shock grade was applied to an observational registry of OOHCA patients on admission to our center between 2012 and 2017. The primary end-point was 30-day mortality and secondary end-points were mode of death and 12-month mortality. Provision of early CAG and mechanical circulatory support (MCS) was evaluated by SCAI shock grade using logistic regression.
RESULTS:
Three hundred and ninety-three patients (median age 64.3?years (24.9% females) were included. One hundred and seven patients (27.2%) were in Grade A, 94 (23.9%) in Grade B, 66 (16.8%) in Grade C, 91 (23.2%) in Grade D, and 35 (8.9%) in Grade E. There was a step-wise significant increase in 30-day mortality with increasing shock grade (A 28.9% vs. B 33.0% vs. C 54.5% vs. D 59.3% vs. E 82.9%; p?
CONCLUSIONS:
Increasing SCAI shock grade after OOHCA is associated with 30-day mortality, requirement for renal replacement therapy and mortality attributed to multiorgan dysfunction syndrome and cardiac etiology death.
© 2020 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.
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Mobile Smartphone Technology Is Associated With Out-of-hospital Cardiac Arrest Survival Improvement: The First Year "Greater Paris Fire Brigade" Experience.
Acad Emerg Med2020 May;():. doi: 10.1111/acem.13987.
Derkenne Clément, Jost Daniel, Roquet Florian, Dardel Paul, Kedzierewicz Romain, Mignon Alexandre, Travers Stéphane, Frattini Benoit, Prieux Laurent, Rozenberg Emmanuel, Demaison Xavier, Gaudet John, de Charry Félicité, Stibbe Olivier, Briche Frédérique, Lemoine Frédéric, Lesaffre Xavier, Maurin Olga, Gauyat Eric, Faraon Eric, Lemoine Sabine, Prunet Bertrand,
Abstract
BACKGROUND:
Out-of-hospital cardiac arrest (OHCA) remains associated with very high mortality. Accelerating the initiation of efficient cardiopulmonary resuscitation (CPR) is widely perceived as key to improving outcomes. The main goal was to determine whether identification and activation of nearby first responders through a smartphone application named Staying Alive (SA) can improve survival following OHCA in a large urban area (Paris).
METHODS:
We conducted a nonrandomized cohort study of all adults with OHCA managed by the Greater Paris Fire Brigade during 2018, irrespective of mobile application usage. We compared survival data in cases where SA did or did not lead to the activation of nearby first responders. During dispatch, calls for OHCA were managed with or without SA. The intervention group included all cases where nearby first responders were successfully identified by SA and actively contributed to CPR. The control group included all other cases. We compared survival at hospital discharge between the intervention and control groups. We analyzed patient data, CPR metrics, and first responders' characteristics.
RESULTS:
Approximately 4,107 OHCA cases were recorded in 2018. Among those, 320 patients were in the control group, whereas 46 patients, in the intervention group, received first responder-initiated CPR. After adjustment for confounders, survival at hospital discharge was significantly improved for patients in the intervention group (35% vs. 16%, adjusted odds ratio = 5.9, 95% confidence interval = 2.1 to 16.5, p < 0.001). All CPR metrics were improved in the intervention group.
CONCLUSIONS:
We report that mobile smartphone technology was associated with OHCA survival through accelerated initiation of efficient CPR by first responders in a large urban area.
© 2020 by the Society for Academic Emergency Medicine.
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Survival from Out-of-Hospital Cardiac Arrest - Comparing the Automated LUCAS-2 Device and Manual CPR.
S D Med2020 Apr;73(4):171-177.
Kupershmidt Sabina, Sudhagoni Ramu G, Fuller Max D, Pickthorn Sean T, Abou Samra Haifa,
Abstract
INTRODUCTION:
Competency in and understanding of the factors impacting cardiopulmonary resuscitation (CPR) are key to emergency medicine. The purpose of this study was to assess the impact of the automated LUCAS-2 device on survival to emergency department (ED) compared to manual CPR as part of the EMS response using a large data set collected in a mostly rural U.S. state.
METHODS:
We conducted a retrospective analysis of South Dakota's electronic Patient Care Reports (ePCR) collected from Jan. 1, 2013 through Dec. 31, 2015. The primary outcome measure was survival to ED.
RESULTS:
A mechanical piston device (LUCAS-2), was utilized in 260 (15 percent) of 1,781 total cases during this period. The odds for survival to ED were calculated and compared between manual and LUCAS-2-assisted CPR. The odds ratio for survival to ED using compressions alone was 3.94 compared to LUCAS-2 and those results persisted after adjusting for significant covariates.
DISCUSSION:
Despite hemodynamic benefits associated with the LUCAS-2 device in the laboratory and in other settings, this and other studies indicate that compression-only CPR outperforms automation-assisted CPR during OHCA. However, the data also suggest that enhanced training of emergency providers to improve response times and levels of expertise with the equipment may improve the outcomes associated with the LUCAS-2 and it is recommended that further training should be pursued.
Copyright© South Dakota State Medical Association.
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