bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 165: Association of Advanced Airway Placement and Time to Epinephrine Administration in Patients With Out-of-Hospital Cardiac Arrest
Authors: Lupton Joshua , Schmicker Robert , Daya Mohamud , Aufderheide Tom , Stephens Shannon , Le Nancy , Nichol Graham , Wang Henry , Hansen Matthew
Published: July 2021

Introduction:
Out-of-hospital cardiac arrest (OHCA) remains a significant source of morbidity and mortality in the United States. In addition to cardiopulmonary resuscitation (CPR) and defibrillation, epinephrine and advanced airway management are often used in treatment. Recent studies suggest early administration of epinephrine is associated with improved survival. The purpose of this study was to evaluate the effect of airway type on timing to epinephrine in OHCA.

Hypothesis:
Patients who had laryngeal tube (LT) insertion as first attempted airway have shorter times to epinephrine administration compared to those with endotracheal intubation (ETI) as first attempted airway.

Methods:
Subjects enrolled in the Pragmatic Airway Resuscitation Trial who received epinephrine and primary ETI or LT were included. The dependent variable was timing to epinephrine administration after EMS arrival in minutes, the independent variable was first airway attempted (LT or ETI). Kaplan-Meier estimates of time to drug administration were used to account for censoring.

Results:
We included 2650 subjects (1423 LT and 1227 ETI). There were no significant differences in age, sex, first rhythm, EMS response time, witnessed arrest status, bystander CPR or proportion receiving epinephrine between the LT and ETI groups. Among all OHCA patients, LT and ETI had median minutes (95% CI) until epinephrine administration of 9.3 (9.0, 9.8) and 9.7 (9.4, 10.0), respectively (p=n.s.). For the VT/VF subgroup, the median minutes (95% CI) to epinephrine administration were 8.0 (7.8, 9.0) and 9.2 (8.7, 9.9) for LT and ETI, respectively (Figure, p=n.s.).

Conclusions:
Overall, advanced airway type did not affect time to epinephrine. Among those with initial VT/VF, there is a weak, non-statistically significant trend of longer time to epinephrine when ETI is used compared to LT. This difference may be a contributing component to improved survival with an initial LT airway strategy for OHCA.
Abstract 169: Prehospital ECPR : An Organizational Challenge!
Authors: Hutin Alice , Raphalen Jean Herle , Dagron Christelle , An Kim , Winchenne Anaïs , Carli Pierre , Lamhaut Lionel
Published: July 2021

Introduction:
ECPR, « extracorporeal cardiopulmonary resuscitation » is a second line treatment for refractory cardiac arrest (CA), and low-flow time is clearly identified as a prognostic factor. Our prehospital ECPR team is made of a physician, an anesthetic nurse and a paramedic. During the day (8am to 6pm), the physician, specifically dedicated to the ECPR team, is on site at the EMS call center, where he can have other clinical or research activities; at night and during the weekend, he is on call at home. The nurse and paramedic are on site 24/7, dedicated to the mobile ICU activities, but available for the ECPR team if necessary. Triggering of the ECPR team occurs as early as possible after cardiac arrest, if possible at the same time as the BLS and ALS teams are sent out. Our ECPR team operates inside the city limits but also outside the city in surrounding cities, without access to ECPR. After ECPR team activation, cancellation can occur during transportation or on site of the CA in several situations including return of spontaneous circulation (ROSC), or absence of inclusion criteria for ECPR.

Methods:
Retrospective monocentric study from January to December 2017. The following data were collected: number of ECPR team activation calls, place and time of intervention, reason for cancellation, number of patients implemented with ECPR.

Results:
Over the 12 month period, ECPR team was activated 336 times; ECPR triggering occurred during the on call period in 185 cases (55%). Most of the time, interventions were within the city limits (N=209, 62%). Reasons for cancelation were as follows: ROSC (N=116, 34%), no inclusion criteria for ECPR (N=102, 30%), absence of CA (N=25, 7%), unknown (N=42, 12%). All together, 61 patients were actually implemented with ECPR for refractory CA (18%).

Conclusion:
In the end, 18% of ECPR activation calls lead to actual ECPR implementation. The necessity of early ECPR implementation justifies for early triggering of the ECPR team, despite the high risk of cancellation, whether it be for ROSC or absence of CA. This intense activity justifies for a dedicated complete ECPR team available 24/7. ECPR process requires specific training and precise coordination of personnel in the EMS call center and in the prehospital setting (ALS and ECPR teams).
Abstract 174: Cost-Utility Analysis of Extracorporeal Cardiopulmonary Resuscitation in Patients With Cardiac Arrest
Authors: Bharmal Murtaza , Venturini Joseph , Chua Rhys , Sharp Willard , Beiser David , Tabit Corey , Hirai Taishi , Rosenberg Jonathan R , Friant Janet , Blair John E , Paul Jonathan D , Nathan Sandeep , Shah Atman P
Published: July 2021

Introduction:
Extracorporeal cardiopulmonary resuscitation (ECPR) provides cardiac and respiratory support and serves as a bridge to definitive therapy or to recovery. However, ECPR is resource intensive and evidence of clear survival benefit is lacking. In this study, we investigated the cost-utility of ECPR (cost/QALY) in cardiac arrest patients treated at our institution.

Methods:
We performed a retrospective review of ECPR patients who suffered cardiac arrest at our institution between 2012 and 2017. Charges for all medical care associated with ECPR and subsequent hospital care were recorded, including direct costs, indirect costs, operating costs and payer charges. The quality-of-life status of survivors was assessed with the Health Utilities Index Mark II.

