bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 12216: Association Between CPR Confidence With Anxiety in Out of Hospital Cardiac Arrest Survivors
Authors: Rojo Joseph , CALLAWAY Clifton W , Doshi Ankur A
Published: December 2021

Introduction:
There is a lack of data about specific interventions or resources that might reduce anxiety and depression in OHCA survivors. One possible factor contributing to anxiety or depression might be worry by the survivor or their family members about performing CPR or responding to a future cardiac arrest.

Hypothesis:
We hypothesize that there is an association of confidence about performing CPR with anxiety and depression during recovery after cardiac arrest.

Methods:
We enrolled subjects who were discharged home from the hospital after cardiac arrest and provided them with self-paced CPR training kits. Subjects reported Generalized Anxiety Disorder 7-item scale (GAD7), Hospital Anxiety and Depression Scale (HADS-A), and CPR knowledge and comfort scores before discharge and at 6 months. Subjects reported use of the training kit. We tested for associations between variables using chi-square and compared follow up scores using Wilcoxon signed-rank test.

Results:
We enrolled 95 subjects (65 male, majority in the age range of 56-65), all of whom completed the initial surveys. 19 patients met criteria for anxiety via GAD7 (=>10), 23 via HADS-A (=>8). Of subjects who were not comfortable performing CPR, 16/60 (27%) met GAD7 criteria compared to 3/32 (9%) who were comfortable (p=0.03).Of those not comfortable performing CPR 20/60 (33%) met HADS-A criteria compared to 3/35 (9%) who were comfortable (p=0.007).. At 6 months post discharge, 25 subjects completed follow up surveys (16 male, majority in the 56-65 age range). 12/25 (48%) used the CPR training kit; 6 met criteria for anxiety via GAD7, 9 via HADS-A. Of subjects who used the CPR kits, 1/12 (8%) met GAD7 criteria compared to those who did not use the CPR kits 5/13 (38%). Of those who used the CPR kits 3/12 (25%) met HADS-A criteria compared to those who did not use the kits 6/13 (46%), these findings however were not statistically significant (p=0.07,0.27) Additionally, those who used the CPR training kits relative to those who did not use kits had a decrease in GAD7 scores (-1.83 vs +1.84) at 6 months.

Conclusion:
Anxiety scores were associated with confidence about performing CPR before being discharged and using the CPR kits was associated with an improvement in anxiety scores.
Abstract 12422: Scoping Review of Early Transthoracic Echocardiography for Diagnosis and Prognosis After Cardiac Arrest
Authors: Liu Linda , Karatasakis Aris , Kudenchuk Peter J , kirkpatrick james , Sayre Michael R , Counts Catherine , Carlbom David , Branch Kelley R
Published: December 2021

Introduction:
Transthoracic echocardiography (TTE) is commonly performed early after resuscitation from cardiac arrest (CA). The ability of early TTE to differentiate cardiac from non-cardiac causes of CA or to inform patient outcomes has not been systematically reviewed.

Methods:
We reviewed MEDLINE, EMBASE, and CENTRAL databases from inception to December 2020 for studies that assessed adult recipients of TTE after resuscitation from non-traumatic CA. Studies were included if TTE was obtained early (<72 hours) after spontaneous return of circulation and reported either 1) their diagnostic accuracy for causes of the CA or 2) survival and neurologic outcomes. Diagnostic endpoints also included regional wall motion abnormalities (RWMA) to ascertain possible acute myocardial infarction (AMI) as the etiology of CA. Prognostic endpoints included TTE parameters and their association with survival to hospital discharge and neurologic outcomes.

Results:
Of 2518 articles screened, 12 (0.5%) studies met inclusion criteria, representing 1570 unique patients. Meta-analysis was not possible due to missing data and study heterogeneity. Five studies were included in diagnosis review and nine in the prognosis review. No studies reported the diagnostic accuracy of TTE for AMI, although in 3 of 5 studies RWMA were associated with AMI in 53-83% of patients. Reduced left ventricular ejection fraction was reported in 8 studies but was not associated with survival (Figure) or neurologic outcomes (n=4). Only high mitral inflow E/e’ ratio (n=1) and decreased right ventricular function (RVD; n=2) were associated with worse survival.

Conclusion:
This scoping review highlights the limited available data on the utility of early TTE after CA. Assessment of left and right ventricular function and other parameters by TTE is feasible, but further research is necessary to determine their diagnostic and prognostic value after CA.
Abstract 12580: An Interprofessional Approach to Standardizing Family Care During Code Blue Events
Authors: Tennyson Carolina , Oliver John , Jooste Karen
Published: December 2021

Introduction:
The development of a standardized practice for family care during resuscitation (FPDR) events was identified as an area for quality improvement at a large academic hospital. Healthcare Chaplains were identified as ideal Family Facilitators for FPDR due to their professional training in therapeutic communication and existential crisis management as well as their current practice of responding to all Code Blue events. An interprofessional workgroup developed guidelines to delineate the role of Chaplain as Family Facilitator in Code Blue events and created an interprofessional education simulation (IPE-sim) training curriculum for their dissemination.

Methods:
The workgroup, which included an acute care nurse practitioner in the nursing faculty, a palliative care physician, and the director of Chaplain Services, conducted a thorough review of FPDR literature, analyzed data on Chaplain care provided at Code Blue events over the past 9 years, and entered into dialogue with stakeholders regarding FPDR. The group authored guidelines which were adopted as an addendum to the institution’s existing Code Blue policy. The workgroup collaborated with the Code Blue team to develop simulation training events to ensure proper application of the new guidelines.

Results:
This work resulted in the addition of FPDR guidelines to the Code Blue policy and the creation of a FPDR flowchart that standardized the Chaplain role in Code Blue events by delineating a communication process as well as FPDR inclusion and exclusion criteria. The implementation of this work was facilitated through three 4-hour IPE-sim training sessions.

