bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 12134: Risk of In-Hospital Deterioration for Children With Single Ventricle Physiology
Authors: Foote Henry , Shaikh Zohaib , Ratliff William , Gao Michael , Hintze Bradley , Sendak Mark , Li Jennifer S , McCrary Andrew
Published: December 2021

Introduction:
Children with single ventricle physiology (SV) are at high risk of in-hospital morbidity and mortality, with much of that increased risk coming in the first year of life. Understanding which children are at the highest risk for clinical deterioration may allow for increased monitoring and earlier escalation of care, with associated decreased mortality.

Methods:
We conducted a retrospective chart review of all admissions to the pediatric cardiology non-ICU inpatient service from 2014 - 2018 for children < 18 years old. Clinical deterioration was defined as an unplanned transfer to the ICU or inpatient mortality. Children with SV were selected by diagnosis codes.

Results:
From the entire cohort of 1612 pediatric cardiology admissions (56 % male, 25% SV), 288 admissions had a deterioration event including 26 deaths. Infants less than one year with SV (n = 197 admissions) were significantly more likely to have a deterioration event (107 events over 62 admissions with an event) than the overall pediatric cardiology cohort (OR 2.11, 95% CI 1.52-2.93). Among infants with SV, those with a deterioration event were significantly younger (median 1.7 v 4.3 months, p < 0.001). Further, at baseline they had significantly lower oxygen saturation (84% v 87%, p < 0.01), lower systolic blood pressure (85mmHg v 90mmHg, p< 0.02), higher respiration rate (48 v 44, p < 0.01), and higher hematocrit (44.0 v 40.2, p < 0.005) compared to those who remained stable. Mean Pediatric Early Warning Scores (PEWS) were significantly higher for infants with SV who had a deterioration event (1.4 v 0.9, p < 0.001) and PEWS scores significantly increased in the 48 hours prior to an event (p < 0.001). Of the 104 non-death events, 61 required an increase in oxygen support and 51 required a fluid bolus prior to the event (p < 0.001).

Conclusions:
Infants with SV are at high risk for clinical deterioration. There are baseline differences in vital signs and lab work between those that remain stable and those that have a deterioration event. PEWS scores and oxygen and fluid treatment significantly increase prior to deterioration events. Leveraging data from the Electronic Medical Record to identify the highest risk patients may allow for earlier detection and intervention to prevent clinical deterioration.
Abstract 12173: Out-of-Hospital Cardiac Arrest and Community First Response: Identifying Data Collection and Analysis Priorities via the Nominal Group Technique
Authors: Heffernan Eithne , Keegan Dylan , Mc Sharry Jenny , Barry Tomas , Murphy Andrew , Menzies David , O'Donnell Cathal , Masterson Siobhan
Published: December 2021

Introduction:
Community First Response (CFR) is an important intervention for out-of-hospital cardiac arrest (OHCA) in many countries. CFR entails the mobilization of volunteers by the Emergency Medical Services (EMS) to respond to OHCAs in their vicinity. These volunteers include lay-people and professionals (e.g. physicians, fire-fighters). CFR can increase rates of cardiopulmonary resuscitation (CPR) or defibrillation performed prior to EMS arrival. However, its impact on additional outcomes (e.g. survival, cognitive function) requires further study. This research aimed to identify the most important CFR data to collect and analyze, as well as the most important uses of CFR data.

Methods:
This study used the Nominal Group Technique: a structured consensus process where key stakeholders develop a set of prioritized recommendations. There were 16 participants, including CFR volunteers, an OHCA survivor, researchers, clinicians, EMS personnel, and policy-makers. They completed an online survey to generate lists of the most important (1) CFR data to collect and analyze and (2) uses of CFR data. They then attended a virtual meeting where they discussed the survey results in groups before voting for their top ten priorities from each list. They also identified barriers to CFR data collection.

Results:
The top ten CFR data to collect and analyze included volunteer response time, interventions performed by volunteers, time of emergency, time of CPR initiation, individuals who performed CPR, and the mental and physical effects of being a volunteer. The top ten uses of CFR data included providing feedback to volunteers, increasing bystander participation in resuscitation, improving volunteer training, measuring CFR effectiveness, and encouraging inter-operability with the EMS. Barriers to data collection included time constraints, prioritization of patient care, and limited training.

Conclusions:
This study established priorities for the collection, analysis, and use of CFR data in consultation with key stakeholders. These findings have important implications for both CFR research and practice. In particular, they can be used to improve the efficiency, consistency, and utility of CFR data collection and to build evidence for this intervention.
Abstract 12185: Impact of Cardiac Arrest Centers on the Survival of Nontraumatic Out-of-Hospital Cardiac Arrest Patients: A Systematic Review and Meta-Analysis
Authors: Yeo Jun Wei , Ng Celeste Z , Goh Amelia X , Gao Jocelyn F , Liu Nan , Ong Marcus E , Ho Andrew
Published: December 2021

Introduction:
The role of cardiac arrest centers (CAC) in out-of-hospital cardiac arrest (OHCA) is uncertain, especially since CACs are inconsistently defined. This study seeks to address knowledge gaps by assessing the impact of CACs on nontraumatic OHCA patients as a whole and among specific subgroups.

Methods:
In this review, Medline, Embase, and Cochrane CENTRAL were searched from inception to 9 March 2021. Studies were included if they compared CAC vs non-CAC among adult patients with nontraumatic OHCA. CACs were explicitly named by study authors and were capable of appropriate interventions. Data abstraction and quality assessment were independently conducted by two authors, and a third author resolved discrepancies. Main outcomes were survival and survival with favorable neurological outcome at hospital discharge or at 30 days. Meta-analyses were performed for adjusted (aOR) and crude (OR) odds ratios. Sensitivity analyses were conducted for wider definitions of CAC such as high volume centers or improved post-resuscitation care, and subgroups analysed to account for heterogeneity.

