bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 190: Hybrid Strategy of Damage Control IR (DCIR) and REBOA Would be Feasible for Traumatic Hemorrhagic Shock Patients Suffering From Severe Pelvic Injuries
Authors: Orita Tomohiko , Matsumoto Shokei , Funabiki Tomohiro , Shimizu Masayuki , Toyoda Yukitoshi , Hiroe Nao , Kazamaki Taku , Nakamichi Yoshimi , Yajima Keitaro , Yamazaki Motoyasu , Kitano Mitsuhide
Published: July 2021

Introduction:
Massive hemorrhage with pelvic injury is sometimes lethal. So, success or failure of hemostatic intervention in the hyperacute phase leads to survival of patients directly. Recently, a hybrid strategy with Operative Management (OM) and Interventional Radiology (IR) and/or Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for torso or pelvic severe trauma has been recognized world-widely. But, awareness of Damage control IR (DCIR) which is conscious of time and coagulopathy as Damage control surgery (DCS) is still not enough. So, we studied the possibility of the hybrid strategy with DCIR and REBOA for traumatic hemorrhagic shock patients with pelvic fracture.

Methods:
This study included patients who underwent traditional IR or DCIR with REBOA, if it were needed, for a traumatic shock state mainly due to pelvic fracture, at our emergency and trauma center. They were sorted into traditional IR group (group IR) and DCIR group (group DCIR). The primary endpoint was a survival rate in the first 30 days after injured. Secondary endpoints were fluid factors such as total amount of crystalloid infusion and blood transfusion within the first 24 hours, and for the duration of the recovery from shock state.

Results:
64 trauma shock patients were sorted into group IR (n=38) and group DCIR (n=26). All REBOA patients (n=18) were in group DCIR. Initial systolic BP (group IR vs DCIR; 75mmHg vs. 54), RTS (5.66 vs. 4.12) and Ps (0.61 vs. 0.39) were significantly lower in group DCIR. ISS (32.8 vs. 41.5) and initial Shock Index (1.9 vs. 2.4) were higher in group DCIR significantly. There were no significant differences in the amount of total crystalloid infusion (7353+/-3152ml vs. 7140+/-5342ml) and blood transfusion (4183+/-3485ml vs. 3972+/-3188ml), and the survival rate (30/38 (79%) vs. 16/28 (62%)). But the required time to recovery from shock state was significantly shorter in group DCIR (65min vs. 43min).

Conclusion:
The hybrid strategy with DCIR and REBOA did not increase any amount of blood transfusion or crystalloid infusion or the mortality rate. But it could shorten the duration of shock state compared with traditional IR treatment. Thus, this hybrid strategy would be feasible for hemorrhage shock patients suffering from pelvic severe trauma.
Abstract 193: Intraosseous Transfusion With Liposome-Encapsulated Hemoglobin (HbV) Comparably Improves Rat Survival and its Arrythmogenesis Undergoing Progressive Lethal 85% Hemorrhage With Central Venous Infusion: Possible Implication for Pre-Hospital Settings
Authors: Takase Bonpei , Higashimura Yuko
Published: July 2021

Liposome-encapsulated hemoglobin (HbV) can serve as blood substitute in hemorrhagic shock (HS). To investigate the resuscitation effect of HbV through intraosseous transfusion (IO) on lethal hemorrhage and its efficacy on myocardial arrhythmogenesis, optical mapping analysis (OMP) and electrophysiological study (EPS) were performed in graded blood exchange up to 85% blood loss in rats. And it was compared with central venous infusion (CVI). Total 90 rats were randomly allocated into 6 subgroups as followings; through IO or CVI, gradually exchanged blood with 5% albumin (Alb-IO/CVI-groups), exchanged with washed rat erythrocyte (wRBC-IO/CVI-groups) and with HbV (HbV-IO/CVI-groups). Survival effects were examined in each six rat groups. After excising the heart, OMP and EPS were performed. All rats died in Alb-IO/CVI-groups whereas excellent and comparably survived for following >48-hours in wRBC-IO/CVI-groups and HbV-IO/CVI-groups (Figure 1). OMP revealed impaired (prolonged) action potential duration (APD) dispersion in LV in Alb-IO/CVI-groups. In contrast, myocardial APD dispersions in LV were substantially attenuated in HbV-IO/CVI-groups and wRBC-IO/CVI-groups (Figure 2). Lethal arrhythmias (VT/VF) were provoked by EPS in Alb-IO/CVI-groups. No VT/VF was induced in both HbV-IO/CVI-groups and wRBC-IO/CVI-groups.

Conclusions:
IO vascular access could a reliable bridging method to resuscitate lethal HS by HbV. This suggests that IO with HbV resuscitation might be useful in pre-hospital settings in HS through preventing lethal arrhythmias.
Abstract 197: What Limits the Use of AEDs by Bystanders?
Authors: Kaneko Hiroshi , Hatanaka Tetsuo , Nagase Aki , Marukawa Seishiro , Sakamoto Tetsuya
Published: July 2021

Introduction:
In Japan, the number of automated external defibrillators (AEDs) placed in public areas has climbed up to the estimated 530,000. We reported previously that a half of out-of-hospital cardiac arrests occurred within 100 m from a public AED in urban areas. However, shocks for defibrillation were given to less than 15% of those patients. The objectives of this study was to identify the limiting factors against the use of AEDs by bystanders.

Methods:
A prospective survey on out-of-hospital cardiac arrest was conducted in the city of Osaka (Dec 2016 through Mar 2017) and the city of Nagoya (Dec 2016 through Nov 2017) searching for patient demographics and AED settings including; absence/presence of a public AED on the scene, attachment of AED pads, delivery of shocks before the time of EMS arrival.