Conclusions:
Standardized FPDR guidelines pertaining to the role of Chaplain as Family Facilitator improve patient- and family-centered care. Institutional FPDR guidelines should be created by an interprofessional team and vetted by multidisciplinary stakeholders. Simulation-enhanced IPE prepares Chaplains and teams for FPDR and can improve interprofessional collaboration during Code Blue events.
Abstract 12956: Racial and Ethnic Disparities in Post-Arrest Care
Authors: Huebinger Ryan , Chavez Summer , Abella Benjamin , Al-Araji Rabab , Jarvis Jeffrey L , Witkov Richard , Waller-Delarosa John , Villa Normandy W , Aggarwal Arjun , Panczyk Micah , Bobrow Bentley
Published: December 2021

Introduction:
Post-arrest care is essential to the chain of survival after out-of-hospital cardiac arrest (OHCA). While racial/ethnic disparities in prehospital care are well studied, there is sparse literature evaluating these disparities in post-arrest care. We sought to measure post-arrest care disparities in a statewide OHCA registry.

Methods:
We evaluated 2014-2020 data in Texas from the Cardiac Arrest Registry to Enhance Survival (CARES) and included all adult OHCAs surviving to hospital admission. We stratified subjects by race and ethnicity. We defined outcomes as targeted temperature management (TTM), percutaneous intervention (PCI), and early prognostication (made DNR and died <72 hours of arrest), survival to discharge, and survival with CPC of 1-2 (good CPC). We used a mixed effects model logistic regression to evaluate the association between strata and outcomes, modeling receiving hospital as the random intercept. We adjusted for age, household income, sex, witnessed arrest, bystander CPR (B-CPR), and initial shockable rhythm. For early prognostication, we performed a multivariable logistic regression adjusted for bystander witnessed arrest and B-CPR.

Results:
Of 37,055 adult OHCAs, 9,346 (25.2%) survived to admission; median age was 62, 60.7% were male, 3,036 (32.5%) received TTM, 533 (5.7%) received PCI, 93 (1.0%) had early prognostication, 34.9% survived to discharge, and 22.0% survived with good CPC. Blacks were less likely than whites to receive PCI (2.7% v 7.9%, aOR 0.6, 95% CI 0.4-0.8), less likely to receive early prognostication (0.3% v 1.0%, aOR 0.3, 95% CI 0.1-0.6), and less likely to have good CPC (17.3% v 26.0%, aOR 0.8, 0.7-0.9). Despite a lower percentage receiving TTM, blacks had a higher odds of TTM (30.7% v 34.5%, aOR 1.2, 95% CI 1.03-1.4). Blacks had a similar survival (1.0, 95% CI 0.9-1.2). Compared to whites, Latinos had higher early prognostication (1.7%, aOR 1.7, 95% CI 1.1-2.7), worse survival (30.3%, v 37.1%, aOR 0.9, 95% CI 0.8-0.99), lower good CPC (17.8%, aOR 0.8, 95% CI 0.7-0.96). Latinos had a similar rate of TTM (aOR 1.0, 95%CI 0.8-1.2) and PCI (aOR 1.0, 95% CI 0.8-1.4).

Conclusions:
Black and Latino OHCA victims experienced disparities in post arrest care and outcomes, even when adjusted for receiving hospital.
Abstract 12975: Socioeconomic Status Impact on Out-of-Hospital Cardiac Arrest Post-Arrest Care and Outcomes
Authors: Huebinger Ryan , Chavez Summer , Abella Benjamin , Al-Araji Rabab , Jarvis Jeffrey L , Witkov Richard , Waller-Delarosa John , Villa Normandy W , Aggarwal Arjun , Panczyk Micah , Bobrow Bentley , Northeim Justin
Published: December 2021

Introduction:
Post-arrest care after out-of-hospital cardiac arrest (OHCA) is critical to optimizing outcomes. Large socioeconomic disparities in prehospital resuscitation interventions have been shown. Less is understood about disparities in post-arrest care and their impact on patient outcomes. We evaluated the association of socioeconomic status (SES) with post-arrest care and outcomes.

Methods:
We included adult OHCA patients who survived to hospital admission using the 2014-2020 data in Texas from the Cardiac Arrest Registry to Enhance Survival (CARES) . We linked CARES data to census tracts and stratified census tracts above and below the median for SES characteristics: household income, employment rate, and high school graduation. We defined outcomes as targeted temperature management (TTM), Percutaneous Coronary Intervention (PCI), survival to discharge, and survival with a Cerebral Performance Category (CPC) 1-2. We fit a mixed effects model, logistic regression evaluating the association between SES characteristics and outcomes, modeling receiving hospital as the random intercept. We adjusted for age, neighborhood race, sex, bystander witnessed arrest, bystander CPR, and initial shockable rhythm.

Results:
There were 37,055 adult cases of OHCA taken to 164 hospitals, 9,346 survived to admission; median age was 62, 60.7% were male, 32.5% received TTM, 5.7% received PCI, 34.9% survived to hospital discharge, and 22.0% had a good CPC score. Low employment was associated with low PCI (1.5% v 2.8%, aOR 0.5, 95% CI 0.3-0.9). Low education was linked to worse survival (32.3% v 37.5%, aOR 0.9, 95% CI 0.8-0.99). Low employment was linked to worse CPC (17.5% v 26.4%, aOR 0.8, 95% CI 0.7-0.9). Low income was not associated with TTM (aOR 1.05, 95% CI 0.9-1.2), PCI (aOR 0.9, 95% CI 0.9-1.3), survival (aOR 0.9, 95% CI 0.8-1.0), or good CPC (aOR 1.0, 95% CI 0.9-1.2). Low employment was not associated with TTM (aOR 1.0, 95% CI 0.8-1.1), or survival (aOR 1.0, 95% CI 0.9-1.1). Low education was not associated with low PCI (4.0% v 7.4%, aOR 0.8, 95% CI 0.6-0.1.01), low TTM (aOR 1.0, 95% CI 0.9-1.1), or survival (aOR 0.9, 95% CI 0.8-1.03).