Results:
The search yielded 4544 articles, and 36 were included for analysis. Survival with favorable neurological outcome significantly improved with treatment at CACs (aOR = 1.88, 95% CI 1.53 to 2.31), even when including high volume centers (aOR = 1.68, 95% CI 1.30 to 2.16), or when including improved care centers (aOR = 2.16, 95% CI 1.76 to 2.64) as CACs. Survival significantly increased with treatment at CAC (aOR = 1.92, 95% CI 1.59 to 2.31), even when including high volume centers (aOR = 1.74, 95% CI 1.38 to 2.18), or when including improved care centers (aOR = 1.97, 95% CI 1.71 to 2.26) as CACs. The effect on favorable neurological outcome was more pronounced among patients with shockable rhythm (p = 0.03) and on survival among patients without prehospital ROSC (p = 0.005). Findings were robust to sensitivity analyses, with no publication bias detected.

Conclusion:
CACs improved survival and neurological outcomes for nontraumatic OHCA patients despite varying definitions of CAC. Patients with shockable rhythms and without prehospital ROSC appeared to yield greater benefit from CACs. Evidence for bypassing hospitals or inter-hospital transfer remains inconclusive.
Abstract 12327: Intravenous Waveform Analysis Correlates With Volume Status in Resuscitation in In-Vivo Rat Model
Authors: Barajas Matthew , Riess Matthias L , Baudenbacher Franz J , Hampton Matthew , li zhu , Eagle Susan
Published: December 2021

Introduction:
Current volume status markers under-perform. Dynamic markers demonstrate improved outcomes in goal directed fluid therapy but maintain validity in a narrow range of clinical parameters. In addition, they assess volume responsiveness over total volume status. Repeated echo assessments may be infeasible.

Hypothesis:
Intravenous waveform analysis-derived F1 more closely models volume status than current markers in a rat resuscitation model.

Methods:
Seven Sprague Dawley rats were anesthetized and mechanically ventilated. Pressure transductions occurred via cannulation of the right femoral vein, left femoral artery and right internal jugular vein. Hemorrhage and resuscitation occurred via the left femoral vein. Heparinized rats were bled to 80% of the estimated blood volume (EBV) then resuscitated with their own whole blood in increments of 2% of the EBV until euvolemia was reached. Cardiac output (CO) and left ventricular end diastolic area (LVEDA) were calculated with echocardiography. Fast Fourier transform was performed on venous waveforms to obtain the heart rate linked F1 amplitude. Pearson’s correlation coefficients were compared using Fisher’s Z transformation. Mixed effects modeling goodness-of-fit was assessed with Akaike information criterion (AIC). Significance was set at p=.05.

Results:
F1 had the strongest correlation with volume status, r= .70, followed by CO, r=.55, LVEDA, r=.55, mean arterial pressure (MAP), r=.50, central venous pressure r= -.02, and pulse pressure variation (PPV), r=.01. When compared, F1 rho was significantly greater than that of all variables except CO and LVEDA, p=.09 and p=.07, respectively. In mixed effects regression, F1 displayed the most significant AIC, -274, followed by CO at -239.

Conclusions:
The novel marker F1 is strongly correlated with volume status during whole blood resuscitation. F1 may be superior to current markers for directing volume resuscitation therapy.
Abstract 12423: Normoxic Therapy Attenuated Oxidative Stress Related mRNA Gene Expressions in a Post-Cardiac Arrest Rat Model
Authors: Aoki Tomoaki , Shinozaki Koichiro , Okuma Yu , Hayashida Kei , Takegawa Ryosuke , Wong Vanessa , Becker Lance B
Published: December 2021

Objective:
We recently reported that post-resuscitation normoxic therapy attenuates oxidative stress in multiple organs and improves post-cardiac arrest (CA) organ injury, oxygen metabolism, and survival. Yet, detailed mechanisms of gene expression patterns and signaling pathways mitigated by normoxic therapy have not been elucidated. Therefore, we assessed post-resuscitation normoxic therapy-modified gene expression of oxidative stress-related signaling molecules.

Methods:
Rats were resuscitated from 10 minutes of asphyxial CA and divided into 2 groups: those that inhaled 100% supplemental O
2
(CA-FIO2 1.0) and those that inhaled 30% supplemental O
2
(CA-FIO2 0.3). Control groups were also prepared for comparison (control-FIO2 1.0, control-FIO2 0.3). At 2 hours after resuscitation, brain and heart tissues were collected, and mRNA purifications followed by real-time PCR measurements were performed to compare gene expression of hyperoxia-induced inflammatory and apoptosis-related signaling pathways amongst these groups.

Results:
In the brain, relative IL-1 beta mRNA gene expression levels, which represent inflammatory signaling pathways, increased post-CA (8.1±2.3 in CA-FIO2 1.0 and 1.0±0.4 in control-FIO2 0.3, p<0.05), but were significantly attenuated by normoxic therapy (2.3±0.2 in CA-FIO2 0.3, p<0.05). Likewise, normoxic therapy significantly reduced oxidative stress-induced inflammatory (NFKB1, TGFB1, MAPK14, TRAF6) and apoptosis-related (BAX, EGF) mRNA gene expression levels in the brain, whereas no statistical differences were detected in the heart.