Results:
ECPR was instituted in 24 patients (54% in-hospital [13 of 24]), mean age 49.8 ± 17.3 years, 71% male (17 of 24), and 58% African American (14 of 24). The mean and median duration of ECMO support was 3.2 and 2.7 days, respectively. The mean and median of total length of stay was 13.4 and 7.5 days, respectively. Survival to hospital discharge and 1-year survival were 17% (4 of 24) and 13% (3 of 23), respectively. The mean score of the Health Utilities Index Mark II at discharge for the survivors was 0.53 ± 0.23 (range, 0.32-0.84). The average operating cost for patients undergoing ECMO was $188,197 per patient. The calculated cost-utility for ECPR was $59,449/QALY gained.

Conclusions:
The calculated cost-utility for ECPR is within the threshold considered cost-effective in the United States (<$100,000/QALY gained). These results are comparable to the cost-effectiveness of orthotopic heart transplantation for end-stage heart failure. Larger studies are needed to assess the cost-utility of ECPR and to identify whether other factors, such as patient characteristics and type of cannula, may affect the cost-utility benefit.
Abstract 175: Evaluation of Team Performance in Video Review of Pediatric Cardiopulmonary Resuscitation
Authors: Myers Sage , Wolfe Heather , Donoghue Aaron
Published: July 2021

Background:
Team dynamics have been a learning objective of AHA courses since 2005. Cardiopulmonary resuscitation (CPR) in a hospital setting involves a multidisciplinary team with multiple specific roles occurring simultaneously. Though evaluation of team performance in simulated resuscitation events has been studied, little information exists on the performance of teams in real CPR events. The development of a video-based resuscitation quality improvement (QI) program has allowed a route for the analysis of team performance during actual patient care.

Objective:
Demonstrate feasibility of team performance rating of real pediatric CPR events using video review.

Methods:
All pediatric resuscitations requiring cardiopulmonary resuscitation (CPR) in the emergency department of a tertiary children’s hospital are video-recorded for QI purposes. Following video review, team performance was rated by study personnel using the validated Behavioral Assessment Tool (BAT). The BAT scores 10 domains of team performance, each on a 0-4 Likert Scale (score range 0 – 40). Univariate comparison of BAT scores was done between patient age categories, event duration, location of arrest (in- vs. out-of-hospital), and chest compression fraction (CCF) below or above 80% using nonparametric methods.

Results:
13 events requiring CPR occurred during the study period. Mean BAT scores were 32 (+/- 6) points. Lowest rated domains were Attention allocation , Distribution of workload, and Utilization of information. Highest rated domains across all events were Recognition of Limitations and Professional behavior. BAT scores were significantly higher in infant CPR events than older children (39 vs. 28, p=0.005) and out-of-hospital events compared with in-hospital (37 vs 27, p=0.04). There were no significant differences in BAT scores based on event duration or CCF.

Conclusions:
Video-based review of pediatric CPR events is a feasible method for efficient evaluation of team performance using validated tools. Quantitative assessment of team performance allows for needs assessments to determine areas in which intervention should be focused for maximum impact on CPR quality. Future work should focus on interventions to address areas of suboptimal performance.
Abstract 176: Effects of the Presence of Emergency Medical Service Physician on Neurologically Intact Survival After an Out-of-Hospital Cardiac Arrest: A Nationwide Population-Based Observational Study
Authors: Funada Akira , Goto Yoshikazu , Tada Hayato , Shimojima Masaya , Okada Hirofumi , Kawashiri Masa-aki
Published: July 2021

Introduction:
Previous observational studies have suggested that prehospital emergency medical services (EMS) physician-guided cardiopulmonary resuscitation (CPR) is associated with improved survival after an out-of-hospital cardiac arrest (OHCA) when compared with paramedic-guided CPR.

Hypothesis:
EMS physician-guided CPR for OHCA is associated with improved 1-month neurologically intact survival compared with paramedic-guided CPR, from the 2010 guideline updates onward.

Methods:
The study included 613,251 Japanese adults (aged ≥18 years) from a prospectively recorded nationwide Utstein-style database who had OHCA between 2011 and 2015. The patients were divided into two groups on the basis of the presence of a physician during CPR before hospital arrival: EMS physician- (n=19,551, 3.2%) and paramedic-guided CPR groups (n=593,700, 96.8%). The study end-points were 1-month and neurologically intact survivals, defined as Cerebral Performance Category scores of 1 or 2 (CPC 1-2).

Results:
Proportions of crude 1-month survival and CPC 1-2 in the EMS physician-guided CPR group were significantly higher than those in paramedic-guided CPR group: 10.9% (2138/19,551) vs. 4.8% (28,448/593,700) for 1-month survival and 5.7% (1114/19,551) vs. 2.5% (14,859/593,700) for 1-month CPC 1-2, both p-values <0.0001. Multivariate logistic regression analysis showed that EMS physician-guided CPR was associated with increased adjusted odds ratios (aORs) for 1-month favorable outcomes: 1.70; 95% confidence interval [CI], 1.61-1.79 for 1-month survival; and 1.51; 95% CI, 1.46-1.62 for 1-month CPC 1-2. In the propensity-matched cohort, EMS physician-guided CPR also showed more favorable outcomes 1 month after OHCA than did paramedic-guided CPR: 11.6% (1931/16,612) vs. 7.9% (1310/16,612) for 1-month survival and 6.0% (996/16,612) vs. 4.6% (766/16,612) for 1-month CPC 1-2, both p-values <0.0001 (aOR, 1.68; 95% CI, 1.55-1.82 for survival; and 1.45; 95% CI, 1.30-1.62 for CPC 1-2.