Results:
Of 558 cases of cardiac arrest registered during the survey period, an AED had already been delivered at the patient side by the time of EMS arrival in 92 case (16.5%). Of those, pads had been attached in 89 cased (96.7%). Shocks had been advised in 35 cases (39.3%) and to all but one of those cases at least 1 shock had been given by the bystanders. There were no statistically significant differences between the groups of cases with and without AEDs at the patient side regarding the patient age (65 years [IQR: 48-74] vs 63 years [IQR49-75], p=0.84), gender (p=0.68) and the time from call to EMS arrival (7 min [IQR: 6-9] vs 7 min [IQR: 6-9], p=0.74). Cases occurring indoors had more chances of AEDs being delivered on the patient side than cases occurring outdoors (24.0% vs 7.8%, p<0.001).

Conclusions:
Our study indicates that once an AED is delivered at the patient side, pads are successfully attached and shocks are given if indicated in almost all cases. This suggests that finding and delivering an AED onto the patient side are the limiting factors against the use of AEDs by bystanders. In order to popularize the use of AEDs by bystanders, informing people with AED placement and clear direction to the AED location seem to be the key steps.
Abstract 199: Pulmonary Embolism and Accidental Hypothermia Have a Favorable Outcome in Cardiac Arrest With PEA Treated by ECPR
Authors: Ijuin Shinichi , Inoue Akihiko , Igarashi Nobuaki , Matsuyama Shigenari , Kawase Tetsunori , Ishihara Satoshi , Nakayama Shinichi
Published: July 2021

Introduction:
We have reported previously a favorable neurological outcome by extracorporeal cardiopulmonary resuscitation (ECPR) for out of hospital cardiac arrest. However, effects of ECPR on patients with prolonged pulseless electrical activity (PEA) are unclear. We analyzed etiology of patients with favorable neurological outcomes after ECPR for PEA with witness.

Methods:
In this single center retrospective study, from January 2007 to May 2018, we identified 68 patients who underwent ECPR for PEA with witness. Of these, 13 patients (19%) had good neurological outcome at 1 month (Glasgow-Pittsburgh Cerebral Performance Category (CPC):1-2, Group G), and 55 patients (81%) had unfavorable neurological outcome (CPC:3-5, Group B). We compared courses of treatment and causes/places of arrests between two groups. Results are expressed as mean ± SD.

Results:
Patient characteristics were not different between the two groups. Time intervals from collapse to induction of V-A ECMO were also not significantly different (Group G; 46.1 ± 20.2 min vs Group B; 46.8 ± 21.7 min, p=0.92). Ten patients achieved favorable neurological outcome among 39 (26%) with non-cardiac etiology. In cardiac etiology, only 3 of 29 patients (9%) had a good outcome at 1 month (p=0.08). In particular, 5 patients of 10 pulmonary embolism, and 4 of 4 accidental hypothermia responded well to ECPR with a favorable neurological outcome. Additionally, 6 of 13 (46%), who had in hospital cardiac arrest, had good outcome, whereas 7 of 55 (15%) who had out of hospital cardiac arrest, had good outcome (p=0.02).

Conclusions:
In our small cohort of cardiac arrest patients with pulmonary embolism or accidental hypothermia and PEA with witness, EPCR contributed to favorable neurological outcomes at 1 month.
Abstract 20: Intraosseous vs. Intravenously Administered Advanced Life Support Drugs in Patients With Out-of-Hospital Cardiac Arrest: Insights From the Resuscitation Outcomes Consortium Continuous Chest Compression Trial
Authors: Mody Purav , Brown Siobhan , Khera Rohan , Pandey Ambarish , Ayers Colby , Kudenchuk Peter , Chan Paul S , de Lemos James A , Kern Karl , Link Mark , Idris Ahamed
Published: July 2021

Background:
There is an urgent need to identify strategies which improve outcomes for out-of-hospital cardiac arrest (OHCA). Determining the optimal access route to deliver medications during resuscitation from OHCA may be one such strategy.

Methods:
Using data from the Continuous Chest compression trial between 2011 and 2016, we examined rates of sustained return of spontaneous circulation (ROSC) i.e. ROSC on ER arrival, survival to discharge and survival with favorable neurological function (modified Rankin scale ≤3) among patients with attempted IV and IO access.

Results:
Among 19,731 patients with available access information, IO or IV access was attempted in 3,068 (15.5%) and 16,663 (84.5%) patients, respectively and was successful in 2,975 (97%) and 15,485 (92%) of these patients. Overall, patients with attempted IO access were younger, more likely female, received less bystander CPR, had lower proportions of shockable and witnessed arrests, marginally faster times to access and to epinephrine administration, and less frequently received therapeutic hypothermia and coronary angiography as compared with patients with IV access (
Table
)
.
Unadjusted rates of sustained ROSC, discharge survival and survival with favorable neurological function were significantly lower in patients with attempted IO access (
Table)
. After adjustment for age, sex, initial rhythm, bystander CPR, public location, witnessed status, EMS response time and trial cluster, attempted IO access was associated with lower sustained ROSC rates (OR 0.79, 95% CI 0.71-0.89, p<0.001) but not with discharge survival (OR 0.88, 95% CI 0.71-1.08, p=0.21) or survival with favorable neurological function (OR 0.86, 95% CI 0.67-1.1, p=0.26).