Conclusions:
Post-CA normoxic therapy significantly attenuated the gene expression of oxidative stress-induced inflammation and apoptosis in the brain, while there were no remarkable changes in the heart. Therefore, it is inferred that the heart is more tolerant to hyperoxic injury compared to the brain.
Abstract 12436: App-Based EMS to ED Communication May Improve Survival to Discharge Rates for OHCA Survivors
Authors: Abrahim Christian , Capatina Alina , Kalyan-Sundaram Arvind , Lotfi Amir
Published: December 2021

Background:
Survival rates for Out-of-Hospital Cardiac Arrest (OHCA) remain low despite advances in therapeutics. Although it seems intuitive, there is little evidence to support a benefit from early activation of emergency services at receiving hospitals from improved Emergency Medical Services provider (EMS) communication. We hypothesize that early, app-based communication from EMS in the field to in-hospital providers may improve survival to discharge rates.

Methods:
We utilized the General Devices Company, Inc. e-BridgeTM mobile application. EMS Providers were trained to use the app and dedicated devices and staff were stationed to monitor EMS transmissions to the emergency department (ED). A single-center, retrospective observational study was conducted on patients transferred to our institution for resuscitated OHCA. We identified 45 cases with OHCA admitted to our institution between February and July 2020 that utilized the app. We excluded interfacility transfers as well as patients certified deceased on the field. Given that standard, radio-based communication with EMS occurs 5 minutes prior to presentation, we used 5 minutes as the cutoff between our standard and intervention groups.

Results:
Of 45 cases, 29 had established communication using the app prior to 5 minutes, with the remaining 16 being considered in the standard group. We noted that 24% of patients (7 of 29) with early EMS notification survived to discharge compared to 0 of the 16 patients in the standard group. There was also an improvement in door-admission times from the ED to appropriate care units in this group (156 versus 228 minutes).

Conclusion:
Implementation of app-based communication between EMS providers and in-hospital providers with GPS tracking led to a trend to improvement in survival to discharge as well as time to admission from the ED in patients admitted for OHCA.
Abstract 12921: One Hand Open Palm Technique for Infant Cardiopulmonary Resuscitation: A Randomized Crossover Study
Authors: Patel Shruti , Balikai Shilpa , Elgin Timothy G , Newell Elizabeth A , Colaizy Tarah T , Raghavan Madhavan L , Atkins Dianne L , Haskell Sarah E
Published: December 2021

Introduction:
The American Heart Association (AHA) CPR guidelines states that effective chest compression depth, rate and recoil are essential factors for establishment of return of spontaneous circulation. A recent survey from an international pediatric resuscitation collaborative showed that healthcare providers failed to meet the metrics of the AHA guidelines, with the greatest difficulty in achieving targeted chest compression depth in infants. The recommended techniques for infant compression include two finger (TFT) or two-thumb technique (TTT). We hypothesized using the heel of one palm (open palm technique, OPT) in infants will result in improved chest compression depth with decreased provider fatigue.

Methods:
Each participant performed three techniques including TFT, TTT, and novel open-palm technique (OPT) with randomization for sequence of techniques for each participant. Each technique was performed for 2 minutes followed by a 5-minute rest period on an infant manikin. Data were collected through Zoll R series defibrillators on chest compression depth, rate, and fraction. At the end of the study, each participant filled out a survey for difficulty level, finger fatigue, and rescuer fatigue.

Results:
Thirty pediatric critical care providers participated in the study consisting of 16 nurses, 9 respiratory therapists, 3 fellows, 2 nurse practitioners. The mean chest compression depth for OPT was significantly deeper (2.61 ± 0.63 cm) in comparison to TFT (2.25 ± 0.54 cm, p= 0.0004) but not significantly deeper in comparison to TTT (2.43 ± 0.46 cm, p= 0.0820). There were no significant differences between the three techniques in chest compression rate or chest compression fraction. The finger fatigue and rescuer fatigue surveys were graded from 0-10 with 10 being the most fatigue. OPT showed significantly less finger and rescuer fatigue in comparison to TTT and TFT (p<0.05).

Conclusion:
This study demonstrated that OPT generated improved chest compression depth with considerably less rescuer and finger fatigue. However, chest compression depth with all three techniques failed to meet the AHA infant goal of 4 cm. Further research is needed to optimize CPR performance to achieve the targeted chest compression depth in infants.
Abstract 13071: Supraglottic Airway Devices Are Associated With Asphyxial Physiology Upon Arrival for ECPR in Patients With Refractory OHCA Treated With Prolonged CPR
Authors: Bartos Jason , Agdamag Arianne , Kalra Rajat , Nutting Lindsay , Frascone Ralph J , Burnett Aaron M , Vuljaj Nik , Lick Charles , Tanghe Peter J , Nystrom Paul , Quinn Ryan , Simpson Nick , Peterson Bjorn , Haley Kari , Sipprell Kevin , Yannopoulos Demetris
Published: December 2021

Introduction:
Multiple clinical trials have failed to show significant differences in survival between use of endotracheal intubation (ETI) and supraglottic airway devices (SGA) in patients with out-of-hospital cardiac arrest (OHCA). However, treatment in these trials was limited to standard ACLS, which favors short duration of CPR. We sought to compare the physiological effect of ETI versus SGA use in patients treated with prolonged CPR and extracorporeal pulmonary resuscitation (ECPR) for refractory ventricular fibrillation/ventricular tachycardia (VT/VF) by the Minnesota Mobile Resuscitation Consortium (MMRC).

Methods:
Consecutive refractory VT/VF OHCA patients transported by the MMRC to the University of Minnesota for ECPR between 2015 and 2021 were included in this retrospective analysis. Patients were considered ineligible for ECPR if they failed specific arterial blood gas metabolic criteria (lactic acid >18 mmol/L, PaO2 <50 mmHg, and ETCO2 <10 mmHg). Metabolic parameters at presentation and survival were compared between patients receiving ETI and SGA.