Conclusions:
This large-scale registry-based study in Japan shows that EMS physician-guided CPR in OHCA before hospital arrival is associated with improved 1-month neurologically intact survival compared with paramedic-guided CPR.
Abstract 178: What is the Role of Clinical Champions for In-Hospital Cardiac Arrest? A Qualitative Study
Authors: Lehrich Jessica , Chan Paul S , Krein Sarah , Kellenberg Joan , Guetterman Timothy , Harrod Molly , Kronick Steven , Trumpower Brad , Girotra Saket , Iwashyna Theodore J , Nallamothu Brahmajee K
Published: July 2021

Introduction:
The presence of a clinical champion has been associated with improved resuscitation care. Yet little is known about specific characteristics of these individuals that make them more effective.

Objective:
To identify characteristics of clinical champions at top performing hospitals for in-hospital cardiac arrest (IHCA) survival.

Methods:
We conducted semi-structured, in-depth interviews with key stakeholders at 9 geographically and academically diverse US hospitals participating in the AHA Get with the Guidelines Resuscitation Registry. We identified these sites using risk standardized IHCA survival during 2012-2014 (top quartile: 5 hospitals; middle quartile: 1 hospital; bottom quartile: 3 hospitals). We gathered data through qualitative interviews on resuscitation processes during 1-2 day site visits that included questions on the presence and role of IHCA clinical champions. Thematic analysis was conducted to identify key elements of high quality resuscitation care.

Results:
158 interviews were conducted with over 78 hours of recording; participants included physicians (17.1%), nurses (45.6%), other clinical staff (17.1%), and administration (20.3%). Of 9 hospitals visited, 4 hospitals (all top) had a physician champion with 2 of these also having a nurse co-champion. One hospital (also top) had a nursing champion with engaged physician support. In contrast, 3 hospitals (1 mid, 2 bottom) had nursing champions but without engaged physician support and 1 hospital (bottom) had no champion identified. Several themes emerged (Table) with clinical champions at top performing hospitals: 1) clearly identified; 2) passionate, respected, and admired; 3) proactive and collaborative; and 4) either physicians or nurses with engaged physician support.

Conclusions:
Top performing hospitals in IHCA have clinical champions with specific clinical characteristics. Leveraging this knowledge may help hospitals improve resuscitation care.
Abstract 179: Sanctifying Sadness: Conducting a Moment of Silence at Time of Patient’s Death is Associated With Decreased Staff Burnout
Authors: Foresman-Capuzzi Joyce R , Sheehan Meghan , Buckley Meghan , Burgess David , Larson Sharon , Jones Christopher
Published: July 2021

Introduction:
Anecdotal stories exist about pausing to honor resuscitation teams and the patient after in-hospital deaths. It is unknown whether conducting a moment of silence (MOS) at the time of death impacts caregivers.

Objectives:
We sought to assess whether implementing a scripted and brief, secular MOS ritual after a patient dies reduces healthcare team burnout or improves resiliency.

Methods:
We conducted an unblinded, prospective cohort study of multidisciplinary intensive care unit (ICU) staff from two hospitals, implementing the MOS in one ICU with the other a control. The Maslach Burnout Inventory (MBI) was administered pre- and post-implementation and focus groups obtained qualitative feedback. Changes in median composite scores were assessed for comparisons using the Wilcoxon Signed-Rank Test.

Results:
We obtained 25 pre-post paired responses. The implementation ICU’s respondents included more physicians (36.4% vs 0%, p=0.032) with no difference in other measured characteristics. MBI scores pre-implementation were similar. After implementation, intervention staff had a significant decrease in median Depersonalization subscore on the MBI (median: 8 vs 6; p=0.045). MBI Emotional Exhaustion subscore trended toward improvement (median: 26 vs 24; p=0.075) and the Personal Accomplishment subscore was unchanged (median: 37 vs 34; p=0.18). No significant changes over time in MBI scores were noted in the staff from the control ICU. Qualitative feedback was universally positive, resulting in dissemination of the MOS system-wide.

Conclusion:
Implementation of a brief, secular MOS ritual in a community hospital’s ICU was associated with decreased burnout, specifically in the Depersonalization domain. This may be due to the creation of a formalized, group time for clinicians, nurses and multidisciplinary staff to attend to their own emotions after a patient death. Rollout of the scripted MOS intervention across the 5-hospital system, including distinctive phraseology for the pediatric, peri-operative, and maternity settings, shows widespread buy-in including within health system leadership. Larger studies and those conducted in other healthcare settings would increase confidence in the generalizability of results.
Abstract 182: Survival Outcome Analysis of Public Automated External Defibrillators in Taiwan
Authors: Lin Hao Y , Lin Chih H , Chiang Wen C , Yang Chih W , Hsieh Ming J , Chang Kuo C , Ko Ying C , Wang Su M , Hsu Szu W , Lee Bin C , Wang Yao C , Tsai Che H , Chung Yu T , Kuo Chan W , Chen Chao W , Sun Jen T , Liu Yueh P , Shih Chung L , Ma Matthew H
Published: July 2021

Background:
Public access defibrillation (PAD) increases survival in out-of-hospital cardiac arrest (OHCA) patients. However, native reports on PAD survival in Taiwan has not yet been described. Public automated external defibrillators (AED) installation at places with high incidence of cardiac arrests were required by law since 2013. A compulsory National AED Registry was set that registered all public AEDs. Incident reports and ECG tracings from those cardiac arrests were mandatory once public AEDs were use.

Objective:
We aimed to describe survival outcomes of PAD, including sustained return of spontaneous circulation (ROSC), survival to discharge, and Cerebral Performance Category (CPC). The effects of shockable rhythm and bystander CPR on survival along with survival of different public locations were analyzed.

Method:
Data was collected prospectively from July 2013 to August 2016 by PAD registry of Ministry of Health and Welfare, including incident reports and uploaded ECGs. Survival data were acquired from Taiwan Cardiac Arrests Registry and through contacting individual EMS systems. Outcomes were examined by locations, initial rhythms and bystander CPR.