Conclusions:
Among patients with OHCA, intraosseous access was attempted in 1 in 7 OHCA patients and associated with worse ROSC rates but no difference in survival. Further studies are necessary to elucidate the optimal access route among OHCA patients.
Abstract 203: A Pilot Study of Using Ice Slurry to Rapidly Induce Hypothermia in a Swine Model of Cardiac Arrest
Authors: Shao Yue , Bailey Lynn , Wu Yue
Published: July 2021

Background:
Therapeutic Hypothermia has been recommended by AHA to treat Out of Hospital Cardiac Arrest (OHCA) patients. Animal studies shown that the less time to reach target temperature (TT), the better the clinical outcome. Some animal experiments even suggested that there is an optimal time window that within which the TT should be reached for optimal outcome. In this pilot study, we developed a medical device to infuse a novel medical coolant, ice slurry which is a partially frozen saline, into the blood vessel to rapidly cool the brain. We aimed to evaluate the time to cool the brain temperature down to TT, which is 3°C below normal body temperature, in a swine model of OHCA protocol.

Methods:
Three Yorkshire swine between 40-50 kg were anesthetized. Bilateral temporal craniotomies were performed for placement of thermocouples at a depth of 1.25 cm for recording cortical temperatures. Two additional thermocouples were placed in esophageal and rectal for measuring the body temperature. A 9.5 French catheter was placed in the right femoral vein for ice slurry infusion. Ventricular fibrillation (VF) was induced by the occlusion of left anterior descending artery. After the onset of VF, there was a 3-minute stand-by followed by a 7-minute chest compression. Ice slurry infusion started at 10 minutes after the onset of VF. Ice slurry with a dosage of 50mL/kg body weight (up to 2L) was infused at constant flow rate while chest compression continues. Chest compressions continued throughout the slurry administration and for 3 minutes post infusion. Thermocouple data were recorded every second for offline processing.

Results:
In swine 1, 1970mL of ice slurry with 13% of ice fraction was infused into a 40kg pig at a flow rate of 120mL/min. The TT was reached at 22 minutes after the start of infusion. In swine 2 and 3, 2000mL of ice slurry with 25% of ice fraction was infused at 150mL/min into pigs with 49.7 kg and 41.7kg body weight, respectively. The TT were reached at 13min and 15min, respectively.

Conclusions:
Ice slurry infusion rapidly lowered the cortical temperature of young swine model in cardiac arrest. This rapid cooling method may meet the optimal time window suggested by animal experiment for dramatically improve the survival rate and neurologic outcome of OHCA.
Abstract 208: Can Transesophageal Echocardiography During CPR Change Resuscitation Outcomes in Prolonged Cardiac Arrest?
Authors: Jung Woo Jin
Published: July 2021

Background and Purpose:
Early diagnosis of a potential cause of cardiac arrest is crucial for resuscitating the cardiac arrest victim. Transesophageal echocardiography (TEE) provides an excellent window to visualize the heart and aorta without any interruption of resuscitation effort during cardiopulmonary resuscitation (CPR). This study was to investigate whether TEE during CPR influences resuscitation outcome in patients with non-traumatic adult cardiac arrest who receive prolonged resuscitation attempt. Subjects and

Methods:
This prospective observational study was conducted by analyzing the patients with non-traumatic adult cardiac arrest (age over 20 year-old) who underwent TEE during CPR in the emergency department of a university hospital. According to the availability of TEE and experienced emergency physicians, TEE was performed during CPR when resuscitation attempt was prolonged longer than 10 minutes. Patients were divided into two groups. TEE (+) group was composed of those who have any structural abnormality observed by TEE. TEE (-) group was those who have no structural abnormality. Primary outcome measure was restoration of spontaneous circulation (ROSC).

Results:
108 patients (mean age: 69 year-old, 66 males) were enrolled. 31 patients (29%) were included in TEE(+) group and 77 patients (61%) were included in TEE(-) group. Abnormalities observed in TEE(+) group included aortic dissection in 18 patients, pulmonary thromboembolism (PTE) in 9 patients, cardiac tamponade in 3 patients and intra-cardiac thrombus in 1 patient. There was no significant difference in age, rate of bystander CPR, time from collapse to CPR, CPR duration, first monitoring ECG rhythm, and etiology of cardiac arrest between two groups. The rate of ROSC and survival discharge was not different between TEE(-) group and TEE (+) group (ROSC: 38 vs 29%, P = 0.268, survival discharge: 6.5 vs. 6.5%). Two patients with pulmonary PTE who received fibrinolysis survived.

Conclusion:
TEE during CPR does not change resuscitation outcomes in patients with prolonged cardiac arrest. However, resuscitation outcome might be changed with TEE in patients with specific etiology such as PTE or cardiac tamponade.
Abstract 213: Secondary CPR Training via Mobile Application Compared to Video Self Instruction Kit
Authors: Murray Andrew , McGovern Shaun , Leary Marion , Abella Benjamin , Blewer Audrey L
Published: July 2021

Introduction:
Hands-only CPR training via a video self-instruction (VSI) kit (DVD & manikin) or a mobile application (app, video-only) allows trainees to share the training materials with others (“secondary training”). This secondary training can amplify the number of individuals trained in CPR, thus increasing the chances of bystander intervention in an out-of-hospital cardiac arrest. Health apps are an emerging tool through which public health information and education can be disseminated. No study has examined whether laypersons trained in CPR via an app share the training as frequently as those trained via VSI.

Hypothesis:
We hypothesized that laypersons trained via mobile app will share the training material more than those trained with VSI.