Results:
Among 260 patients (58.0±11.8 years), 46.5% received ETI and 53.5% received SGA. During the index hospitalization, 78/260 (30%) achieved neurologically favorable survival. Compared to those receiving ETI, patients receiving SGA had lower PaO2 (116.8±118.7 versus 135.8±128.3 mmHg, p=0.03), higher PaCO2 (69.7±28.9 versus 60.7±25.6 mmHg, p=0.01), and lower pH (7.00±0.19 versus 7.06±0.21, p=0.008). Significantly more patients who received SGA had PaO2 <50mmHg (29.1% versus 16.9%, respectively; p=0.02) and ≥1 ECPR exclusion criteria (33.1% versus 20.7%, respectively; p=0.03). Among patients excluded for PaO2 <50 mmHg, the presenting PaO2 was 35.5±11.0 mmHg and the presenting PaCO2 was 94.5±26.2 mmHg, suggestive of absence of effective ventilation (asphyxia) at presentation. Survival with CPC 1-2 was 34.7% versus 25.9% for ETI versus SGA, respectively (p=0.12).

Conclusion:
Use of SGA, during prolonged CPR in refractory VT/VF OHCA, was associated with a significant increase in the proportion of patients presenting with significant hypoxemia and asphyxial physiology, thus increasing ineligibility for ECPR.
Abstract 13213: The Prognostic Role of Serum Neutrophil Gelatinase Associated Lipocalin in Out of Hospital Cardiac Arrest Patients Who Underwent Targeted Temperature Management
Authors: An Changjoo , Park Jung Soo , Kang Changshin , You Yeonho
Published: December 2021

This study investigated the prognostic value of serum neutrophil gelatinase-associated lipocalin (NGAL) in patients treated with targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA). The study included 85 comatose adult patients with OHCA who underwent TTM between May 2018 and December 2020. Serum NGAL and neuron-specific enolase (NSE) were measured at 24-h intervals until 72 h after return of spontaneous circulation (ROSC). The primary outcome was neurological status at 3 months after OHCA. Forty-nine patients (57.6%) had a poor neurological outcome; NGAL levels at all time points measured were significantly higher in these patients than in those with a good outcome (p<0.01). NGAL showed lower maximal sensitivity (95% CI) under a false-positive rate of 0% for the primary outcome compared with NSE (18.2% [95% CI 8.2-32.7] vs. 66.7% [95% CI 50.5-80.4]). Combination of NGAL with NSE at 48 h showed the highest sensitivity (69.1% [95% CI 52.9-82.4]) and had the highest AUC (0.91 [95% CI 0.81-0.96]) for a poor outcome. The prognostic performance of NGAL alone was inadequate at all time points. However, NGAL obtained at 24 and 48 h after ROSC showed improved sensitivity when combined with NSE. NGAL should be considered as an additional biomarker to improve accuracy for prognostication in these patients.
Abstract 13237: Motivations and Barriers to Join an Automated External Defibrillator Network: A Nationwide Survey
Authors: Kjoelbye Julie , Karlsson Lena , Gregers Mads Christian Tofte , Jørgensen Anne Juul , Jakobsen Louise Kollander , Kragh Astrid Rolin , Andelius Linn , Lippert Freddy , Hansen Carolina Malta , Folke Fredrik
Published: December 2021

Introduction:
Since 2007, citizens have been able to register an automated external defibrillator (AED) with the Danish AED Network, which holds >23,000 AEDs (394 AEDs/100,000 inhabitants) linked directly to the Emergency Medical Dispatch Centers. In 2019, 60.8% of sold AEDs were registered in the network. This study aimed to identify motivations and barriers for registration with the nationwide Danish AED Network.

Methods:
A cross-sectional survey among owners of newly registered AEDs in the Danish AED Network was carried out from September 2017 to December 2020. Each month, 30-50 random AED-owners participated. The survey included items on motivations and barriers to join the AED network and items on AED accessibility.

Results:
In total, 1,540 AED-owners were included (25.3 % of newly registered in the period (n=6087)). The time from AED-purchase to AED-registration was “<1week” in 25.7%, “<1month” in 23.4%, “1month-1year” in 28.6%, “>1year” in 20.4%, and “Do not know” in 1.9%. Knowledge about the AED network is illustrated in Figure 1. Over half of the AED-owners registered their AED because they felt it was a ‘good cause’ (64.0%), followed by ‘registering upon request’ (20.6%), and ‘after a first aid course’ (5.5%). Of newly registered AEDs, 73.8% (n=1137) were 24/7-accessible. The most frequent reason for choosing limited AED accessibility (AED placed indoors/not available 24/7, n=403) was “greater expenses” (26.8%), whereas “fear of theft/vandalism” only accounted for 12.4%.

Conclusion:
Among AED-owners registering their AED to the Danish AED Network, most heard about the registry through word of mouth, registered their AED within the first year of purchase, and registered primarily because they felt it was a good cause. Most newly registered AEDs were 24/7-accessible. The biggest expressed barrier to AED accessibility was increased expenses whereas fear of theft or vandalism was a minor issue.
Abstract 13658: Characterization of Acute Respiratory Distress Syndrome in Post-Cardiac Arrest Patients
Authors: Shih Jenny A , Issa Mahmoud S , Robertson Hannah , Grossestreuer Anne V , Donnino Michael , Berg Katherine , Moskowitz Ari
Published: December 2021

Introduction:
Acute respiratory distress syndrome (ARDS) may be precipitated by cardiac arrest, but the incidence and epidemiology of post-arrest ARDS is not well characterized in the in-hospital cardiac arrest (IHCA) setting. This study aimed to describe the incidence of ARDS after IHCA and ARDS-associated IHCA outcomes.

