bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 208: MicroRNA 122 and 300 as a Potential Prognosticator of Brain, Kidney and Liver Damage in Response to Ischemic-reperfusion Injury After Severe Rodent Cardiac Arrest
Authors: Choudhary Rishabh , Haque Shabirul , Shoaib Muhammad , Yin Tai , Becker Lance B
Published: November 2020

Introduction:
Cardiac arrest (CA) causes ischemia and reperfusion damage to the entire body. Augmented expression of circulating microRNA (miR)-122 has been associated with poor neurological outcome after CA, as well as drug and alcohol-induced liver injury in human. Plasma exosomal miR-300 has shown to be up regulated in transient ischemic attack while cellular miR-300 expression increased after traumatic brain injury in rodent model.

Hypothesis:
The response of tissue injury can be determined by measuring differential expression of miR. This study sought to quantify two specific miR-122 and 300, from the intracellular compartment of the brain, kidney, and liver tissues to determine the injury pattern after severe CA and resuscitation.

Methods:
Male Sprague-Dawley rats were assigned into 2 groups: control (no CA or CA and resuscitation) and 20 min CA followed by 30 min cardiopulmonary bypass (CPB) resuscitation (n=3). Brain, kidney, and liver tissues were isolated and homogenized. Total RNA was isolated from homogenized tissue by trizol method, RNA was then converted to cDNA by RT kit and processed for miR-122 and miR-300 quantification using quantitative real-time polymerase chain reaction (qRT-PCR). RNU6 was used as an endogenous control and results were expressed in fold change.

Results:
Brain after CA and resuscitation revealed an increased trend in expression of miR-122 (p=0.053) and miR-300 (p=0.57). Liver also demonstrated an increasing trend in miR-122 (p=0.15) and miR-300 (p=0.007) expression. The increasing trend of miR-122 and miR-300 expression in brain and liver following CA and resuscitation suggests reperfusion injury in the early phase of resuscitation. Kidney demonstrated a lower expression of both miR-122 and miR-300 after CA and resuscitation, which suggests that the event of CA and resuscitation further down regulate miR-122 and miR-300 expression.

Conclusion:
Levels of intracellular miR-122 and 300 in the brain, kidney, and liver appear to be altered after CA and resuscitation. Although, only one of the miR showed a significant difference in our small exploratory study, the current finding suggests that tissue specific miR levels may provide insight about specific injury following CA.
Abstract 214: Cardiac Arrest and Extracorporeal Cardiopulmonary Resuscitation Impairs Left Ventricle Hemodynamic Function in a Ventricular Fibrillation Cardiac Arrest Model in Rats
Authors: Warenits Alexandra Maria , Müller Matthias , Magnet Ingrid Anna Maria , Ettl Florian , Hamza Ouafa , Kottbauer Felix , Högler Sandra , Podesser Bruno , Holzer Michael , Weihs Wolfgang , Kiss Attila
Published: November 2020

Introduction:
Extracorporeal Cardiopulmonary Resuscitation (ECPR) may achieve ROSC after prolonged CA when conventional cardiopulmonary resuscitation fails. We investigated the impact of ECPR on cardiac hemodynamic recovery and hypothesized, that left ventricular hemodynamic function is impaired in resuscitated hearts.

Methods:
Adult male Sprague-Dawley rats (500 g, n=36) were subjected to 6 or 8 min of ventricular fibrillation CA, thereafter resuscitated with ECPR (open reservoir, roller pump, membrane oxygenator, draining catheter in the right jugular vein, inflow catheter in the right femoral artery; custom made bypass system), mechanical ventilation and drugs (epinephrine, bicarbonate, heparin). After defibrillation and ROSC, rats survived for 14 days and were compared to 7 sham animals. The hearts were isolated and mounted onto an erythrocyte-perfused, isolated working heart (WH) system. Cardiac output, left ventricular systolic pressure (LVSP), coronary flow and pressure-volume (P-V) relationships (by increasing the afterload in 10 mmHg increments) were measured. Myocardium of all rats was evaluated pathohistological in hematoxylin-eosin staining.