Methods:
This work represents a sub-investigation of an in-hospital CPR training study for families of cardiac patients. Subjects were trained with either a VSI kit or a mobile app and completed an interview 6-month post-training that measured whether training materials were shared and with how many others they were shared. Multivariate logistic regression was performed controlling for age, race and level of education to determine the likelihood that an individual shared the training.

Results:
Of 697 participants who completed the interview between 6/2016-5/2018, 281 stated they shared the training with at least 1 person (VSI n=213/356, App n=68/341). Subjects who received VSI training were more likely to share than those trained with the app (OR: 7.16, 95% CI: 4.91-10.43, p<0.01). Subjects trained with VSI had an average multiplier rate of 2.27 ±4.13 versus 0.56 ±1.66 (p<0.01) for those trained with the app. Subject-level analysis revealed that increased age is associated with decreased likelihood that an individual shared the training in both training arms (App OR: 0.98, 95% CI: 0.96-0.99, VSI OR: 0.98, 95% CI: 0.97-0.99).

Conclusion:
Subjects in the app arm were less likely to share CPR training. While it has been widely assumed that app-based solutions may afford unique dissemination opportunities, these results suggest the most effective solution to increasing hands-only CPR training may lie in kit-based options currently available. Further work is needed to determine why app-based training is shared less.
Abstract 218: Efficacy and Safety of a Novel Transnasal Cooling Device for Targeted Temperature Management (CoolStat™)
Authors: Assis Fabrizio , Bigelow Emma G , Chava Raghuram , Sidhu Sunjeet , Kolandaivelu Aravindan , Halperin Henry , Tandri Harikrishna
Published: July 2021

Background:
Targeted temperature management (TTM) is recommended as a standard of care for post cardiac arrest patients. Current TTM methods have significant limitations to be used in an ambulatory setting. We explored the efficacy and safety of a novel non-invasive transnasal evaporative cooling device (CoolStat™).

Methods:
Eleven pigs underwent hypothermia therapy using a transnasal cooling device (CoolStat™). CoolStat™ induces evaporative cooling by blowing de-humidified ambient air over the nose in a unidirectional fashion. CoolStat’s efficacy and safety were assessed by applying different cooling strategies (Groups A, B and C). In group A (efficacy study; n=5, TTM for 8h), time to achieve brain target temperature, and the percentage of time in which the temperature ranged within 0.5
o
C after reaching the target temperature were investigated. In the safety assessment (Groups B and C), two worst-case therapy situations were reproduced: in group B (n=3), continuous maximum air flow (65L/min) was applied without temperature control and, in group C (n=3), subjects underwent 24-hour TTM (prolonged therapy). Hemodynamic and respiratory parameters, nasal mucosa integrity (endoscopic assessment) and other therapy-related adverse effects were evaluated.

Results:
Efficacy study.
CoolStat™ cooling therapy successfully induced and sustained managed hypothermia in all subjects. Brain target temperature was achieved in 0.5±0.6h and kept within a ±0.5
o
C range for the therapy duration (99.9±0.1%). All animals completed the safety studies. Maximum air flow (Group B) and 24-hour (Group C) therapies were well-tolerated and no significant damage was observed on nasal mucosa for neither of the groups.

Conclusion:
CoolStat™ was able to efficiently induce and maintain hypothermia using unidirectional high flow of dry air into the nostrils of porcine models. CoolStat therapy was well-tolerated and might account for early hypothermia in cardiac arrest settings.
Abstract 219: The Effect of Therapeutic Hypothermia for Patients With Cardiovascular Shock: Results From the Japanese Circulation Society Cardiovascular Shock Registry
Authors: Yagi Tsukasa , Nagao Ken , Tachibana Eizo , Yonemoto Naohiro , Sakamoto Kazuo , Ueki Yaushi , Imamura Hiroshi , Miyamoto Takamichi , Takahashi Hiroshi , Hanada Hiroyuki , Chiba Nobutaka , Tani Shigemasa , Matsumoto Naoya
Published: July 2021

Background:
Recent guidelines on cardiopulmonary resuscitation have stressed that comatose adult patients with return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA) have targeted temperature management, including therapeutic hypothermia (TH). However, it is unknown whether the TH for patients with ROSC after cardiac arrest presenting with cardiovascular shock is useful. The aim of the present study was to clarify the effects of the TH for patients with ROSC after OHCA presenting with cardiovascular shock at hospital arrival, using the data of the Japanese Circulation Society (JCS) Cardiovascular Shock registry, a prospective, observational, multicenter cohort study.

Methods:
From the data of this registry between 2012 and 2014, we included comatose adult patients presenting with cardiovascular shock. The primary endpoint was survival rates at 30 days after hospital arrival, and the secondary endpoint was favorable neurological outcome at the discharge.

Results:
Of the 1004 patients registered in the JCS-Shock Registry, the data of 339 patients were included in this analysis. Of the 339 patients, 149 had received TH, 190 had not received (p=0.026). Figure showed the endpoints in the entire study population, in patients with ROSC after OHCA and in the patients with ROSC after OHCA, who had not received veno-arterial extracorporeal membrane oxygenation (VA ECMO). In the multivariate analysis, the adjusted odds ratio for 30-day survival in patients receiving TH as compared to patients not receiving TH was 2.806 (95%CI 1.195-5.268, p=0.001) in the entire study population, 3.194 (95% CI 1.597-6.386, p=0.001) in patients with ROSC after OHCA, 2.469 (95%CI 1.238-4.924, p=0.01) in the patients with ROSC after OHCA not receiving VA ECMO, respectively.