Methods:
This was a single-center retrospective study of adult patients admitted to the hospital between 2017-2018 who suffered IHCA, were resuscitated, and were intubated within 2 hours of arrest. Patients who died or were extubated on the day of resuscitation and those with pre-arrest ARDS were excluded. Post-IHCA ARDS was defined as meeting the Berlin criteria in the first 3 days after the cardiac arrest. Outcomes included hospital length-of-stay and hospital mortality.

Results:
Of the 105 patients included, 78 (74.3%) developed ARDS within 3 days of arrest. The mean PaO2:FiO2 ratio was 222 (SD 105). Of those with ARDS, most had mild (32%) or moderate (41%) disease. Patients with ARDS had a median hospital and ICU length of stay of 17 (IQR: 8, 31) and 7.5 (IQR: 3, 16) days compared to patients without ARDS, who had a median hospital and ICU length of stay of 10 (IQR: 7, 19) and 5 (IQR: 3, 11) days (p>0.1 for both comparisons). There was a higher use of midazolam in patients with ARDS (18% vs 4%), but this was not statistically significant (p=0.1).

Conclusion:
There is a high incidence (74%) of post-arrest ARDS in IHCA patients. This compares to recent estimates suggesting a post-arrest ARDS incidence of approximately 50% in the out-of-hospital arrest population. While there was no statistically significant difference in outcomes, this study was limited by a small sample size. Future studies should further investigate these relationships in a larger cohort.
Abstract 13737: Enhanced Prehospital End-Tidal CO2 Monitor Data Analysis for Intubated Severe Traumatic Brain Injury: Striking Findings From the EPIC Study
Authors: Spaite Daniel W , Barnhart Bruce J , Helfenbein Eric , Jorgenson Dawn , Babaeizadeh Saeed , Gaither Joshua B , Rice Amber D , Keim Samuel M , Hu Chengcheng
Published: December 2021

Background:
Studies show that EMS patients are often inadvertently hyperventilated (HV), resulting in hypocapnia. In TBI, HV markedly increases mortality. We evaluated continuous prehospital ETCO2 data in intubated TBI patients.

Methods:
Analysis of monitor data files (Philips MRx™) from a sample of intubated TBI cases in the EPIC Study (NIH-R01NS071049).

Results:
Among hundreds of cases, graphical display of continuous ETCO2 from 3 subjects dramatically exemplified commonly-occurring inadvertent HV. Fig 1 shows unrecognized HV lasting nearly 15 min. Fig 2 reveals nearly 14 min of increasing ventilatory rate and progressively worsening hypocapnia. Fig 3 shows nearly 4 min of HV that ends abruptly with clear, sudden recognition and slowing of ventilatory rate that leads to restoration of normal ETCO2 in only a few breaths. The corresponding EMS patient care records (PCR) failed to document the presence, severity, and duration of HV.

Conclusions:
In a study emphasizing prevention of HV, subsequent evaluation of continuous ETCO2 data revealed many cases of unintentionally rapid manual ventilation and severe hypocapnia, often occurring for long periods. These findings, even in the face of explicit guideline-based training, demonstrate a clear need for routine access to continuous monitor data among intubated patients for quality improvement and in clinical studies. Review of PCRs does not reliably identify mismanagement of ventilation. Furthermore, these findings make it likely that real-time audiovisual feedback technology would improve ventilatory management by alerting providers to unidentified HV that results from the frequent distractions occurring during EMS care.
Abstract 13811: Cognitive and Psychological Outcomes of Patients 6 Months After Cardiac Arrest or Intensive Care Stay
Authors: Potter Matthew R , Mion Marco , Nikolopoulou Eleni A , Magee Neil , Farrell Kelly , Davis Jean , Perilla Daryl , Gudde Ellie , Davies John R , Keeble Thomas R
Published: December 2021

Background:
The neuropsychological and cognitive consequences of an ICU stay can cause a large burden on many patients. In this study, we assessed the outcomes of a group of patients attending a newly set up, multi-disciplinary outpatient clinic focused on assessing neuropsychological and cognitive outcomes following a significant (>72 hours) ICU stay, and compared patients whose ICU was post-OHCA (out of hospital cardiac arrest), and those non-OHCA.

Methods:
Between 2016 and 2019, 152 patients were assessed within the Care after REsuscitation (CARE) / ICU follow up clinic, 6 months following hospital discharge, using the SF-36, HADS, PTSS-14 and MoCA. The OHCA group were compared to other non-OHCA, ICU patients (>72 hour stay).

Results:
No significant differences (p<0.05) were found between the groups outcomes, however we found that 6 months post-discharge, the non-OHCA group experience significantly more pain, are older, and required a longer length of stay (p<0.05). However, we found compared to normative data of the SF-36, over half of the OHCA group (on 6 out of the 8 subscales) and the non-OHCA (on 7 out of the 8) were below population norms, especially Role-Physical (66.7% OHCA and 71.6% non-OHCA) and Energy/ fatigue (66.7% OHCA and 61.4% non-OHCA). Anxiety was observed in 33.3% of the OHCA group, and 35.2% of the non-OHCA group had an abnormal total HADS score. PTSD was seen in 12.7% of the OHCA group and 10.2% of the non-OHCA group. Cognitive impairment was observed in 61.9% of OHCA and 59.1% of non-OHCA patients. Age and hospital length of stay had no significant effect on outcomes on our OHCA population, however females had significantly worse health related quality of life (HRQoL) on 6 out of the 8 subscales (p<0.05).