Results:
ROSC was achieved in 18 animals after 6 min of CA, of which 10 survived 14 d and 7 were investigated in WH, in 8 min CA group 15 achieved ROSC of which 5 survived to 14 d and 2 were investigated in WH and compared to the hearts of 7 sham animals. At defined afterload (60 mm Hg; baseline) there was no difference in cardiac hemodynamics between sham and 6 min CA group. In contrast, 8 min CA rats showed a tendency towards decrease in cardiac output and LVSP compared to sham animals. Notably, both CA groups showed impaired P-V loop relationship and subsequently less tolerance to hemodynamic stress. Histologically all 8 min CA rats showed multiple foci of myocardial scarring.

Conclusions:
CA led to impaired left ventricular hemodynamics in 8 min CA rats resuscitated with ECPR. In addition, hearts were more vulnerable to hemodynamic stress after successful resuscitation. For investigating the effects of future therapy approaches during and after resuscitation from CA on the heart function, isolated WH might be a promising approach in resuscitation research.
Abstract 215: Adam17 Regulates Renal Function
Authors: Zhang Bo , Chen Kai , Sun Zhongjie
Published: November 2020

A disintegrin and metalloproteinase 17 (ADAM17) is a ubiquitously expressed membrane-bound sheddase that cleaves a diverse variety of membrane-bound molecules, including cytokines, growth factors, and their receptors to activate or inactivate various cellular signaling pathways. Although it was reported that ADAM17 may mediate renal diseases, the role of ADAM17 in the regulation of normal kidney function has never been identified. The objective of this study is to investigate whether renal ADAM17 plays a role in maintaining normal kidney function and structure. Tamoxifen-inducible kidney-specific cre (Ksp) and ADAM17-floxed mice were cross-bred for generating Ksp/ADAM17-floxed mice. Injection of tamoxifen initiated deletion of the
ADAM17
gene in renal tubule cells. We found that conditional kidney-specific knockout of
ADAM1
7 gene (Ksp-ADAM17 -/-) decreased urinary creatinine and sodium excretion were decreased in Ksp-ADAM17 -/- mice, indicating that
ADAM17
gene deficiency impairs kidney function. H&E staining showed glomerulus collapse and tubule dilation in Ksp-ADAM17 -/- mice. The epithelial cells fall off into the lumen in the renal tubule. Mesangial expansion and fibrosis were found in glomeruli in Ksp-ADAM17 -/- mice. Moreover, apoptosis was increased in tubule cells in both cortex and medulla areas in Ksp-ADAM17 -/- mice. In conclusion, ADAM17 is critical to the maintenance of normal renal function and structure.
Abstract 217: Glycation of Ryanodine Receptors in Peripheral Lymphocytes Predicts the Response to Cardiac Resynchronization Therapy
Authors: Morelli Marco Bruno , Gambardella Jessica , Matarese Alessandro , Wang Xujun , D'Ascia Salvatore , Sardu Celestino , Santulli Gaetano
Published: November 2020

Introduction:
Cardiac resynchronization therapy (CRT) is an effective treatment for patients with advanced heart failure (HF). The management of these patients depends on biomarkers for monitoring disease progression and therapeutic response. HF patients exhibit a pathologic remodeling of Ryanodine Receptors (RyRs) in heart, muscle, as well as circulating lymphocytes, leading to intracellular calcium leak, which has been shown to correlate with the clinical outcome.

Hypotheses:
1) post-translational modifications of RyR in circulating lymphocytes in HF patients can predict CRT response; 2) CRT can improve the remodeling of RyRs and intracellular calcium leak.

Methods:
To test this hypothesis, we enrolled 34 patients who underwent CRT and examined RyR remodeling in peripheral lymphocytes before and 1 year after CRT using established biochemical and flow-cytometry assays. Non-responders to CRT were defined after 1 year of follow-up as patients with at least one of the following characteristics: deteriorating function (HF-related death, need for heart transplantation), increase in LVEF ≤ 4%, worsening in peak O
2
consumption, in Quality-of-Life score, or in the distance walked in 6 min.

Results:
We found that post-translational remodeling of RyR (
i.e.
oxidation, phosphorylation, glycation) was significantly (
P<0.01
) reduced in circulating lymphocytes isolated from CRT responders compared to pre-CRT levels and to non-responders. Similarly, the binding to RyR of its stabilizing subunit (calstabin) was markedly increased by CRT, whereas intracellular Ca
2+
leak was attenuated (
P<0.01
). Importantly, these phenomena were not observed in CRT non-responders. Moreover, in a multivariate regression analysis, we observed that RyR glycation in peripheral lymphocytes at baseline was independently associated with CRT response at 1-year follow-up (
P<0.05
).