Conclusion:
On the basis of these results, the TH for the patients with ROSC after OHCA presenting with cardiovascular shock was useful in terms of 30-day survival, but not neurological benefits.
Abstract 22: When Laws Save Lives: Impact of Legislation Requiring Cardiopulmonary Resuscitation Education in High Schools on Survival After Sudden Cardiac Arrest
Authors: Vetter Victoria L , Dalldorf Katherine F , Rossano Joseph , Naim Maryam Y , Glatz Andrew C , Vellano Kimberly , McNally Bryan , Griffis Heather
Published: July 2021

Introduction:
Thirty eight states have laws requiring education of high school students on cardiopulmonary resuscitation (CPR) and the use of automated external defibrillators (AED). No study has measured the association of these laws and outcomes.

Hypothesis:
Out of hospital cardiac arrests (OHCAs) occurring in states with CPR high school education laws will have higher bystander CPR, survival, and favorable neurological survival than states without such laws.

Methods:
We conducted an analysis of the Cardiac Arrest Registry to Enhance Survival database and included all nontraumatic OHCAs with at least 50% population catchment from 1/2013-12/2017 in all ages. We excluded OHCAs witnessed by 911 responders, in healthcare facilities, or nursing homes. Outcomes were bystander CPR, survival to hospital discharge and neurologically favorable survival (Cerebral Performance Category score of 1 or 2 at hospital discharge). Chi-square tests were used to assess associations.

Results:
The 110,902 subjects with OHCA included Male, 64.0%; <18 yrs., 3.2%; <35 yrs., 10.7%; <50 yrs., 23.9%; White, 49.3%; Black, 19.1%; Hispanic, 2.3%; Other, 2.9%; Unknown, 26.5%. Most OHCAs occurred at home, 81.4%. 44.4% were witnessed by bystanders. 75.5% occurred in states with CPR high school education laws. A higher percent of OHCAs received bystander CPR prior to emergency medical services (EMS) arrival in states with CPR high school education laws (40.1%) compared to states without laws (37.0%) (p<0.001). Bystander CPR was less common in males (40.3% vs. 37.7% for females), those >50 yrs. (38.9% vs. 40.7% for ≤50 yrs.), Black and Hispanic subjects (25.7% and 34.9%, respectively, vs. 42.4% for Whites) (p<0.001 for all). Overall survival to hospital discharge was 10.4%; 8.8% had a favorable neurological outcome. A higher percent survived to hospital discharge in states with CPR high school education laws (11.0%) compared to states without laws (8.7%) (p<0.001). Neurologically favorable survival was more likely in states with CPR high school education laws, (9.3%) compared to states without laws (7.5%) (p<0.001).

Conclusions:
Bystander CPR, survival to hospital discharge, and neurologically favorable survival was higher in states that had CPR high school education laws.
Abstract 232: Three-Dimensional Models of Complex Interactions Between Age, Prehospital Blood Pressure, and Mortality in Major Traumatic Brain Injury
Authors: Spaite Daniel W , Hu Chengcheng , Bobrow Bentley J , Barnhart Bruce J , Chikani Vatsal , Gaither Joshua B , Denninghoff Kurt R , Rice Amber D , Keim Samuel M
Published: July 2021

Background:
Traumatic brain injury (TBI) studies with extensive
prehospital
data linked to trauma center (TC) outcomes have been small. Thus, risk adjusters like age and systolic BP have been treated dichotomously (e.g. age ≥55, SBP <90). In contrast, the size and linkage rate (98%) of the EPIC Study allows complex analysis.

Hypothesis:
The interactions between age, SBP, and mortality are neither simple nor dichotomous.

Methods and Inclusion:
Major TBI cases, age ≥10, in EPIC (NIH 1R01NS071049) before TBI guideline implementation (1/07-3/14). Logistic regression was used to associate death with age and lowest EMS SBP, adjusted for confounders, and fitted nonparametrically using penalized thin plate regression splines through the generalized additive model.

Results:
Included were 13,435 cases (Excl: 6.2% missing data; Med. age 46; 67.8% male). The Figure shows 3D planar images of the associations between adjusted risk of death (vertical axis), age and SBP. Fig A reveals: 1) there is no “hypotension threshold” below 120 mmHg at any age and this inflection point increases to 135 in older adults; 2) the optimal SBP vs outcome “valley” is very broad (e.g. ~120-180 in the young) and increases with age (~135-190 in the elderly). Figs B/C reveal: 1) mortality increases across the entire spectrum of age, 2) in hypotensive cases (SBP <90), mortality increases
linearly
with increasing age, 3) in
non
-hypotensive patients, the adjusted risk of death increases much more rapidly after age 40.

Conclusion:
Due to the small size of extant EMS studies, the evidence supporting parameters in triage guidelines (e.g. “older adults”) and EMS treatment guidelines (e.g. SBP <90) is weak. This analysis reveals that: 1) the interactions between age and SBP are far more complex than previously understood, 2) the rapidly-increasing risk for “older adults” with TBI begins around age 40, 3) the inflection point for hypotension is much higher than current guidelines suggest and increases steadily with age.
Abstract 24: Sex Differences in Outcomes After Out-of-Hospital Cardiac Arrest Patients: Insights From the Resuscitation Outcomes Consortium Continuous Chest Compression Trial
Authors: Mody Purav , Pandey Ambarish , Khera Rohan , Ayers Colby , Link Mark , Idris Ahamed
Published: July 2021

Background:
Previous studies examining sex-based differences among out-of-hospital cardiac arrest (OHCA) patients have been conflicting.