Conclusion:
Despite the OHCA and non-OHCA groups having no significant difference between their outcomes, there is a great disease burden upon many individuals following ICU stay, with many experiencing poor HRQoL, mood disorders, PTSD and cognitive impairment. The factors contributing to poor outcome following both ICU related illness and cardiac arrest should be further studied. The creation and validation of new assessment tools is imperative to ensure we fully appreciate the extent of the morbidity in this group to improve care for all ICU patients.
Abstract 13824: Computerized Tomography vs Ultrasound Imaging for Detecting Hypoxic-Ischemic Brain Injury
Authors: Karfunkle Benjamin , Kotini-shah Pavitra , Gordon Richard , Li Jing , Granado Misha , Doshi Pratik B , Wang Henry , Vanden Hoek Terry L
Published: December 2021

Introduction:
After an out-of-hospital cardiac arrest (OHCA), the resulting hypoxic-ischemic injury (HII) to the brain remains the main cause of mortality. Standardized approaches for measuring the extent of injury and monitoring of changes are lacking and continue to be a critical barrier to progress in improving neurological survival. Objective: We sought to characterize the prevalence of HII detected on computerized tomography of the brain and its correlation to point-of-care optic nerve sheath diameter (ONSD) measurements as an alternative modality for detecting brain injury.

Methods:
Adult OHCA patients at an urban academic ED were included in this study on a convenience sample basis from 2018-2019. The patients were grouped by findings of hypoxic-ischemic injury (HII) on both initial and subsequent CT brain imaging performed after ROSC in respective groups. CT Brain findings were compared to ONSD measurements as performed with point-of-care ultrasound by fellowship-trained emergency physicians within one hour of hospital arrival and at 6 hours, after return of spontaneous circulation (ROSC) and to cerebral performance category (CPC) at hospital discharge.

Results:
76 patients enrolled in the study had a median age was 59, 49% were female, and 37% survived to hospital discharge. 58 patients had CT head performed, 40 had ONSD measured within one hour, and 27 patients had both. Of that 27, 9 (33%) had evidence of HII on initial imaging and 15 (55%) had evidence of HII on subsequent imaging for a total of 20 unique patients. The average ONSD within 1 hour of ROSC for those with no HII on any imaging was 0.59 cm, and for those without HII on initial imaging but with HII on subsequent imaging was 0.67 cm, and this difference was statistically significant (p< 0.05). Of the 20 patients with HI, 14 (70%) patients died and 6 (30%) survived with a CPC of 4. The average time to first CT head was 4 hours and 45 mins and the average time to subsequent imaging was 97 hours and 45 mins.

Conclusion:
After an OHCA, early time point ONSD measurements can potentially indicate brain injury within 1 hour of ROSC even in those without initial evidence of HII on CT imaging.
Abstract 16643: Pacemaker For First Degree AV Block Without Bradycardia: Pseudo-pacemaker Syndrome
Authors: Saad Shaukat Muhammad Hamza , Khalil Fouad , Ahmed Mamoon , Petrasko Marian S
Published: December 2021

Case Presentation:
An 86 year old man underwent PCI of distal LAD for severe single vessel coronary artery disease identified after a high risk pharmacologic nuclear stress test (evaluation of exertional fatigue prior to abdominal aortic aneurysm surgical repair). ECHO was consistent with preserved LVEF (60-65%), moderate concentric LVH and mild left atrial enlargement. Less than a week after PCI, he presented to the emergency department for NYHA III dyspnea and fatigue. The patient was not taking any negative chronotropic medications. CT angiography of the chest excluded pulmonary edema, pneumonia and pulmonary embolism; repeat limited ECHO was unchanged. EKG showed first degree AV block (PR 400ms, figure 1). Severely prolonged PR interval with otherwise-unexplained exertional symptoms raised suspicion for pseudo-pacemaker syndrome. In the absence of an alternative cause of declining exertional tolerance, a dual chamber pacemaker with short programmed AV delay (<200ms) was implanted. The patient reported resolution of exertional fatigue and dyspnea on one-month followup.

Discussion:
Pseudo-pacemaker syndrome is a rare, infrequently reported, complication of first degree AV block with severely prolonged PR>300ms. P-wave at the end of the preceding T-wave suggests AV dyssynchrony (arrowhead, figure 1). Left atrial contraction against a closed mitral valve led to loss of atrial contribution to cardiac output, and elevated left atrial pressure. These changes, accentuated by physiologic increase in heart rate on exertion, most likely caused symptoms in this patient. It is interesting that AV dyssynchrony in pacemaker syndrome is caused by the pacemaker (VVI pacing) whereas the AV dyssynchrony in pseudo-pacemaker syndrome from severely prolonged PR interval is treated with a pacemaker. In the appropriate clinical picture, it is an indication for dual-chamber pacemaker implantation for first degree AV block without bradycardia or pauses.
Abstract 16831: Provoked PFO Shunt And Posterior Circulation Stroke: An Underrecognized Association
Authors: Saad Shaukat Muhammad Hamza , Ahmed Mamoon , Petraskova Terezia , Georgiev Alex , Jonsson Orvar
Published: December 2021

Case Presentation:
A 50 year old man presented with nausea and weakness. MRI brain showed a small acute infarct in the right pons. CT angiography of the head and neck was unremarkable. No thrombus, vegetation, or inter-atrial communication was seen on transthoracic echocardiogram: LVEF was 55-60% with normal left atrial size. No history of atrial fibrillation, hypertension, diabetes or drug abuse was reported; lower extremity duplex was negative for deep venous thrombosis. TSH was normal. Transesophageal echocardiography showed an aneurysmal atrial septum: agitated saline injection did not demonstrate an inter-atrial communication (figure 1). Repeat saline injection during the same procedure with Valsalva maneuver demonstrated a moderate-sized, provoked right-to-left, patent foramen ovale (PFO) shunt (figure 2).