Results:
A total of 344 AED utilization was recorded, in which 231 had complete ECG records. Overall shockable rate was 32.9 % (n=76), and bystander CPR rate was 69.3% (n=160). 152 cases had complete outcomes data. Sustain ROSC was 43.5% (69.6% in shockable group (n=46) and 70.3% in shockable plus B-CPR group (n=37)). Forty-two cases (29.4%) survived to discharge or transfer (mean age 53.5 (±21.9 year), male 78.6%). Most surviving patients had good neurological recovery. (CPC1:71.8%, n=28; CPC2:10.3%, n=4). For those with shockable rhythm and received B-CPR, survival to discharge (STD) were 56.8% and CPC1-2 54.1% . ROSC were highest among “Public Baths or Hot Spring Resorts” (60%), followed by “Traffic Hubs” (53.3%), “Schools/Large Gathering Venues” (47.6%), “Hotels” (46.7%), and “Others” (36.8%).

Conclusions:
Overall survival rates of PAD patients were three-fold compared to data from best performing EMS in Taiwan. PAD also doubled the survival for those with shockable rhythms. Policy facilitating PAD deployment and utilization have made a difference and should be continued and optimized.
Abstract 185: Optimization of Public Access Defibrillators Compared to Actual Deployment: An
In Silico
Trial
Authors: Sun Christopher , Karlsson Lena , Thorp-Pedersen Christian , Folke Fredrik , Chan Timothy C
Published: July 2021

Introduction:
Unguided placement of automated external defibrillators (AEDs) often leads to placements in low risk areas and locations with limited temporal availability. Mathematical optimization may improve AED placements and increase AED use in out-of-hospital cardiac arrests (OHCAs).

Aim:
To conduct the first
in silico
public AED location trial to determine whether optimization models (interventions) trained on historical OHCA data will recommend AED locations that significantly improve OHCA coverage on prospective OHCAs, compared to locations of actually deployed AEDs (control).

Methods:
We identified all public OHCAs of presumed cardiac cause (1994-2016) and already deployed AEDs (2007-2016) in Copenhagen, Denmark. We computed the number of OHCAs that occurred within 100m of a temporally available AED after it was deployed (“OHCA coverage”). We then divided 2007-2016 into 30-day intervals and determined the number of AEDs deployed in each interval. Using previously validated optimization models, we determined an equal number of optimal AED locations in each time interval, either indoor locations with actual availability (intervention #1) or outdoor locations with 24/7 availability (intervention #2). OHCA coverage was calculated for the interventions similarly to the already deployed AEDs. Finally, we repeated the analysis 25 times to evaluate sensitivity and generate confidence intervals, by randomizing the location and time of the OHCAs.

Results:
A total of 2,149 public OHCAs (744 between 2007-2016) and 1,573 registered AEDs were identified. OHCA coverage of actually deployed AEDs was 22.3% (166 of 744 OHCAs). For optimally located indoor AEDs, mean OHCA coverage was 32.6% (mean: 242.5 OHCAs; 95% CI: 239.7 - 245.3). For optimally located outdoor AEDs, mean OHCA coverage was 43.9% (mean: 326.6 OHCAs; 95% CI: 324.0 - 329.2).

Conclusions:
Optimizing AED locations in a real-time deployment approach mimicking the time horizon of actual AED deployment in Copenhagen, Denmark results in significantly higher OHCA coverage compared to the actual AEDs deployed. Between the two interventions, optimal locations that are 24/7 available significantly outperform optimal indoor locations with more limited temporal availability.
Abstract 186: Remote Limb Ischemic Preconditioning Improves Short and Long Term Survival and Maintains Intravascular Blood Volume During Resuscitation of Hemorrhagic Shock
Authors: Dai Wangde , Shi Jianru , Carreno Juan , Hale Sharon , Kloner Robert A
Published: July 2021

Background:
We further examined the protective effects of experimental bilateral lower limb remote ischemic preconditioning (RIPC) in rats undergoing experimental hemorrhagic shock.

Methods:
Sprague Dawley rats (both genders) were randomized into RIPC (n= 26) or control group (n= 27), and anesthetized with intraperitoneal ketamine/xylazine. RIPC was induced by 4 cycles of inflating small bilateral pressure cuffs to 200 mmHg around the femoral arteries for 5 minutes, followed by 5 minute deflation of the cuffs. Hemorrhagic shock was induced by withdrawing blood from the carotid artery. Target mean blood pressure of 30 mmHg was maintained for 30 minutes followed by reinfusion of shed blood within the next 30 min. Rats remained anesthetized for another 30 min before recovery; endpoints were survival at 72 hours and 6 weeks.

Results:
The % of estimated total blood volume withdrawn to maintain a level of 30 mmHg was similar in the RIPC group (41.7 ± 1.0 %) and control group (41.9 ± 1.0 %). Recovery of blood pressure during the early resuscitation phase was significantly improved in the RIPC group. The diastolic internal dimension of the left ventricle (echocardiogram), which indicates circulating intravascular blood volume, was significantly larger in the RIPC group at 1 hour after initiation of shed blood reinfusion (5.8 ± 0.1 mm) compared to 5.4 ± 0.1mm in the control group (p=0.04). Left ventricular fractional shortening was comparable between RIPC (50.9 ± 1.9 %) and control group (49.6 ± 1.8 %; p=0.64) at 1 hour after initiation of resuscitation. At 48 hours after shock, BUN was within normal range in the RIPC group (17.3 ± 1.2 mg/dl); but elevated in the control group (22.0 ± 1.7 mg/dl). At 72 hours after hemorrhagic shock injury, 6 of 27 (22.2 %) rats in the control group and 13 of 26 (50 %, p = 0.047) rats in the RIPC group survived. At 6 weeks, 5 of 27 (18.5 %) rats in the control group and 13 of 26 (50 %; p = 0.021) rats in the RIPC group survived. RIPC significantly increased survival rate at both 72 hours and 6 weeks.