Conclusion:
SES characteristics were linked to lower PCI rates and worse outcomes, but SES was not associated with TTM.
Abstract 13048: A Simple Model to Describe the Relationship Between Compression Force and Depth During CPR
Authors: Gutiérrez Jose Julio , SANDOVAL CAMILO L , Leturiondo Mikel , Redondo Koldo , Russell James K , Daya Mohamud R , Ruiz De Gauna Sofia
Published: December 2021

Aim:
The relationship between force and depth during manual chest compressions depends on the patient and on the dynamics with which the rescuer applies the force. Force-depth models with many fitting parameters have been proposed making physical interpretation complicated. The aim of this work was to design a simpler force-depth model, accommodating anticipated differences in compression and recoil phases.

Materials and Methods:
Force and acceleration signals were extracted from out-of-hospital-cardiac arrest (OHCA) defibrillator recordings (TVF&R, OR, USA), equipped with CPR technology. Compression depth and velocity signals were computed from acceleration. We analyzed intervals of 20-s within the 1st min of chest compressions. Our model decomposes the applied force as the sum of an elastic and a damped term, considering different damping coefficients for the compression and recoil phases. Coefficient of elasticity was calculated at the instant of maximum compression depth (null velocity) and damping coefficients at the instants of maximum compression and recoil velocities. The estimated depth signal is shown in the figure. The goodness of the model was assessed through the determination coefficient R
2
.

Results:
We analyzed 1,074 compressions from 30 OHCA recordings. Median (IQR) compression depth was 4.6 (4.0-5.4) cm; compression rate was 107 (102–113) cpm; coefficient of elasticity was 100.67 (78.95–125.01) N/cm; compression damping coefficient was 2.57 (1.84–3.29) N/(cm/s) and recoil damping coefficient was 3.59 (2.58–4.90) N/(cm/s). Median R
2
was 0.993 (0.984–0.996).

Conclusions:
This model, derived using fewer parameters, could help with the interpretation of the mechanical properties of the chest during CPR. It may also be useful for the assessment of inter-patient differences with age, sex, and body constitution, as well as of the evolution of elasticity and damping of patient’s chest during the course of resuscitation.
Abstract 13193: Hispanics/Latinos Lack Access to Hospitals With Therapeutic Hypothermia Programs Following Out-of-Hospital Cardiac Arrest
Authors: Morris Nicholas , Mazzeffi Michael , McArdle Patrick , May Teresa , Waldrop Greer , Perman Sarah A , Burke James F , Bradley Steven M , Agarwal Sachin , Figueroa Jose F , Badjatia Neeraj
Published: December 2021

Introduction:
Variation exists in outcomes following out-of-hospital cardiac arrest (OHCA), but whether racial/ethnic disparities exist in post-arrest provision of therapeutic hypothermia (TH) is unknown.

Hypothesis:
Racial/ethnic disparities exist in the utilization of guideline-recommended TH following OHCA.

Methods:
We performed a retrospective analysis of a cohort of 96,695 patients who survived to hospital admission following OHCA from the Cardiac Arrest Registry to Enhance Survival, whose catchment area represents ~40% of the United States, from 2013 through 2019. Our primary exposure was race/ethnicity, and the primary outcome was utilization of TH. We performed a secondary analysis to assess for racial/ethnic disparities in the reasons why TH was not used (supplemental data element data available since 2016).

Results:
Among 96,695 patients [mean (SD) age 61.4 (16.3) years, 24.6% Black, 8.0% Hispanic/Latino, 63.4% White] that survived to hospital admission following OHCA, 54,687 (56.6%) did not receive TH. Using a mixed-effects model that adjusted for patient, arrest, neighborhood, and hospital factors with state of arrest modeled as a random intercept to account for clustering, we found that Hispanics/Latinos were less likely to receive TH than Whites (Odds Ratio [OR] 0.79, 95 % Confidence Interval [CI] 0.75-0.83). When the clustering variable was changed from the state of arrest to the admitting hospital, Hispanics/Latinos were more likely to receive TH (OR 1.07, 95% CI 1.00 to 1.14). In the 22,896 patients with data regarding why they did not receive TH, a higher percentage of Hispanics/Latinos compared to Blacks and Whites did not receive TH due to lack of a TH program at the hospital (4.0% vs. 2.5 % vs 1.8%, p < .001). No disparity in TH utilization was found for Black patients.

Conclusion:
We found disparities in access to TH for Hispanics/Latinos following OHCA. Reassuringly, we did not find any disparity in TH utilization for Black patients.
Abstract 13198: Impact of Targeted Resident Education on Perceptions of Communication and Participation in Cardiac Arrest
Authors: Jumkhawala Saahil , Tysarowski Maciej , Ali Hasan , Hemam Majd , Sutherland Anne
Published: December 2021

Introduction:
Debriefing sessions after in-hospital cardiac arrest have been demonstrated to improve teamwork and survival outcomes. Though recommended in 2020 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, implementation remains low.

Hypothesis:
We postulated that a didactic training session provided to code leaders would increase rates of participation of AHA-recommended post-arrest debriefing sessions.