Discussion:
Physiologically decreased sympathetic innervation spares posterior cerebral circulation from Valsalva-induced vasoconstriction. The disproportionate increase in posterior cerebral blood flow when venous return/cardiac output increases in the immediate post-strain period explains the association of provoked PFO shunt and paradoxical embolism to posterior circulation. Although the association has been described in literature, it remains underappreciated. Recognition of the association expedited secondary prevention of stroke in this non-elderly patient by circumventing the need to exclude atrial fibrillation on ambulatory rhythm monitoring (3-6 months) before referral for PFO closure.
Abstract 17116: Recurrent Atrial Myxomas As A Presenting Feature Of Carney Complex
Authors: Alam Mustafa , Singh Tavleen , Bath Anandbir , Alsafwah Shadwan
Published: December 2021

Case Presentation:
A 24-year-old man with a history of adrenal insufficiency on hydrocortisone presented to the hospital after losing consciousness in a swimming pool and was found to have an acute MCA stroke. PMHx was significant for left atrial myxoma status post resection 3 years ago, known L frontal brain, L adrenal, and testicular masses status post-resection. His father had a history of resected left atrial mass. Cardiology was consulted for a L atrial mass on the bedside echocardiogram upon initial emergency evaluation, during which the patient was placed on mechanical ventilation with stable vitals. The cardiovascular exam revealed a midsternal scar but was otherwise normal. Pulses were 2+ bilaterally on the upper and lower extremities. The skin was noted to have multiple hyperpigmented macules resembling cafe-au lait spots. The patient underwent mechanical thrombectomy with thrombolysis for his large MCA occlusion. His postoperative course was complicated by a worsening neuro exam in the setting of mid-line shift for which he had undergone decompressive hemicraniectomy. His adrenal insufficiency was managed by endocrinology. A TTE was significant for a L atrial mass measuring 4.8 cm attached to the interatrial septum with a stalk. A CT scan identified 2 discrete hypodensities of 8 mm and 3.8 cm which were thought to be the cardioembolic source for the stroke. An abdominal CT revealed a recurrent L adrenal neoplasm with absent R adrenal gland post resection of neoplasm. Conservative cardiac management was elected in the setting of a worsening neuroprognosis with follow-up post neurologic insult.

Discussion:
Considering the constellation of neoplastic and cutaneous findings, this was diagnosed as a case of Carney complex. This case identifies recurrent myxoma as a unique feature of Carney complex, ruling out other differentials such as neurofibromatosis and MEN syndrome. It highlights the importance of screening to prevent embolic stroke from recurrent myxomas.
Abstract 17147: Multidisciplinary-team Management Of A Severely-ill Pregnant Covid-19 Patient With A Newly Diagnosed Severe Mitral Stenosis
Authors: Aljabery Yazan , Manla Yosef , Gobolos Laszlo , Bhatnagar Gopal , Traina Mahmoud
Published: December 2021

A 30-year-old female who was 26 weeks pregnant, presented to an outside facility with acute hypoxic respiratory failure and was initially treated as an asthma exacerbation. Her chest X-ray and CT revealed extensive bilateral airspace disease of ground glass opacities (Figure 1A) and a main pulmonary artery diameter of 3.5 cm. Transesophageal echocardiogram revealed severe mitral stenosis (MS) with a high Wilkins-Abascal score of 11/16, a mean mitral gradient of 19 mmHg, and a right ventricular systolic pressure of 94 mmHg consistent with severe pulmonary hypertension (Figure 1B, 1C). Rapid COVID test was positive, patient clinically deteriorated and was emergently transferred to our facility. She rapidly required intubation and vasopressor support. Our multi-disciplinary team (MDT) decided to perform an emergent rescue percutaneous balloon mitral valvuloplasty, which led to an improvement of mitral stenosis, but with a resultant significant MR. Intraoperative decision was taken to proceed with an emergency cesarean section and a live male was delivered. Postoperatively, she was treated supportively for COVID pneumonia with rapid improvement in clinical status. She was extubated on the 3
rd
postoperative day (POD), and was ambulating without any need for oxygen by the 7
th
POD, and discharged home on the 11
th
POD. Her infant continued to improve and was discharged 1 month later.

Discussion:
Rheumatic MS constitutes a major cause of acquired heart disease complicating pregnancy in the developing world. This case report features some of the challenges in the diagnosis and management of a complex condition in the pandemic environment and highlights the importance of MDT approach.
Abstract 8875: Early Compared to Late Administration of Epinephrine in Adults With Shockable Initial Rhythm Out-of-Hospital Cardiac Arrest
Authors: Luo Shengyuan , Gu Liwen , Zhang Wanwan , Zhang Yongshu , Li Wankun , Qiu Feipeng , Zhang Guanchun , Tao Jun , Xiong Yan , Idris Ahamed H
Published: December 2021

Introduction:
The optimal timing of epinephrine administration in shockable initial rhythm out-of-hospital cardiac arrest (OHCA) is unclear.

Hypothesis:
Early compared to late epinephrine following first electrical defibrillation attempt is associated with better outcomes in shockable initial rhythm OHCA.

Methods:
We conducted a retrospective study in adults with shockable initial rhythm OHCA from 2011-2015 in North America. We used multivariable logistic regression to assess associations between timing of epinephrine and prehospital return of spontaneous circulation (ROSC), survival to hospital discharge, and hospital discharge with favorable neurological outcome (modified Rankin Scale score≤3). We used propensity-score-matching and subgroup analyses to assess robustness of associations.