Conclusions:
This is the first study showing that CRT response can be predicted by the level of RyR glycation in peripheral blood lymphocytes. Moreover, we demonstrate that CRT responders exhibit a significantly reduced intracellular Ca
2+
leak through RyR in lymphocytes, mirrored by diminished post-translational modifications compared to baseline and to CRT non-responders.
Abstract 218: Novel Blood Biomarker Taurine and Glutamate for Early Predicting Outcomes After Out-of-hospital Cardiac Arrest
Authors: Li Jing , Qin Kevin , Doshi Pratik B , Zhu Xiangdong , Kotini-Shah Pavitra , Granado Misha , Kim Hajwa , Yen Pei-Shan , Gordon Richard , Wang Henry E , Vanden Hoek Terry L
Published: November 2020

Introduction:
Out-of-Hospital cardiac arrest (OHCA) is the leading cause of death with an overall survival rate of less than 10%. Organ failure and metabolic impairment are two critical elements of post-CA syndrome. Taurine and glutamate are amino acids that are expressed primarily in heart and brain. The compensatory release during osmotic stress, as seen in CA, amplifies reperfusion injury, heart stunning and brain edema. Thus, taurine and glutamate concentrations in blood likely reflects the extent of injury in the heart and brain following CA.

Hypothesis:
Plasma taurine and glutamate concentration correlates with CA outcomes.

Methods:
Adult OHCA patients (n=37) at an urban academic ED were enrolled from 2018-2019. Among them, 14 were survivors (S) and 23 were nonsurvivors (NS). Blood samples were collected at various time points including the time at hospital arrival, 6, 24, 48, 72 hours after arrival (T0, 6, 24, 48 and 72 h, respectively), and measured. T-test and GEE were used for mean comparison and longitudinal trend analysis, respectively.
p
< 0.05 was considered as statistically significant.

Results:
Plasma taurine and glutamate concentrations were compared between S and NS at T0 and across all time points. Both concentrations were significantly higher in NS vs S group at T0 (for taurine: 77.7 ± 40.0 in NS vs. 60.0 ± 31.9 μM in S,
p
=0.014; for glutamate: 176.4 ± 98.7 in NS vs. 162.8 ± 111.1 μM in S,
p
=0.0496), and showed a decreasing trend over time. In the first 6 h, taurine and glutamate level decreased more in S group than NS group (over 30% drop in S compared to <15% drop in NS). In addition, a positive correlation of cerebral performance category was seen at T6 with taurine (p=0.0354), but not with glutamate.

Conclusions:
Blood taurine and glutamate may serve as early biomarkers in predicting OHCA outcomes. Monitoring their change over time can help physicians tailor treatment decisions and patient management.
Abstract 224: Videographic Assessment of Pediatric Endotracheal Intubation in the Covid-19 Era: A Report From the Videography in Pediatric Resuscitation Collaborative
Authors: Neubrand Tara L , O'Connell Karen , Nishisaki Akira , Myers Sage , Kerrey Benjamin , Donoghue Aaron
Published: November 2020

Introduction:
Endotracheal intubation (ETI) of critically ill children is a high acuity, low frequency procedure in the pediatric emergency department that presents unique challenges to both pediatric and general acute care providers. COVID-19 and the associated requirements for PPE use, limitations of in-room personnel, communication difficulties, and reorganization of equipment have created new complexities.

Objective:
To use video review to compare intubator training level, first-attempt ETI success and presence of hypoxia during ETI attempts in the pediatric emergency department in the pre-COVID and COVID era.

Methods:
This is a retrospective multi-center case series of videorecordings of endotracheal intubations at the four tertiary care pediatric emergency departments comprising the VIPER Collaborative. All children undergoing emergent ETI between 1/1/2019-6/1/2020 in whom videorecordings were available were included for analysis. Data on patient age and intubator background was collected. Outcomes were first-attempt intubation success and hypoxia, defined as SpO2 <90%. Data was compared before (PRE) and after (POST) implementation of COVID-19 airway protocols, which each PED adopted in March 2020. Univariate analysis comparing PRE and POST for both outcomes was done by c2 testing. Multivariate analysis with a generalized estimating equation to control for clustering by site was done to determine the independent association between PRE and POST and outcomes.