Methods:
Surveys were distributed to hospital personnel who participate in code blue/ERTs at an academic, tertiary-care medical center. Questions were graded on Likert scale to assess provider-reported perceptions of teamwork, communication, and confidence in conducting and participating in Code Blues. Participants were stratified in groups depending on whether they had previously participated in debriefing sessions. Primary outcomes were quantified using a Likert-type scale ranging from 1 to 5. Surveys were compared to surveys from prior years to assess if the intervention of a code blue didactics lecture delivered to code leaders resulted in any change in overall participation rate in the debriefing protocol.

Results:
Among 181 participants (61% female), 32% were residents, 54% nurses, 1.7% respiratory therapists. Self-evaluated current knowledge of ACLS protocols was significantly higher in the debriefing group (p = 0.0098), while there were no differences in perceived communication (p=0.76), and confidence in leading (p = 0.2) and participating (p = 0.2). We did not find a statistically significant difference in debriefing participation rate after our intervention (57% pre vs 58% post intervention, p=0.8), even when stratified by hospital role: critical care nurses (50% vs 71%, p=0.3), non-ICU nurses (68% vs 57%, p=0.3) and residents (67% vs 50%, p=0.2).

Conclusions:
Our study demonstrated that participation in post-code debriefing sessions was associated with a statistically significant increase in knowledge of cardiac arrest protocols. A code blue didactics lecture did not result in a statistically significant increase in post-arrest debriefing participation. Further study to elucidate methods to enhance adoption of this crucial, guideline recommended practice is warranted.
Abstract 13205: Short and Long-Term Outcomes of OHCA Patients Admitted to Wards From the Emergency Department
Authors: Bray Janet , Howell Stuart , Bernard Stephen , Smith Karen L , Finn Judith , Stub Dion , Cameron Peter
Published: December 2021

Introduction:
The majority of research has examined out-of-hospital cardiac arrest (OHCA) patients admitted to intensive care units (ICU). Little is known about patients who are admitted to non-ICU wards. Our study aims to describe short and long term outcomes in OHCA patients admitted directly to medical wards from the emergency department.

Methods:
Data were obtained from the Victorian Ambulance Cardiac Arrest Registry and 12 hospitals for adult, non-traumatic OHCA cases transported to ED between 2014 and 2016.

Results:
Of 1578 OHCAs, 213 (13.5%) were admitted to medical or cardiac wards -only four were admitted for palliation. The majority were witnessed (38% bystander, 58% paramedic), received bystander CPR (91%, n=81/89), median downtime was 4 minutes (IQR 2-12), 179 (84%) were in a shockable rhythm, and 15 received public access defibrillation. Most had ROSC on arrival at ED (99%) and were conscious in ED (91%). Re-arrest inhospital occurred in 16 cases, the majority had a cardiac aetiology (85%) and underwent angiography (75%, 112/160 proceeded to PCI). The majority were discharged alive (n=194, 91%) and most survivors were discharged home (n=176/194, 84%) with good neurological outcomes (CPC 0-2 =94%, CPC 3= 4%). Survivors from the wards made up 30% of the overall OHCA survivors. Of survivors, 175 were alive at 12 months and 159 completed follow-up. The majority of those working prior were working at 12-months (78/92, 85%), 87% in the same role. The mean EuroQol index score for respondents was 0.77 (SD, 0.15). The mean 12-item short form Mental Component Summary score for patients was 55.0 (SD, 8.1), whereas the mean Physical Component Summary score was 49.1 (SD, 9.1).

Conclusion:
In our region OHCA patients admitted to wards have favourable arrest characteristics, and have good short- and long-term outcomes which are similar to regular acute coronary syndrome patients.
Abstract 13209: Law Enforcement-Initiated Cardiopulmonary Resuscitation in the Care of Out-of-Hospital Cardiac Arrest
Authors: Wohlford Luke A , Barnhart Bruce J , Spaite Daniel W , Gaither Joshua B , Rice Amber D , Bradley Gail , McDannold Robyn , Keim Samuel , Hu Chengcheng
Published: December 2021

Background:
Little is known about the provision of care by law enforcement (LE) personnel within modern EMS systems. We evaluated LE performance of bystander CPR (BCPR) and associated outcomes in OHCA across Arizona.

Methods:
A total of 5,654 OHCA cases (1/1/2019-12/31/2019) were evaluated using the Save Hearts in Arizona Registry and Education (SHARE) cardiac arrest registry. Data were abstracted from all EMS patient care records (PCRs). If two parties provided BCPR, the first to give compressions was considered the provider for this analysis. Cases identified as “Stranger” or “Unknown” BCPR were manually evaluated for narrative data to identify BCPR provider when possible.

Results:
BCPR was provided in 2285 cases [48.8%; (95% CIs 47.4%, 50.3%)] after excluding 850 cases that occurred in healthcare facilities where personnel are duty-bound to provide CPR. LE provided BCPR in 444 patients [19.4% (17.8%, 21.1%)], second only to family/spouse [1143 pts; 50.0% (48.0%, 52.1%)]. Overall, 279 patients survived to hospital discharge [12.2%, (10.9%, 13.6%)]. The Table shows the rates of BCPR in each provider category and the associated rates of survival. Of note is that the rate of bystander AED use was more than four times higher in LE BCPR [6.3% (4.23%, 8.99%)] than family-provided BCPR [1.5% (0.87%, 2.37%; p < 0.0001)], but was still very low.