Conclusions:
RIPC improved recovery of blood pressure and maintained more circulating intravascular blood volume in the early phase of resuscitation, improved BUN, and markedly and significantly improved short and long term survival in rats subjected to hemorrhagic shock.
Abstract 187: Effects of Anesthetic Agents on the Hemodynamic Stabilization and Long Term Survival in an Experimental Model of Hemorrhagic Shock
Authors: Dai Wangde , Shi Jianru , Carreno Juan , Hale Sharon , Kloner Robert A
Published: July 2021

Background:
We investigated the cardiovascular responses to acute bleeding and shed blood restoration under different anesthetic agents, and their effects on long-term survival rate after hemorrhagic shock in rats, after our initial pilot study suggested differences between anesthetics.

Methods:
Sprague Dawley rats (both genders) were randomized to receive either intraperitoneal ketamine/xylazine (K/X, 90 mg/kg and 10 mg/kg; n=12), or isoflurane (5% isoflurane induction and 2% maintenance in room air; n=12) for anesthesia. Blood was withdrawn from the carotid artery to maintain mean arterial blood pressure (MBP) at 30 mm Hg for one hour, followed by 30 min of resuscitation with shed blood. Rats remained anesthetized for another 30 min before they were allowed to recovery and survive for 6 weeks. Hemodynamics were monitored during the surgical procedure.

Results:
During the shock phase, the total withdrawn blood volume (expressed as % of estimated total blood volume) to maintain MBP at 30 mmHg was significantly higher in the isoflurane group (51 ± 1.5 %) compared to the K/X group (45.3 ± 1.8 %; p=0.023). The diastolic internal dimension of the left ventricle, which indicated circulating intravascular blood volume, was significantly larger in the isoflurane group at the end of 1 hour of the shock phase (4.5 ± 0.2 mm compared to 3.5 ± 0.2 mm in K/X group; p=0.0003) and at 1 hour after initiation of shed blood reinfusion (6.3 ± 0.2 mm compared to 5.3 ± 0.3 in K/X group; p=0.014). Recovery of blood pressure during the resuscitation phase was significantly improved in the isoflurane group compared to the K/X group. The survival rate at 6 weeks was 1 of 12 (8.3%) in rats receiving K/X and 10 of 12 (83.3%) in rats receiving isoflurane (p < 0.001). Histology demonstrated brain infarction in the 1 surviving rat receiving K/X; no brain infarction in the 10 surviving rats that received isoflurane at 6 weeks. No infarction was detected in heart, lung, liver or kidneys in all surviving rats.

Conclusions:
These results suggest that isoflurane stabilizes the cardiovascular response to acute blood lose and benefits the perfusion of tissue, which resulted in significantly higher long term survival rate and improved blood pressure response to resuscitation, without end-organ infarction.
Abstract 189: Intraosseous Transfusion With Hemoglobin Vesicles for Severe Hemorrhagic Shock Rabbits
Authors: Hagisawa Kohsuke , Kinoshita Manabu
Published: July 2021

Background:
We developed a Hemoglobin vesicle (HbV) and which is an artificial substitute for Red blood cells (RBCs).

Objective:
To evaluate the efficacy of intraosseous HbV transfusion for alternative treatment instead of massive RBCs transfusion in rabbits with hemorrhagic shock.

Methods:
Hypohemoglobinemia (Hb 5.0 ± 0.7 g/dl) was induced in rabbits by blood withdrawal (70% of total blood volume) and half compensative infusion of normal saline (35% of total blood volume), which resulted severe hemorrhagic shock (mean arterial pressure 21 ± 2 mmHg). Immediately, shortage of the blood volume (35% of total blood volume) was intraosseously infused of lactate ringer (n=8), 5% human serum albumin (n=10) or HbV with 5% human serum albumin (3:2=vol: vol) (n=8). During the experiment hemodynamics and blood cell counts were measured with time.

Results:
Mean arterial pressure immediately recovered (44 ± 11 mmHg), improving hypohemoglobinemia (7.1 ± 0.6 g/dl) by administration with HbV, although rabbits receiving 5% Albumin and lactate ringer never improved hemodynamics and hypohemoglobinemia. (33 ± 7 mmHg / 3.4 ± 0.4 g/dl, 26 ± 4 mmHg / 4.5 ± 0.4 g/dl, p < 0.05 vs HbV group, respectively) As a result, 75% of rabbits receiving HbV survived after 24hours, while half of rabbits with 5% Albumin were dead within 18hours and all rabbits with lactate ringer were dead within 6hours.

Conclusions:
Intraosseous infusion of HbV effectively restore the Hb and maintain the hemodynamics for acute hemorrhagic shock in the difficult situation to get blood access.
Abstract 194: Public Perception Towards Out-of-Hospital Cardiac Arrest Victims: Potential Reasons Influencing the Decision to Perform Bystander Cardiopulmonary Resuscitation
Authors: Gul Sarah S , Becker Torben K , Maciel Carolina B , Murphy Travis , Youn Teddy S , Cohen Scott A , Martin Emmett , Tyndall Joseph A , Alviar Carlos L
Published: July 2021

Background:
Bystander cardiopulmonary resuscitation (CPR) after out-of-hospital cardiac arrest (OHCA) improves survival and neurological outcomes. Unfortunately many OHCA victims do not receive bystander CPR during a witnessed arrest. It is known that gender disparities play a role with lower rates of bystander CPR in women suffering OHCA in public places. Our aim was to identify potential factors influencing the decision to perform bystander CPR.

Methods:
Participants at CPR training events were surveyed prior to training. Using different scenarios, subjects were asked about their comfort level performing CPR on female, geriatric, and pediatric victims. Anonymous responses were collected and transformed into categorical variables by a psychometrist.