Methods:
Patients with OHCA enrolled in the Continuous Chest Compression trial between 2011 and 2016 were included in the present analysis. Hierarchical multivariable logistic regression models were constructed to evaluate the association between sex and sustained ROSC i.e. ROSC on ER arrival, discharge survival and survival with favorable neurological function after adjustment for age, witnessed status, presenting rhythm, public location, bystander CPR, resuscitation duration, and EMS response time.

Results:
Among 22,540 OHCA patients, 8,099 (35.9%) were women. Women were older (median 71 vs. 67 years), received less bystander CPR (45% vs. 47%), and had a lower proportion of cardiac arrests that were witnessed (39% vs. 45%) or had an initial shockable rhythm (15% vs. 28%, p<= 0.001 for all). There was no difference in sustained ROSC rates (24.7% vs. 24.8%, p=0.7) but discharge survival (6.5% vs. 10.3%, p<0.001) and survival with favorable neurological function (4.9 vs. 8.6%, p<0.001) were significantly lower in women (vs. men). In adjusted analysis, women (vs. men) had significantly higher likelihood of sustained ROSC (
Table
) but no difference in likelihood of discharge survival and survival with favorable neurological function. In the adjusted landmark analysis beginning after achieving ROSC, women had significantly lower likelihood of discharge survival and survival with favorable neurological function
(
Table
)
.

Conclusions:
Among resuscitated OHCA patients, women have a higher likelihood of achieving sustained ROSC despite a higher burden of poor prognostic factors. However, after successful ROSC, the likelihood of discharge survival is significantly lower in women (vs. men). Future studies are needed to understand how care provided post-ROSC may modify the sex-disparities in discharge survival outcomes.
Abstract 240: Are the Same Resuscitation Protocols Needed for Highly Aged Victims With Out-of-Hospital Cardiac Arrest as Middle or Younger Aged?
Authors: Hanada Hiroyuki , Tahara Yoshio , Yasuda Satoshi , Noguchi Teruo , Nishimura Kunihiro , Yonemoto Naohiro , Shimokawa Hiroaki , Nonogi Hiroshi , Nagao Ken
Published: July 2021

Backgrounds:
The population of elderly people aged 65 years or older in 2014 is 33 million, and the aging rate (proportion of the total population) is 26.0% in Japan. Victims facing to out of hospital cardiac arrest (OHCA) are getting older and older. Emergency medical system (EMS) in Japan must do the same resuscitation protocols once called to the patient with OHCA, even when he or she is very old and activity of daily life is very low. We need to clarify whether same resuscitation protocols are required to very highly aged patients with OHCA or not.

Methods and Results:
From January 2005 through December 2014, we conducted a prospective, population-based, observational study involving the consecutive patients across Japan who had OHCA (n= 1,299,784). The percentage of patients with OHCA aged more than 80 years old was increasing from 37.1% in 2005 to 47.8% in 2014 by 1% each year. Survival at one month after OHCA with cerebral performance category (CPC) scale 1 or 2 were 4,368 out of total 318,590 OHCA (1.4%) in 80’s, 1043 out of 126,546 (0.8%) in 90’s, and 35 out of 5,544 (0.6%) in aged more than 100 (from 100 to 114). Survival at one month after OHCA with CPC scale 1 or 2 was 11.084 out of 234,366 (4.7%) in 50- 60’s. Patients with witnessed OHCA with shockable rhythm and by-stander CPR survived to CPC 1 or 2 at one month after OHCA were 8.0% in 80’s, 4.1% in 90’s, 0 in aged more than 100, and 22.2% in 50-60’s respectably.

Conclusion:
Number of survivors with CPC 1 or 2 were very few in patients with OHCA aged more than 80 years old, but still existed. Although the same resuscitation protocols are needed for highly aged victims with OHCA, another system which arrow EMS to stop resuscitation should be established in the highly aging society.
Abstract 245: Impact of the Socio-Economic Factors on Clinical Outcome in the Patients With the Cardiac Arrest: A National Health Insurance Database Study
Authors: Kim Su Jin , Lee Sung Woo , Han Kap Su
Published: July 2021

Introduction:
There are a few reports on including socio-economic characteristics of the patients with cardiac arrest over a long period. We intended to analyze discrepancy of pre-existing condition, medical services and find the influencing factors on long-term outcome in cardiac arrest using National health Insurance Service (NHIS) database.

Methods:
The patients (≥20 yrs) with claim with cardiac arrest event from 2004-2015 were included. The variables including demographics, insurance type, location of residence, pre-existing disease, medical expenses were defined from the raw data of NHIS database. Death within 30 days, 6 months, and 1 year were endpoints. The variables and endpoints were compared according to the type of insurance. The influencing factors and prediction model were analyzed and developed. The t-test, ANOVA, chi-square, logistic regression with generalized estimating equations methods were used (SAS ver 9.4, R software).

Results:
Health insurance group and medical aid group accounted for 86.7% and 13.3 % of total 488,129 patients. Medical aid group showed higher rate of middle-aged, pre-existing disease, residence in rural area, use of a low level hospital and longer hospitalization days. The mortality rate within 30 days, 6 months and 1 year was higher as 84.9%, 92.9% and 94%, respectively in medical aid group than in health insurance group. Short-term medical expense per 1-year survivor in medical aid group was lower as $5,896, compared with $7,088 in health insurance group and long-term expense was $23,735 in medical aid group compared with $26,524. Age, male, admission through emergency room, high comorbidity index were the prognostic factors for poor outcome. Coverage by health insurance program, care in higher level hospital, ischemic heart disease, arrhythmia and defibrillation were the prognostic factors for survival. The c-statics for 30-days, 6-months, and 1-year mortality were 0.643, 0.679, and 0.687.