Conclusions:
In this statewide study that included more than 130 EMS agencies from frontier to urban settings, LE personnel were frequently involved in the care of OHCA patients within the 911 system response. To our knowledge, this magnitude of provision of BCPR by LE (nearly one in five BCPR cases) has not been reported previously. Furthermore, the consequential rate of LE response to OHCA provides the opportunity to significantly increase AED use. Our findings support the widespread and intentional training of LE in CPR and AED use and has the potential to improve survival in diverse settings.
Abstract 13216: Initial Survey of Respiratory Mechanics During Prehospital Bag Ventilation
Authors: Yang Betty Y , Blackwood Jennifer E , Shin Jenny , Guan Sally , Gao Mengqi , Jorgenson Dawn , Boehl James , Sayre Michael R , Rea Thomas , Johnson Nicholas J
Published: December 2021

Introduction:
Respiratory mechanics, such as tidal volume and inspiratory pressures, affect outcome in hospitalized patients with respiratory failure. The ability to accurately measure respiratory mechanics in the prehospital setting is limited, thus the relationship between prehospital respiratory mechanics and clinical outcome is not well understood. In this feasibility study, we examined respiratory mechanics of bag-valve mask (BVM) ventilation by emergency medical services (EMS) using a novel in-line measuring device during a period when agencies switched from larger to smaller ventilation bags.

Methods:
This prospective cohort study included a convenience sample of adult patients who received BVM ventilation by EMS, from August 2018 to January 2020, in Bellevue, Washington. The airway monitoring device was applied by paramedics after intubation to passively record in black box mode, until termination of efforts or hospital arrival. Respiratory parameters included tidal volume, airway pressure, flow rates, end-tidal carbon dioxide, and respiratory rate. Prehospital agencies transitioned from large (1500 mL) to small (1000 mL) ventilation bags during the study period.

Results:
7371 post-intubation breaths were measured in 54 patients, 32 treated for out-of-hospital cardiac arrest (OHCA) and 22 treated for non-arrest conditions, primarily respiratory etiology. EMS ventilated 19 patients with a small bag and 35 patients with a large bag. Ventilation with a smaller bag was characterized by less variability in tidal volumes and higher proportion of breaths delivered within 4-10 mL/kg of predicted body weight (Figure) (p<0.05).

Conclusions:
Respiratory mechanics can be measured in EMS patients receiving BVM ventilation following intubation. Ventilation with a smaller bag might reduce variation in tidal volume, but further study is needed. These data provide the first evaluation of respiratory mechanics during manual ventilation provided by EMS.
Abstract 13249: Temporal Trends in Out-of-Hospital Cardiac Arrest Bystander CPR and Defibrillation Following Implementation of Citizen Responder Programs
Authors: Jakobsen Louise Kollander , Moeller Sidsel Gamborg , Ringgren Kristian Bundgaard , Moeller Amalie Lykkemark , Andelius Linn , Hansen Carolina Malta , Gregers Mads Christian Tofte , Christensen Nanna B , Kjoelbye Julie , Torp-Pedersen Christian , Folke Fredrik
Published: December 2021

Introduction:
In Denmark, survival after out-of-hospital cardiac arrest (OHCA) has increased markedly in the past years, from 3.9% in 2001 to 15.8% in 2019. Still, bystander defibrillation remains low, especially for OHCAs in residential areas. To improve bystander defibrillation, smartphone activated Citizen Responder (CR) Programs have expanded to nationwide coverage in Denmark during September 2017 to May 2020.

Hypothesis:
Implementation of CR programs in Denmark was associated with increased bystander CPR and defibrillation.

Methods:
We conducted an observational study of 15,308 OHCAs from the Danish Cardiac Arrest Registry from 2016-2019. App-based CR programs were implemented in four out of five Danish regions during the study period. All OHCAs were divided into two groups according to the date of CR implementation (“before” and “after CR” implementation). The groups were compared focusing on bystander defibrillation, bystander CPR and 30-day survival.

Results:
“Before CR” included 8,819 OHCAs and the “after CR” 6,489 OHCAs. The proportion of bystander CPR was 77.9% and 78.0% (p-value 0.91) for the before -and after CR implementation groups, respectively. The corresponding numbers for bystander defibrillation were 7.4% and 9.5% (p-value < 0.001), respectively. In residential OHCA, bystander defibrillation went from 4.0% to 6.3% (p-value<0.001) in the before -and after group respectively. In public, bystander defibrillation was 19.3% and 22.2% (p-value 0.05) in the groups respectively. 30-day survival was 12.7% before and 13.1% after CR implementation (p-value 0.49).

Conclusion:
We found no changes in bystander CPR or 30-day survival following implementation of CR programs in Denmark, but a significant increase in bystander defibrillation for all OHCAs. Importantly bystander defibrillation also increased significantly in residential locations, where the majority of OHCAs occur and where bystander defibrillation has remained low for decades.
Abstract 13292: Comparison of Outcomes Between Pulseless Electrical Activity by Electrocardiography and Pulseless Myocardial Activity by Echocardiography in Out-of-Hospital Cardiac Arrest
Authors: Gaspari Romolo ,   REASON Rsch Network
Published: December 2021

Objective:
To measure prevalence of discordance between electrical activity recorded by electrocardiography (ECG) and myocardial activity visualized by echocardiography (echo) in patients presenting after cardiac arrest and to compare survival outcomes in cohorts defined by ECG and echo.

Methods:
This is a secondary analysis of a previously published prospective study at twenty hospitals. Patients presenting after out-of-hospital arrest were included. The cardiac electrical activity was defined by ECG and contemporaneous myocardial activity was defined by bedside echo. Myocardial activity by echo was classified as
myocardial asystole-
-the absence of myocardial movement,
pulseless myocardial activity
(PMA)--visible myocardial movement but no pulse, and
myocardial fibrillation-
-visualized fibrillation. Primary outcome was the prevalence of discordance between electrical activity and myocardial activity. Secondary outcome was survival to hospital discharge.