Results:
Of the 677 participants, 585 (86.4%) responded the survey, with 87.5% between 18-29 years of age, 58.8% without prior CPR training and 93.3% without prior CPR experience. Reasons to hesitate starting bystander CPR in women included concern about exposing the victim (12.9%), being accused of sexual assault (6.1%), and possible pregnancy (6.5%). In participants with prior CPR training, 61.1% reported concerns about performing CPR on women, with 18.9% having concerns about performing chest compressions in relation to breast location. In participants without prior CPR training, 73.2% reported having concerns about performing CPR on women. Causing injury and exposing the patient were top concerns to perform CPR in women amongst participants who were uncomfortable (30.5% and 17.5% respectively) and comfortable (14.5% and 9.8% respectively) performing CPR in public. Causing injury was the top concern in performing CPR on geriatric (45.4%) and pediatric patients (41.7%), followed by fragility (18.1% and 10.2% respectively). Lack of skills to perform CPR on children was reported in 22% of CPR-trained participants.

Conclusion:
Public perception of OHCA victims influences willingness to perform bystander CPR. Factors such as age, gender, fear of injury, pregnancy status and sexual assault concerns can negatively impact this life saving intervention. Awareness of the importance of bystander CPR on any cardiac arrest victim must be improved.
Abstract 195: Stages of Bystander Intervention to Sudden Cardiac Arrest in a Virtual Reality Environment
Authors: Buckler David G , Almodovar Alfredo , Snobelen Paul , Blewer Audrey L , Leary Marion
Published: July 2021

Introduction:
Four stages of bystander intervention (BI) have been described in social behavioral research: noticing the situation as a problem, interpreting when it is appropriate to intervene, recognizing personal responsibly to intervene, and knowing how to intervene (i.e. having the skills to respond). Using virtual reality (VR), emergency events such as sudden cardiac arrest (SCA), can be used to observe the progression through these stages.

Objective:
We sought to compare bystander self-efficacy with action, based on each stage of BI before and after an unannounced simulated VR SCA scenario.

Methods:
In a secondary analysis of an observational cohort study, we analyzed self-efficacy with each stage of BI using a forced Likert scale survey before and after a simulated SCA. Each subject participated in a single-player, immersive, VR SCA scenario. Subjects interacted with avatars through voice commands such as “call 911” and “get an AED”. Actions taken in the scenario, such as performing CPR, were recorded. Scenario BI stage progression was compared based on dichotomized comfort/discomfort.

Results:
From 9/2016 to 6/2017, 119 subjects completed the study. Average age was 37±14 yrs, 44% were female and 58% had a bachelor’s degree or higher. During the scenario, 98% of subjects “noticed the event” and “interpreted it as a problem”, 78% “took responsibility”, and 54% “possessed the necessary skills” to act. Self-efficacy increased from pre- to post-scenario: noticing the event as a problem increased from 80% to 96%; interpreting it as a problem increased from 86% to 97%; taking responsibility increased from 56% to 93%; possessing necessary skills to intervene increased from 47% to 63% (p<0.001, respectively). More subjects who reported pre-scenario comfort with responsibility to act, took responsibility for dealing with the SCA during the scenario (85% vs 71%, p=0.004).

Conclusion:
Bystanders who felt more comfortable taking responsibility for an emergency event pre-scenario were more likely to respond appropriately during the scenario. VR represents a potentially powerful tool to promote self-efficacy and understand how bystanders may respond during emergency situations.
Abstract 200: Glycopyrrolate Does Not Ameliorate Bradycardia During Prolonged Cooling in Awake Subjects
Authors: Rittenberger Jon C , Weissman Alex , Flickinger Kate , Guyette Francis X , Repine Melissa , Dezfulian Cameron , Doshi Ankur A , Elmer Jonathan , Sawyer Kelly , Callaway Clifton W
Published: July 2021

Introduction:
Hypothermia may help improve outcomes in patients with large vessel occlusion cerebrovascular accidents or other reversible ischemia. Dexmedetomidine infusion reduces shivering in awake subjects undergoing hypothermia but has dose-limiting bradycardia. If vagally mediated, anticholinergic drugs might reduce bradycardia.

Hypothesis:
Glycopyrrolate prevents bradycardia during dexmedetomidine-assisted prolonged hypothermia.

Methods:
Eight healthy subjects were randomly assigned to 0.4mg glycopyrrolate bolus, glycopyrrolate rescue (0.01mg every 3 minutes as needed for heart rate <50), or no glycopyrrolate during three separate sessions of 3 hours cooling. Following 1mg/kg dexmedetomidine bolus, subjects received 20cc/kg of (4
0
C) cold saline and surface cooling (EM COOLS, Weinerdorf Austria). Dexmedetomidine infusion was titrated to suppress shivering but allow arousal to verbal stimuli. After 3 hours of cooling, we allowed subjects to rewarm. We compared heart rate, core temperature, and mean arterial blood pressure between groups using Kruskal-Wallis test and ANOVA.

Results:
Mean age was 27 (SD 6) years and most (N=6, 75%) were male. Mean pre-treatment resting heart rate was 73 [SD 13] bpm. Neither heart rate nor core temperature differed between the groups during the stable hypothermia period (p>0.05). (Figure) Mean arterial blood pressure was higher in the glycopyrrolate bolus group than the other two groups during the study period (p<0.048).