Conclusion:
There are disparities related to demographic data, pre-existing desased, type of medical institute used and clinical outcome. Insurance type, level of medical institute, urbanization level of residence were shown as the influencing factors for short-term and long-term outcome. (NRF-2017R1A2B1005037)
Abstract 246: The Relationship Between Favorable Neurological Outcome in Patients With Out-of-Hospital Cardiac Arrest Due to Cardiac Etiology and Regional Disparity of the Number of Physicians
Authors: Yagi Tsukasa , Nagao Ken , Tani Shigemasa , Tachibana Eizo , Chiba Nobutaka , Ashida Tadashi , Yonemoto Naohiro , Takayama Morimasa , Nonogi Hiroshi , Matsumoto Naoya , Okumura Yasuo
Published: July 2021

Background:
Cardiac arrest is a major public health issue worldwide. In Japan, the regional disparity of the number of physicians per 100000 population is also a major public health problem. However, it is unknown whether there is the relationship between favorable neurological outcome in patients with out-of-hospital cardiac arrest (OHCA) due to cardiac etiology and this regional disparity. The aim of the present study was to clarify this relationship using the data of the All-Japan Utstein Registry, a prospective, nationwide, population-based registry of OHCA.

Methods:
From the data of the All-Japan Utstein Registry between 2011 and 2015, we included adult patients who had OHCA due to cardiac etiology. 47 prefectures of Japan were divided into quartiles on the basis of the number of physicians in each prefecture, reported by Ministry of Health, Labor and Welfare in Japan. In addition, study patients were divided into four groups based on these quartiles. We compared favorable neurological outcome at 30 days after OHCA in each group, using the multivariable logistic-regression analysis.

Results:
Four quartile ranges of the number of physicians were set for this study (Figure). Moreover, of the 629,471 OHCA victims between 2011 and 2015, 358,993 met the inclusion criteria. Figure represented favorable neurological outcome at 30 days after OHCA in each quartile. In the multivariable analysis, the adjusted odds ratios for Quartile 2, Quartile 3 and Quartile 4 compared with Quartile 1 for favorable neurological outcome at 30 days after OHCA was 0.971 (95%CI 0.918- 1.027; P=0.307), 1.011 (95%CI 0.956- 1.069; P=0.703) and 0.850 (95%CI 0.809- 0.893; P<0.001), respectively.

Conclusion:
The regions in which the number of physicians per 100000 population was larger were inferior to the regions in which the number of these was smaller, in terms of neurological benefits in patients with OHCA due to cardiac etiology.
Abstract 248: Geographic Variability in Population Outcomes for Out-of-Hospital Cardiac Arrest
Authors: Zebrowski Alexis , Wiebe Douglas J , Karp David , Buckler David G , Liu Manqing , Gaieski David F , Abella Benjamin S , Carr Brendan G
Published: July 2021

Introduction:
Significant work has described patient and hospital level variability in survival after out-of-cardiac arrest (OHCA). OHCA requires a population based systems response in order to optimize regional outcomes, but no regional or systems level incentives exist. We used population based claims data to empirically describe geographic utilization patterns for OHCA and then benchmarked and compared population level outcomes.

Methods:
OHCA cases were identified from the Healthcare Cost and Utilization Project’s State Emergency Department Databases and State Inpatient Databases for 2011 in 3 states, (NY, NE, FL). Patient cohorts were identified using an ICD-9-CM code of 427.5 for the principal (outpatient) or admitting (inpatient) diagnosis. Exclusion criteria included living outside of the study area and no valid residential ZIP code. Geographic clusters were identified based on hospital utilization patterns at the ZIP code tabulation area level using hierarchical clustering. Boundary zip codes could belong to more than one regional cluster. Adjusted survival was calculated using multi-level logistic regression controlling for demographic, hospital, and community-level variables for each cluster.

Results:
In 2011, there were 17,086 OHCA treated in the study region, with a mean survival rate to admission of 18.2%; 5.1% to discharge. Hospitals and ZIP codes were grouped into 26 regions (OHCA cases per region: range 7-4,698). Regional unadjusted survival to admission ranged from 0-26.6% and adjusted from 2.8-25.0%. Crude survival to discharge rates ranged from 0-12.8%, and adjusted rates ranged from 1.7-7.6% (Figure 1).

Conclusions:
This novel approach demonstrates a method by which to measure regional variability in OHCA survival. Because the region is determined empirically based on a utilization based attribution method, population based incentives (or penalties) could be created by payers.
Abstract 252: Older Brains vs. Younger Brains: Effect of Cardiac Arrest on Hemodynamic Fluctuations and Neurologic Impairment in a Rodent Model
Authors: Wang Qihong , Modi Hiren R , Sherman David , Thakor Nitish V , Geocadin Romergryko G
Published: July 2021

Introduction:
The patient suffering from cardiac arrest (CA) is elderly. Numerous laboratory experimental studies of CA are based on the young rodent model. Post-CA patients are often hemodynamically unstable, hypotension is correlated with poor neurologic outcomes. To improve the clinical relevance of CA research in laboratory, we compared the effect of CA in retired breeder (RB) and young group (YG) rats.

Hypothesis:
The objective of this study was to investigate the effect of CA on systemic arterial blood pressure and neurologic impairment outcomes in RB and YG rats. We hypothesize that RB rats will demonstrate lower mean arterial pressure (MAP) and delayed restoration of electroencephalogram (EEG) associated with neurologic recovery.

Methods:
Male RB Wistar rats (10-12 months, n=7) and male YG Wistar rats (2-2.5 months, n=6) were subjected to 7 min of asphyxia CA. Multiple parameters including MAP, EEG were recorded. The neurological outcomes were evaluated via neurological deficit score (NDS).