Results:
793 patients and 1943 pauses in CPR were included. 28.6% of CPR pauses demonstrated a difference in electrical activity (ECG) and myocardial activity (echo), 5.0% with asystole (ECG) and PMA (echo), and 22.1% with PEA (ECG) and myocardial asystole (echo). Survival to hospital admission for patients with PMA (echo) was 29.1% (95%CI-23.9-34.9) compared to those with PEA (ECG) (21.4%, 95%CI-17.7-25.6). Twenty-five percent of the 32 pauses in CPR with a shockable rhythm by echo demonstrated a non-shockable rhythm by ECG and were not defibrillated. One of these patients survived, a patient with asystole on ECG and vfib by echo survived because vfib was identified on ECG during a subsequent pause and was defibrillated.

Conclusion:
Patients in cardiac arrest commonly demonstrate different electrical (ECG) and myocardial activity (echo). Further research is needed to better define cardiac activity during cardiac arrest and to explore outcome between groups defined by electrical and myocardial activity.
Abstract 13412: Gender Based Differences in Duration of Cardiopulmonary Resuscitation in the Inpatient Setting
Authors: Baillie Anna , Sell Rebecca , Speck Victoria , Wardi Gabriel
Published: December 2021

Introduction:
The decision to terminate cardiopulmonary resuscitation (CPR) prior to return of spontaneous circulation (ROSC) may be impacted by resuscitation parameters or by patient demographics. Studies show that longer resuscitation efforts have a higher likelihood of ROSC and survival to discharge. It is unclear if gender of the code leader and the patient may be associated with duration of unsuccessful CPR attempt.

Methods:
Retrospective chart review of inpatient CA that occurred at the UC San Diego Health System between 2011-2019. All adult inpatients with an index cardiac arrest who expired within three days of admission were included. Exclusion criteria included patients who achieved ROSC, CA that occurred outside of the wards or ICU, those with active pre-arrest DNR status, and patients with CA > 3 days after admission (done to minimize provider bias based on prior knowledge of the patient). Data were identified from an internal cardiac arrest quality improvement database. Patient gender was self-reported and code leader gender was identified. Primary outcome was duration of resuscitation efforts. To determine differences in duration of CPR between code leader and patient gender a one-sided ANOVA test was used. A
p
value < 0.05 was considered statistically significant.

Results:
We identified 91 patients between 2011 and 2019 that met inclusion criteria. Thirty-eight patients (41.8%) identified as female, fifty-three identified as male (58.2%), the average age was 62.7 years old, and seventeen (18.7%) had initial shockable rhythm. Thirty (33%) of the code leaders identified as female and sixty-one (67%) identified as male. Average duration of CPR was 31.6 minutes (2 - 135 minutes) for male patients with male code leader, 32.2 minutes (9 - 71 minutes) for male patients with female code leader, 27.0 minutes (7 - 60 minutes) for female patients with female code leader, and 33.7 minutes (10 - 73 minutes) for female patients with male code leader. No significant difference in duration of unsuccessful CPR attempt associated with gender of code leader and gender of patient in ANOVA analysis was found (p = 0.512).

Conclusions:
We did not identify a significant association between code leader and patient gender on duration of CPR in the inpatient setting.
Abstract 13607: Correlation in Hospital Survival Following Out-of-Hospital Cardiac Arrest With Variation in Post-Arrest Inpatient Intervention Rates in Michigan
Authors: Swor Robert A , Paxton James , Berger David , Miller Joseph B , Brett Christine , Chen Nai-Wei
Published: December 2021

Introduction:
Wide variations in rates of survival to hospital discharge exist for survivors of out-of-hospital cardiac arrest (OHCA). The potential influence of variation in post-OHCA hospital care has not been adequately explored. We hypothesized that variation of in hospital survival rates may be influenced by variation of in-hospital care in Michigan.

Methods:
We performed a secondary analysis of a statewide cardiac arrest database constructed from two probabilistically-linked cardiac arrest registries [Cardiac Arrest Registry to Enhance Survival (CARES) and Michigan Inpatient Database (MIDB)] from 2014 - 2017. A novel composite rank score was created to characterize post-arrest in-hospital care, incorporating four specific interventions: left heart catheterization within 24 hours (LHC), emergent mechanical circulatory support (EMCS), targeted temperature management (TTM), and do-not-resuscitate order placed within 72 hours of arrival (DNR). The highest score (1 of 38) was given to the hospital with highest procedure rate (LHC, TTM, LHC) and the lowest rate of early DNR. Spearman’s correlation coefficients assessed the relationship between the equal weight composite rank score and rate of hospital survivors.

Results:
We included 3,644 patients admitted to 38 hospitals who treated >30 OHCA patients during the study period. Patient mean age was 62.4 years, and 59.3% were male. Survival, rank scores and correlation coefficients are listed below: We observed four-fold variation in survival for all patients and witnessed arrest, with a non-significant correlation with care provision. However, we identified a sixteen-fold variation in survival among unwitnessed arrests, which was significantly correlated with a higher rank of care provided.

Conclusions:
In Michigan, the greatest variation in survival was identified among unwitnessed arrests. This variation was robustly associated with a composite rank of in-hospital post-arrest interventions.
Abstract 13649: Asymmetric Cerebral Perfusion in Comatose Extracorporeal Membrane Oxygenation Patients
Authors: Khan Imad , Johnson Thomas , Dar Irfaan , Donohue Kelly , Xu Yan , Santiago Esmeralda , Loose Emily , Selioutski Olga , Marinescu Mark
Published: December 2021

Asymmetric cerebral perfusion can occur when extracorporeal membrane oxygenation (ECMO) flow competes with native cardiac circulation. It is unclear whether this phenomenon associates with brain injury. Diffuse correlation spectroscopy (DCS) provides continuous, laser-based, non-invasive, bedside monitoring of relative cerebral blood flow (rCBF). This study measured rCBF in ECMO patients via DCS to determine whether comatose patients experience asymmetric cerebral perfusion.