Conclusions:
Glycopyrrolate did not prevent the bradycardic response to hypothermia and dexmedetomidine. Mean arterial blood pressure was higher in subjects receiving a bolus of glycopyrrolate before induction of hypothermia.
Abstract 202: Fast Hypothermia Induced by Continuous Renal Replacement Therapy Alleviates Systemic Inflammation and Intestinal Injury After Cardiopulmonary Resuscitation in Swine
Authors: Xu Jiefeng , Chen Qijiang , Jin Xiaohong , Wu Chunshuang , Li Zilong , Zhang Mao
Published: July 2021

Introduction:
Systemic inflammation and intestinal injury contribute to post-resuscitation multiple organ dysfunction and death in cardiac arrest victims, and they can be partly alleviated by therapeutic hypothermia. Recently, continuous renal replacement therapy (CRRT) was shown to be an effective cooling method to induce fast hypothermia. In this study, we investigated the effects of CRRT cooling (CRRT-C) on systemic inflammation and intestinal injury after cardiopulmonary resuscitation (CPR) in swine.

Hypothesis:
Fast hypothermia induced by CRRT-C would alleviate post-resuscitation systemic inflammation and intestinal injury better than surface cooling (SC).

Methods:
Twenty-seven male domestic swine weighing 36 ± 2 kg were utilized. Ventricular fibrillation was induced for 8 mins while defibrillation was attempted after 5 mins of CPR. At 5 mins after resuscitation, the animals were randomized to receive either CRRT-C, SC or normotherma (NT). In the two hypothermic groups, the animals were cooled by either the combination of 8-hr CRRT and 16-hr SC or the whole 24-hr SC. In animals treated with CRRT-C, a higher rate of 180 ml/min of blood flow was initially set with the infusion line submerged in 4 °C of ice water. The temperature was normally maintained in the NT group.

Results:
After resuscitation, the rate of temperature decrease was significantly faster in the CRRT-C group than in the SC group (9.8±1.6 vs. 1.5±0.4 °C/h,
p
<0.01). The serum levels of tumor necrosis factor-α, interleukin-6, intestinal fatty acid binding protein and diamine oxidase after resuscitation were significantly lower in the two hypothermic groups compared with the NT group. However, post-resuscitation systemic inflammation and intestinal injury were further significantly alleviated in the CRRT-C group compared to the SC group (Table).

Conclusion:
Fast hypothermia induced by CRRT-C was superior to SC in alleviating post-resuscitation systemic inflammation and intestinal injury.
Abstract 209: The Triple CPR 16 study: Does rhythm truly needed to be checked every 2 minutes in Cardiopulmonary Arrest Patients?
Authors: Takegawa Ryosuke , Shiozaki Tadahiko , Ohnishi Mitsuo , Tachino Jotaro , Muroya Takashi , Sakai Tomohiko , Hayakawa Koichi , Shimazu Takeshi
Published: July 2021

Purpose:
Current guidelines recommend rhythm checks every 2 minutes during cardiopulmonary resuscitation (CPR), but evidence for this recommendation is insufficient. Recent reports identified regional cerebral oxygen saturation (rSO
2
) monitoring as useful in detecting return of spontaneous resuscitation (ROSC) and that coronary and cerebral perfusion decreases with the 2-minute rhythm check. On the basis of our previous study, we began the TripleCPR 16 study, which omits 2-minute rhythm checks because stopping chest compression to check rhythm may increase cerebral damage and decrease the ROSC.

Methods:
The multicenter, prospective TripleCPR 16 study began in January 2017. The inclusion criterion is a cardiopulmonary arrest patient aged ≥16 years with a non-shockable rhythm on hospital arrival. Subjects are divided into 3 groups based on their mean cerebral rSO
2
value in the first minute of arrival: ≥50%, <50% to 40%, and <40%. Continuous mechanical chest compression is performed on all subjects for 16 minutes or until their rSO
2
value exceeds the initial value by 10%, 20%, or 35%, respectively. We are comparing the TripleCPR 16 study results with our previous hospital data obtained from 90 patients who underwent every 2-minute rhythm checks and mechanical chest compression.

Result:
Currently, 162 patients are registered. Rates of ROSC were 32.1% for these patients and 38.9% for the previous 90 patients (p=0.33). There were no severe adverse events. Subanalysis of the data of Osaka University Hospital alone showed no significant increase of rSO
2
value in the 24 patients with non-sonographic cardiac activity and 21 patients with Stanford type A aortic dissection diagnosed by CT scan, and only one patient in each group achieved ROSC. When excluding the patients with Stanford type A aortic dissection, rates of ROSC were 49.4% for the patients in this study and 39.3% for the previous 90 patients (p=0.21).

Conclusion:
The TripleCPR 16 study is ongoing without severe adverse events. In the patients with non-sonographic cardiac activity or Stanford type A aortic dissection, rSO
2
values did not increase and it was difficult to achieve ROSC. The 2-minute rhythm check is not essential for chest compression in patients with a non-shockable rhythm.
Abstract 210: Goal-Directed CPR is Less Effective With an Increased Interval From Cardiac Arrest Onset to Initiation of Chest Compressions
Authors: Hala Pavel , Caceres Matias , Prater Aaron , Jung Josh , VanZalen Jensyn , McCracken Brendan M , Tiba Mohamad H , Hsu Cindy H , Harvey Stephen , Enciso Alyssa , Pitcher Jake , Cummings Brandon C , Bartlett Robert H , Rojas-Pena Alvaro , Neumar Robert W
Published: July 2021

Introduction:
The interval from cardiac arrest (CA) to initiation of chest compressions (no-flow time) plays an important role in outcome of CA. The purpose of this study was to evaluate impact of no-flow time on the effectiveness of a goal-direct CPR strategy during prolonged cardiac arrest.

Hypothesis:
The effectiveness of goal-directed CPR declines with increased no-flow time.

Methods:
Porcine model of CA was utilized with a period of untreated ventricular fibrillation of 4 or 8 min (groups CA-4, CA-8, n=5/group) followed by a goal-directed CPR protocol for up to 40 minutes. Manual and mechanical chest compressions with impedance threshold device were used sequentially to achieve PetCO2 goal >20 mmHg. Epinephrine infusion and boluses were adjusted with the goal of achieving an arterial diastolic blood pressure >35 mmHg. Hemodynamic parameters were collected throughout the protocol, averaged in 5-minute intervals and compared between groups by an unpaired t-test.