Results:
Between 1/1/2019 and 6/1/2020, a total of 272 patients underwent ETI (239 PRE, 33 POST). Overall first attempt success was 155/239 (65%) in PRE and 28/33 (85%) in POST (p=0.02). Hypoxia was noted in 15% of PRE patients and in 12% of POST patients. Analysis of the training level of the intubator was notable for a significant increase in the number of intubations performed by anesthesiologists (55% POST vs. 13% PRE, p<0.001). In multivariate analysis controlling for intubator background, the POST phase was associated with greater first attempt success (AOR 2.4, 95% CI 1.6 – 3.7).

Conclusion:
Pediatric ETI in the COVID-19 era is associated with increased first attempt success when compared to the pre-COVID era.
Abstract 225: The Adverse Mental Health Impact of Emergency Medical Services Related Public Health Messaging for Cardiac Arrest Patients During the Covid-19 Pandemic
Authors: Preston Caroline , Shen Edmund , Abukhadra Sabine L. , Roh David , Park Soojin , Claassen Jan , Edmondson Donald , Agarwal Sachin
Published: November 2020

Introduction:
In light of the COVID-19 pandemic, various emergency medical services (EMS) and health agencies in New York City (NYC), and other hard-hit cities, issued new guidelines terminating resuscitation efforts in cases of out of hospital cardiac arrests (CA). This guidance was issued to protect the health and safety of EMS providers, to conserve hospital resources, and to ensure optimal use of equipment to save the greatest number of lives. However, the psychological impact of this public health messaging on existing CA survivors has not yet been studied.

Methods:
Between 5/15 - 5/18 of 2020, a month after the NYC COVID-19 pandemic peak, CA survivors from an ongoing, prospective study, were invited to participate in a telephone-based assessment of the pandemic’s impact on psychological and behavioral dimensions. COVID-19 anxiety was assessed using the 7-item Perceived Coronavirus Threat Questionnaire (PCTQ; e.g., “I am stressed around other people because I worry I’ll catch the coronavirus;” range 1-42). Survivors’ self-reported fear and uncertainty in receiving immediate life-saving care in the event of a CA due to recent public health messaging was assessed on a 5-point Likert-scale (Not at all—extremely).

Results:
Of 100 approached, 75 CA survivors participated (53% male; age 61±15 years; 44% non-Hispanic White, 20% Black, and 31% Latinx). The majority, 63 of 75 (84%), had no COVID-19 symptoms or had not been tested. The median COVID-19 anxiety score was 28 (interquartile range [IQR]: 21-37). Participants who were “very to extremely” afraid that emergency care would not come if they had another CA made up 45% (34 of 75; 95% C.I: 34-57) and scored 1 SD higher (mean±SD 34±6 vs 23±9, p<0.001) on COVID-19 anxiety scores than those with little fear about the availability of emergency care. The association was significant after adjusting for age, race, sex, and COVID-19 testing status (Odds Ratio = 1.17; 95% CI: [1.079, 1.274]; p<0.001).

Conclusion:
A better understanding of the potential psychological impact of disaster-related public health messaging is needed to prevent campaigns from causing additional distress and contributing to poor mental health and quality of life.
Abstract 226: Statewide Out-of-hospital Cardiac Arrest During the Covid-19 Pandemic
Authors: Rauch Lindsey K , Bergquist Emily , Pribble James , Fales William
Published: November 2020

Introduction:
Little is known about statewide out-of-hospital cardiac arrests (OOHCA) during a global pandemic.

Objective:
To characterize the impact of the COVID-19 pandemic on state OOHCA rates.

Methods:
Data for non-traumatic, OOHCA were obtained and analyzed from a statewide EMS information system from March 1, 2000 to May 31, 2020 (pandemic) and compared to data obtained from the same 3-month period the prior year (control). Analysis occurred using a web-based application designed to analyze state EMS data. OOHCA were identified using a validated data filter applied to 911 calls and limited to transporting EMS units. Shockable OOHCA and arrests occurring in 5 counties with the highest number of COVID-19 deaths during the pandemic were also analyzed.