Adults receiving ECMO for any indication were prospectively recruited from 12/2019-3/2021. Patients with prior neurologic injury, scalp/facial lacerations, and SARS-CoV-2 infection were excluded. DCS monitoring was performed daily during ECMO support with sensors placed on bilateral foreheads. Mean arterial pressure (MAP) was continuously recorded from the bedside monitor. The Glasgow Coma Scale (GCS) was assessed by clinical staff multiple times daily with sedation pauses, if possible, per standard of care. rCBF was calculated by comparing continuous cerebral blood flow (CBF) measurements to the daily median CBF, then averaged at each MAP value. Daily rCBF asymmetry was calculated by summing the absolute difference of rCBF between the two hemispheres at each MAP value, normalized for the total MAP range experienced by the patient that day.

Twelve subjects were enrolled in this study (ages 21-78, 6 with cardiac arrest, 4 with acute heart failure, 2 with ARDS) and grouped by maximum GCS motor (GCS-M) score during ECMO, with 3 “comatose” subjects (GCS-M ≤ 4), and 9 “awake” subjects (GCS-M > 4). DCS was performed over 66 sessions with a mean duration of 131.83 ± 1.13 minutes. Comatose subjects exhibited more rCBF asymmetry than awake subjects (0.28 ± 0.06 mmHg-1 vs. 0.10 ± 0.001 mmHg-1, p=0.045). No difference in asymmetry was noted between patients with or without cardiac arrest.

We found that comatose ECMO subjects exhibited higher inter-hemispheric rCBF asymmetry over a range of blood pressures than awake subjects. Though our comatose sample is small, further validation of this finding and its causes, such as cerebrovascular dysregulation, is warranted.
Abstract 13761: Does Targeted Temperature Management Modify the Association Between Increasing Epinephrine Dose and Survival Outcomes Following Out-of-Hospital Cardiac Arrest?
Authors: Yang Betty , Bulger Natalie , Chocron Richard , Counts Catherine , Drucker Christopher , Sootedehnia Nona , Kudenchuk Peter , Sayre Michael R , Rea Thomas
Published: December 2021

Introduction:
Epinephrine (EPI) improves return of circulation after out of hospital cardiac arrest (OHCA). These beneficial cardiac effects are not accompanied by improved neurological survival possibly due to EPI induced microvascular effects and critical brain ischemia. We hypothesized that these dose-dependent adverse EPI effects may be mitigated by targeted temperature management (TTM) such that the relative benefit of TTM is greater at higher EPI doses.

Methods:
This was a retrospective cohort study of adult non-traumatic OHCA patients in Seattle and King County, Washington from 2008-2018, who were unconscious at hospital admission. We used logistic regression to assess the relationship among EPI dose, TTM, and survival to hospital discharge, and survival with favorable neurological status (Cerebral Performance Category (CPC) 1 or 2). The model evaluated whether TTM modified the association of increasing EPI dose using an interaction term between TTM and EPI dose. Results were stratified by initial shockable vs non-shockable rhythm.

Results:
Of 5254 eligible patients, the median EPI dose was 2.0 mg (IQR 1.0 - 3.0); 3052 (58%) received TTM. In all, 2177 (41%) survived to discharge, and 1889 (36%) survived with CPC 1-2. Increasing dose of EPI was associated with a decreasing likelihood of survival (OR 0.58, [95% CI 0.55-0.61] for each additional mg of EPI) and CPC 1-2 (OR 0.56, [0.53-0.59]). The dose-dependent EPI association was modified by TTM. After adjustment for Utstein covariates, for each additional mg of EPI, TTM was associated with a relative stepwise improvement in odds of survival (interaction OR 1.35, [1.23, 1.49]) and CPC 1-2 (OR 1.34, [1.21, 1.50]) (Figure). This interaction was consistent among shockable and non-shockable OHCA (Figure).

Conclusions:
We observed an interaction between TTM and EPI dose such that the beneficial association of TTM increased with increasing EPI dose, suggesting TTM may attenuate the adverse effects of higher dose EPI.
Abstract 13945: Central Cannulation During Pediatric Extracorporeal Cardiopulmonary Resuscitation is Faster Than Peripheral Approaches
Authors: Marquez Alexandra M , Vargas-Gutierrez Mariella , Todd Mark , Goco Geraldine , Moga Michael-Alice , Floh Alejandro , Honjo Osami , Haller Christoph , Guerguerian Anne M
Published: December 2021

Introduction:
Favorable survivorship after pediatric extracorporeal cardiopulmonary resuscitation (ECPR) may be limited by prolonged resuscitations. Surgical cannulation metrics for pediatric ECPR have not been widely reported by centers that use time interval benchmarks with a cardiovascular service responding to different hospital locations.

Hypothesis:
We hypothesize that survival is associated with resuscitation duration, and cannulation duration differs between peripheral and central approaches.

Methods:
This was a single-center retrospective study of patients 0-18 years with in-hospital ECPR between January 2015 and December 2020. Primary outcome was survival to hospital discharge. Secondary outcomes were odds of favorable neurologic outcome (dichotomized pediatric cerebral performance category), total resuscitation duration defined as cardiac arrest start to ECMO flow start (CA-ECMO), and cannulation duration. Non-parametric and regression methods were used.

Results:
Of the 92 events that met ECPR criteria, median weight and age were 4 months (IQR 1 month, 16 years) and 4.4 kg (range 1.9-133 kg). Cannulation occurred in the cardiac intensive care unit (ICU) (66%, 61 of 92), followed by operating room (13%, 12 of 92), pediatric ICU (12%, 11 of 92), and catheterization lab (9%, 8 of 92). Central cannulation was performed in 43% (40 of 92), and 21% (19 of 92) had open chests at the time of the event. Median duration of CA-ECMO was 35 min (IQR 26, 45 min); cannulation duration was 11 min (IQR 5, 16.5 min) for central compared to 18.5 min (IQR 12, 23 min) for peripheral approaches (P=0.01). Survival was 40% (37 of 92), and favorable neurologic outcome occurred in 38% (35 of 92). Survival (adjusted OR, 0.94; 95% CI 0.91-0.99, P=0.018) and favorable neurologic outcome (adjusted OR, 0.95; 95% CI 0.917-1.000, P=0.053) were associated with CA-ECMO duration after adjusting for cannulation approach, location, difficulty, shockable rhythm, and weight.