Results:
A higher average DBP was achieved in the CA-4 vs. CA-8 group during CPR (19 ± 11 mmHg vs. 12 ± 9 mmHg: p<0.04) with stronger responses to epinephrine boluses (max increase 23 vs. 11 mmHg). Brain perfusion through internal carotid artery during CPR relative to baseline averaged 24 ± 34 % vs. 10 ± 12 % in the CA-4 vs. CA-8 group respectively (p<0.006). PetCO2 remained above 20 mmHg 71 ± 35 % vs. 31 ± 13 % of time during CPR in the CA-4 vs. CA-8 group respectively (p<0.001).

Conclusion:
In this swine model of prolonged VF cardiac arrest, increased no-flow time limits the effectiveness of a goal-directed CPR strategy. Moreover, the response to standard dose of epinephrine was higher after shorter no-flow time.
Abstract 211: The Effect of Competitive Gamification on Self-Directed CPR Training Among Healthcare Professionals: A Multi-National Randomized-Control Study
Authors: Chang Todd P , Raymond Tia , Dewan Maya , Whitfill Travis , Harwayne-Gidansky Ilana , Doughty Cara B , Frisell Karin , Kessler David O , Wolfe Heather , Auerbach Marc A , Rutledge Chrystal , MacKinnon Ralph , Mitchell Diana , Jani Priti , Walsh Catharine M
Published: July 2021

Background:
Low-dose, high-frequency CPR training, such as the AHA Resuscitation Quality Improvement program, is designed to prevent skills decay. Preliminary studies have shown success in using gamification- namely a competitive leaderboard - for self-directed CPR training using a feedback-enabled CPR simulator. The purpose of this study was to determine the effect of a larger-scaled gamification system across multiple institutions on self-directed CPR practice frequency and resulting performance.

Methods:
This was a randomized-control study with 14 institutions. Subjects were healthcare professionals with unlimited access to a feedback-enabled CPR manikin. Subjects were asked to upload CPR scores and a ‘Selfie’ upon completion of any practice chest compressions. Each institution’s scores and photos were displayed on an online leaderboard for 4 months during the Intervention phase, and were denied access into the leaderboard for 4 additional months for the Control phase. The order of the phases was randomized per institution. Outcome variables included mean number of CPR episodes per person and mean CPR performance score measured by the simulator. Independent t-tests compared outcome variables between the 2 phases for unadjusted and adjusted results based on treatment and crossover effects.

Results:
A total of 919 subjects performed 1850 CPR episodes during the study period. Unadjusted mean CPR episodes per subject was higher in Control phase than the Intervention phase (2.9 +/- 7.2 vs. 1.6 +/- 1.7, p<0.001). However, when controlling for a crossover effect, there was no difference in mean CPR episodes per subject between the Intervention (1.6 [95CI 1.4, 1.9]) and Control phase (1.7 [95CI 1.5, 2.0], p=0.6). No difference in mean CPR performance scores were found (90.7 [89.4, 92.0] vs 89.3 [87.6, 91.0], p=0.2).

Conclusion:
A competitive gamification system did not affect self-directed simulated CPR practice frequency or CPR performance.
Abstract 214: Basic Life Support Instructors Overestimate Their Own Ability to Perform Cardiopulmonary Resuscitation
Authors: Stærk Mathilde , Vammen Lauge , Hansen Camilla , Krogh Kristian , Løfgren Bo
Published: July 2021

Introduction:
High-quality cardiopulmonary resuscitation (CPR) increases survival from cardiac arrest. Laypeople attend basic life support (BLS) courses to learn CPR, but unfortunately, skill quality and retention are often poor. BLS instructors teach by demonstrating CPR skills. However, BLS instructors’ ability to correctly demonstrate CPR remains to be investigated.

Aim:
To determine BLS instructors’ competence in demonstrating CPR skills.

Methods:
Certified BLS instructors were asked to demonstrate CPR on a resuscitation manikin (AMBU ® Man, AMBU) in a simulated teaching setting but without verbal explanations. Data on CPR quality was collected from the manikin and the first three cycles of CPR were analyzed. Correct CPR was defined according to the European Resuscitation Council 2015 Guidelines: chest compression (CC) depth of 50-60 mm, CC rate of 100-120 min
-1
, and rescue breath volume of 500-600 mL. Instructors were asked to rate their own ability to perform CPR on a 5-point Likert scale before the demonstration and after receiving a performance report thereof.

Results:
Data from 125 certified instructors were analyzed. Median instructor age was 45 years (Q1;Q3: 30;56), 72% were male, and instructor experience was 8 years (3;14) with a median of 14 courses/year (6;44)). Mean CC depth was 64 mm (SD: 7.3). In total, 22% of chest compressions were performed within guideline recommendations (72% were too deep and 5% were too shallow). Mean CC rate was 115 min
-1
(10.8). Full recoil was achieved in 86% of CCs. Of all attempted rescue breaths, 94% resulted in any amount of air registered (mean volume: 499 mL (291)). Only 11% of rescue breaths were within guideline recommendations (52% were too shallow and 37% were excessive). Instructors rated their ability to perform CCs lower after receiving a performance report (p=0.02). Similarly, ratings of rescue breathing ability were lower after receiving a performance report (p=0.01).

Conclusion:
Certified and experienced BLS instructors performed CC with excessive depth, but with acceptable CC rate and recoil. Instructors were unable to correctly demonstrate rescue breathing. Instructors overrated their ability to demonstrate correct CPR even when provided with their own CPR performance report.