Results:
There was no significant difference between the two groups’ pre-arrest baseline characteristics except for the body weights (RB vs YG as 581 ± 54 vs 395 ± 9 g). This includes baseline heart rate, MAP, EEG and time to CA. After CA, RB rats showed significantly longer time to achieve return of spontaneous circulation (ROSC) compared to the YG (123 ± 42 vs 81 ± 9 sec,
p
< 0.05). RB rats showed lower MAP post ROSC compared to YG (98.8 ± 19.0 vs 115.0 ± 16.2 mmHg,
p
< 0.05 during 0-30 min post ROSC). The recovery sequences of EEG post ROSC are as follows: non-detectable cortical activity (non-DCA); intermittent cortical activity (ICA); continuous cortical activity (CCA). Analysis of recovering EEG indicates a higher gamma fraction for the RB rats during CCA period (p<0.03). High gamma is a surrogate for better EEG recovery for complex cognitive function. NDS scores were no significant difference for both groups from 4 hours to 7 days post ROSC.

Conclusion:
It appears that older rats have slower hemodynamic recovery post ROSC compared to younger rats. The neurologic deficits are similar in both groups, but cognitive recovery by Gamma fraction seems better in RB. More study is needed to fully understand the effect of aging on the post ROSC brain.
Abstract 258: Dynamic Assessment of Lung Injury by Ultrasound in a Porcine Model of Cardiac Arrest Undergoing Therapeutic Hypothermia
Authors: Wu Chunshuang , Xu Jiefeng , Jin Xiaohong , Chen Qijiang , Wang Moli , Li Zilong , Zhang Mao
Published: July 2021

Introduction:
Acute lung injury (ALI) is common in post-cardiac arrest syndrome (PCAS), which is associated with increased morbidity and mortality. Lung ultrasound, known as a noninvasive and easily-performed method, has a growing role in the assessment of lung injury. In this study, we investigated the effectiveness of lung ultrasound in monitoring ALI in a porcine model of cardiac arrest undergoing therapeutic hypothermia.

Hypothesis:
Lung ultrasound would be a promising approach to evaluate the severity of ALI in PCAS.

Methods:
Twenty-three male domestic swine weighing 36±3 kg were randomized into three groups: 1) therapeutic hypothermia (TH, n=9), 2) normothermia (NT, n=9), and 3) sham control (Control, n=5). Sham animals underwent the surgical preparation only. The animal model was established by 8 mins of ventricular fibrillation and then 5 mins of cardiopulmonary resuscitation. At 5 mins after resuscitation, therapeutic hypothermia was induced and maintained until 24 hrs post-resuscitation in the TH group. Body temperature was normally maintained in the other two groups. Lung ultrasound score (LUS), extra-vascular lung water index (ELWI), pulmonary vascular permeability index (PVPI) and PO
2
/FiO
2
were measured at baseline and at 1, 3, 6, 12, 24 hrs after resuscitation.

Results:
After resuscitation, LUS, ELWI and PVPI were significantly increased and PO
2
/FiO
2
was significantly decreased in the HT and NT groups than in the Control group. However, all of them were significantly better in the HT group compared to the NT group (Table). Additionally, increases in LUS were highly correlated with increases in ELWI (
r
=0.613;
p
<0.001) and PVPI (
r
=0.683;
p
<0.001), and decreases in PO
2
/FiO
2
(
r
=-0.468;
p
<0.001).

Conclusions:
Lung ultrasound was a feasible approach to evaluate the severity of ALI in PCAS.
Abstract 263: CPR Posture for Life-Threatening Bleeding
Authors: Charlton Nathan P , Solberg Robert , Rizer Justin , Woods William , Singletary Eunice , Goolsby Craig
Published: July 2021

Introduction:
Bleeding from traumatic injury is a major source of morbidity and mortality, however, little data is available to aid guidelines developers in best practice of applying direct pressure when treating life-threatening hemorrhage.

Hypothesis:
This study investigated the use of two-handed pressure with bent arms versus two-handed pressure with straight arms to apply direct pressure to a hemorrhage model.

Methods:
Participants were recruited as a convenience sample in this IRB-approved study. A standardized hemorrhage control trainer with electronic feedback (Z-Medica), was set to record a minimum pressure of 3 psi (155 mmHg) as satisfactory pressure. Participants were randomized and instructed to use either two hands overlapping using arm strength only, or two hands overlapping with arms straight in a “CPR-like” position to apply force. Participants were allowed to train for 30 seconds and then were asked to hold pressure at or above 3 psi for a three minute time period. Participants were not given any feedback during testing. The program output reported the percent of time above the 3 psi pressure following participant completion of the 3 minute time period.

Results:
Thirty participants were enrolled and had data available for analysis. Demographics were statistically similar across groups. When using bent arms, participants provided pressure at or above 3 psi 63.7 % (SD 33.1) of the time. Participants using the “CPR posture” were above 3 psi 100% (SD 0) of the time [mean difference 36.27% (95% CI 18.78-53.75%]. The difference between the two experimental arms remained statistically significant when examined by age, gender, or medical experience.

Conclusions:
A straight-armed “CPR posture” allowed participants to successfully apply pressure to stop simulated bleeding, according to study parameters, 100% of the time. This information provides evidence about the most efficient way to provide high quality direct pressure to stop life-threatening hemorrhage. This method appears applicable to a broad demographic. As this posture is already widely taught in CPR classes, it can be easily adopted for hemorrhage control.