Conclusion:
In pediatric in-hospital ECPR, total CA-ECMO duration remains a key metric associated with patient outcomes. Central cannulation is faster than peripheral approaches. Since cannulation strategy alters CPR maneuvers, CPR effectiveness with each approach needs further study.
Abstract 14095: Use of Femoral Arterial Doppler Velocity to Detect Perfusing Pulses During Cardiac Arrest
Authors: cohen allison , Li Timmy , Becker Lance B , Gold Allen , nelson mathew , Owens Casey , Singh Neha , Rolston Daniel
Published: December 2021

Introduction:
Manual pulse detection is inaccurate in cardiac arrest(CA) and Doppler ultrasound may detect blood flow without an adequate perfusion blood pressure (pseudo-pulseless electrical activity). The purpose of this study is to assess whether maximum femoral arterial velocity during a pulse check is correlated with arterial line systolic blood pressure (SBP) and whether it can be used to accurately identify a SBP of ≥60mmHG.

Methods:
This is a prospective study of CA patients at a quaternary care Emergency Department. During a pulse check, a linear ultrasound was placed at the common femoral artery and the presence or absence of an arterial Doppler waveform, the associated maximum velocity value, and arterial line SBP were recorded simultaneously. The correlation between SBP and maximum waveform velocity was assessed. Arterial SBPs were dichotomized as <60mmHG or ≥60mmHg, as this was deemed as an adequate perfusion pressure, and a receiver operator characteristic curve analysis was performed to determine optimal cutoff value of maximum velocity associated with SBP ≥60mmHG. Sensitivity (Sn), specificity (Sp), and accuracy (Acc) of manual palpation and femoral artery pulse wave doppler for detection of SBP ≥60mmHg were calculated.

Results:
A total of 51 patients and 183 pulse checks were analyzed. There was a strong correlation between arterial line SBP and maximum waveform velocity (Spearman correlation coefficient: 0.92; p<0.001). The optimal cutoff value of waveform velocity associated with a SBP ≥60mmHG was 20 cm/second (Sn: 0.89; specificity: 0.94; area under the curve: 0.98) with an Acc of 0.92. To detect SBP ≥60mmHg, manual palpation had a Sn of 0.45, Sp of 0.82, and Acc of 0.67 McNemar's test showed that Sn (p<0.001), Sp (p=0.009), and Acc (p<0.001) was significantly higher for doppler ultrasound >=20cm/sec compared with manual palpation.

Conclusion:
In this study, during a pulse check, patients with a femoral arterial doppler waveform with a maximum velocity greater than 20cm/sec had a high probability of having a SBP ≥60mmHg, and improved Sn, Sp and Acc over manual palpation. The results demonstrate femoral arterial doppler maximum velocity is an accurate and objective tool to determine the presence of a pulse with adequate perfusion pressures.
Abstract 14195: Impact of Leukocyte Filtration and Leukocyte Modulation on Recovery of Heart Function After Prolonged Cardiac Arrest Treated With ECPR in a Porcine Model
Authors: VanZalen Jensyn , Nakashima Takahiro , Phillips Annie , Hill Joseph , Enciso Alyssa , Pak Olivia , Harvey Stephen , Longan Keenan , Bartlett Robert , Rojas-Pena Alvaro , Neumar Robert W
Published: December 2021

Background:
Extracorporeal cardiopulmonary resuscitation (ECPR) improves survival of patients with prolonged cardiac arrest (CA) that is refractory to standard CPR and ACLS. It has been proposed that ECPR accentuates inflammation after CA, potentially limiting its effectiveness. The benefits of leukocyte filters or leukocyte-modulating devices in conjunction with ECPR have not been studied.

Hypothesis:
When paired with ECPR, inflammation-modulating devices targeting leukocytes may improve recovery of cardiac function after prolonged cardiac arrest.

Methods:
In a randomized study, 24 swine (40±5kg) underwent 8min of untreated ventricular fibrillation CA followed by CPR with mechanical chest compressions and impedance threshold device for 30 min (total arrest time = 38min), immediately followed by 8h of ECPR with heparin anticoagulation and temperature maintained at 33°C. Group 1 (n=8) had standard ECPR system (control), Group 2 (n=8) had a leukocyte filter device (LF) added to the ECPR circuit, an and Group 3 (n=8) had a leukocyte modulation device (LMOD) added to the ECPR circuit. Recovery of cardiac function was measured using a cardiac resuscitablity score (CRS) and left ventricular ejection fraction (LVEF) via transthoracic echocardiography. Data was collected at baseline (prior CA) and after 8h of ECPR. Data analysis: single-factor ANOVA test (p<0.05 significance).

Results:
There were no statically significant differences between the groups in CRS (Control = 3.3 ± 2.4, LF = 4.0 ± 2.8, LMOD = 2.1 ± 2.6; p=0.37) or LVEF (Control = 59% ± 27%, LF = 49% ± 29% LMOD = 34% ± 38%: p=0.34) at 8 hours after ECPR initiation (Table 1).

Discussion:
In this swine model of prolonged cardiac arrest treated with ECPR, addition of a leukocyte filter or leukocyte modulation device to the ECPR circuit did not improve recovery of cardiac function during the first 8 hours after initiating ECPR.