Results:
Of 6416 patients, median age was 64 (IQR: 54-74) years, 5136 (80%) were men, 2226 (35%) received epinephrine within four minutes after first defibrillation, 5119 (80%), 1237 (19%), and 996 (16%) had prehospital ROSC, survival to hospital discharge, and favorable neurological outcome at discharge respectively. Adjusted for confounders, we observed lower odds of prehospital ROSC (OR=0.95, 95%CI 0.94-0.96; p<0.001), survival to hospital discharge (OR=0.91, 95%CI 0.89-0.92; p<0.001), and favorable neurological outcomes at discharge (OR=0.92, 95%CI 0.90-0.93; p<0.001) per minute later epinephrine administration. Compared to epinephrine administration within four minutes following first defibrillation attempt, later epinephrine was associated with lower odds of prehospital ROSC (OR=0.58, 95%CI 0.51-0.68; p<0.001), survival to hospital discharge (OR=0.50, 95%CI 0.43-0.58; p<0.001), and favorable neurological outcome at discharge (OR=0.51, 95%CI 0.43-0.59; p<0.001). Associations remained significant in a well-balanced propensity score matched cohort and subgroup analyses by witness status, EMS response time, and total epinephrine dose.

Conclusion:
In shockable initial rhythm OHCA, early compared to late epinephrine administration following first defibrillation attempt was associated with better odds of prehospital ROSC, survival to hospital discharge, and hospital discharge with favorable neurological outcome.
Abstract 8883: Pre-hospital Physician’s Presence and Neurological Outcome Among Patients Performed Pre-hospital Advanced Airway Management: A Nationwide Multicenter Observational Study in Japan (the Japanese Association for Acute Medicine-out-of-Hospital Cardiac Arrest Registry)
Authors: Hatakeyama Toshihiro , Kiguchi Takeyuki , Sera Toshiki , Nachi Sho , Ochiai Kanae , Kitamura Tetsuhisa , Ogura Shinji , OTOMO YASUHIRO , Iwami Taku
Published: December 2021

Purpose:
Using the out-of-hospital cardiac arrest (OHCA) registry in Japan, we evaluated the effectiveness of pre-hospital advanced airway management under physicians’ presence after adjusting in-hospital treatments.

Methods:
This was a multicenter cohort study. We registered all consecutive OHCA patients in Japan who, from 1 June 2014 through 31 December 2017, were transported to institutions participating in the Japanese Association for Acute Medicine OHCA Registry. We included OHCA patients performed pre-hospital advanced airway management, who were ≥18 years of age with medical etiology and who received resuscitation from emergency medical services (EMS) personnel and medical professionals in hospitals. The primary outcome was one-month favorable neurological survival.We estimated the propensity score by fitting a logistic regression model that was adjusted for several variables before the arrival of EMS personnel and/ or pre-hospital physician. A multivariable logistic regression analysis in propensity score-matched patients was used to adjust confounders including extracorporeal membrane oxygenation, percutaneous coronary intervention, intra-aortic balloon pumping, and targeted temperature management.

Results:
We analyzed 9,672 patients. Among them, 2.3% (N = 218) had a neurologically favorable outcome. The adjusted odds ratio (AOR) of pre-hospital advanced airway management under physicians’ presence compared with their absence for primary outcome was 0.96 (95% confidence interval (CI): 0.61-1.51). Among first documented non-shockable cardiac rhythm, the AOR was 3.10 (95% CI: 1.05-10.77). Among first documented shockable cardiac rhythm, the AOR was 0.90 (95% CI: 0.53-1.53).

Conclusion:
In Japan, pre-hospital advanced airway management under physicians’ presence was not associated with one-month favorable neurological survival among patients with first documented shockable cardiac rhythm, whereas it was associated with a neurologically favorable outcome among patients with first documented non-shockable cardiac rhythm.
Abstract 9499: Prehospital Factors Associated With Cardiopulmonary Resuscitation Performance in Out-of-Hospital Cardiac Arrests
Authors: Villani Melanie , Nehme Ziad , Andrew Emily , Ball Jocasta , Smith Karen
Published: December 2021

Introduction:
Although high quality cardiopulmonary resuscitation (CPR) has been associated with improvements in survival from cardiac arrest, little is known about the arrest factors that influence CPR performance. This study examined the association between CPR performance and patient and arrest factors in out-of-hospital cardiac arrest (OHCA).

Methods:
A retrospective observational study using data from a statewide cardiac arrest registry in Victoria, Australia. The study included 2,408 adult, medical OHCA patients who arrested between 11 February 2019 and 10 February 2021. Fractional and logistic regression models were used to analyse factors associated with CPR performance outcomes, including the proportion of compressions at target depth and target rate and a compression fraction ≥90%.

Results:
The median proportion of compressions at target depth and target rate were 80% (interquartile range [IQR] 58, 92.5) and 62% (IQR 40, 79), respectively, and 70% achieved a compression fraction ≥90%. After multivariable adjustment, achieving a compression depth in the target range was associated with female sex (OR 1.14 [95% CI: 1.02, 1.28]), patient weight (per 10 kg increase, OR 1.08 [95% CI: 1.05, 1.12]), aged care facility location (OR 0.74 [95% CI: 0.58, 0.94]), fire-fighter presence (OR 1.29 [95% CI: 1.14, 1.46]), resuscitation duration (per 5 min increase, OR 1.08 [95% CI: 1.06, 1.10]) and number of rescuers (per 1 person increase, OR 1.06 [95% CI: 1.03, 1.09]). Achieving compressions within target rate were associated with public location (OR 0.81 [95% CI: 0.72, 0.91]) and fire-fighter presence (OR 1.12 [95% CI: 1.02, 1.24]). Achieving a compression fraction ≥90% was associated with female sex (OR 0.75 [95% CI: 0.62, 0.91]), arrests witnessed by emergency services (OR 0.44 [95% CI: 0.32, 0.61]), initial shockable rhythms (OR 0.66 [95% CI: 0.53, 0.81]), fire-fighter presence (OR 1.24 [95% CI: 1.01, 1.54]) and resuscitation duration (per 5 min increase, OR 1.05 [95% CI: 1.02, 1.08]).

Conclusion:
This study demonstrates that several prehospital factors that are associated with CPR performance which may help inform operational strategies to improve OHCA outcomes.