Results:
There were 4,665 OOHCAs identified during the pandemic compared to 3,261 OOHCA during the control period, a 43.1% increase (p<0.00001). Bystander AED use (10% vs 10%), bystander CPR (38% vs. 38%), and bystander witnessed arrests (34% and 33%) were similar. Rates of EMS termination of resuscitation (TOR) were higher (59% vs. 47%), while endotracheal intubation (ETI) (12% vs. 31%), and ROSC (5% vs. 8%) were lower during the COVID-19 period. Blacks had a higher rate of OOHCA during the pandemic period (26.6% vs 18.6%, p<0.00001). Overall shockable OOHCA increased by 14.8% (403 vs. 351, p=0.002) during the pandemic. Bystander AED use (10% vs 11%), bystander CPR (55% vs. 51%), and bystander witnessed (71% and 71%) were similar. Rates of field TOR were 33% vs. 24%, ETI were 14% vs. 31%, and ROSC were 16% vs. 17%. Within the 5 highest impact counties total OOHCA increased by 61.4% (2,702 vs. 1,674, p<0.00001) and shockable OOHCAs increased by 21.4% (207 vs 170, p=0.004).

Conclusions:
OOHCA and shockable OOHCA increased during the COVID-19 pandemic statewide and to a higher degree in the 5 high impact counties. Little change was noted in rates of bystander AED use, CPR, and witnessed arrests. EMS TOR rates increased while ETI rates decreased. ROSC rates decreased in the overall OOHCA group but were not significantly changed in shockable OOHCA. OOHCA involving the black race occurred more frequently. Further research is warranted to understand the causes of these observations.
Abstract 228: Evaluation of Telephone-Assisted Cardiopulmonary Resuscitation Performance Recommendations for Out-Of-Hospital Sudden Cardiac Arrest
Authors: Blewer Audrey L , Guerrero Angel , Leong Benjamin Sieu-Hon , Shahidah Binte Ahmad Nur , Pek Pin Pin , Joiner Anjni , Ng Yih Yng , Arulanandam Shalini , Ostbye Truls , Ong Marcus E
Published: November 2020

Introduction:
Telephone-assisted CPR (T-CPR) may improve bystander CPR (B-CPR) rates and survival from sudden cardiac arrest (SCA). The American Heart Association (AHA) has specified performance measures to ensure rapid provision of T-CPR instructions. Few studies have examined whether these individual T-CPR recommendations are associated with SCA outcomes.

Objectives:
We sought to assess whether the 2012 AHA Scientific Statement’s T-CPR evaluation metrics are associated with increased B-CPR and survival from SCA. We hypothesized that recognition of arrest and compliance with the T-CPR protocol will result in increased likelihood of B-CPR.

Methods:
We conducted a retrospective assessment of non-traumatic SCAs from the Singapore T-CPR Pan-Asian Resuscitation Outcomes Study. We modeled the likelihood of receipt of B-CPR and survival to hospital discharge controlling for potential confounders. Exposure variables were identified from the Scientific Statement including adherence to T-CPR algorithms, dispatcher recognition of need for CPR, barriers to CPR (yes/no), and time intervals.

Results:
From 7/2012-2016, the Singapore T-CPR registry contained 3,224 adjudicated SCA events. Mean age was 67±19, 62% of the patients were male, and 87% of the arrests occurred in the home; of these arrests, 75% received T-CPR and 4% survived to hospital discharge. Compliance with the T-CPR protocol algorithm was not associated with an increased likelihood of B-CPR and survival (p=ns, both). Dispatcher recognition of the need for CPR was associated with a 24.9 (12.9-47.9) increased likelihood of B-CPR p<0.01, but was not associated with survival (OR: 1.77(0.37-8.45)). Recognized barriers to CPR were associated with a lower likelihood of B-CPR and survival (p<0.05, both). B-CPR was associated with a 2.40 (1.04-5.45) increased likelihood of survival (p=0.04). Call time to dispatch of EMS of <2 min was associated with a 1.33 (1.07-1.67) p=0.01 increased likelihood of receipt of B-CPR.

Conclusion:
Rapid dispatch of EMS (<2 min) and successful recognition of need for CPR increased the likelihood of B-CPR. B-CPR was associated with a two-fold increased likelihood of survival. Future work should consider refining T-CPR evaluation metrics using a data driven approach.
Abstract 230: Bystander Cardio Pulmonary Resuscitation Quality: Potential for Improvements in Cardiac Arrest Resuscitation
Authors: Chocron Richard , Jobe Julia , Kim Madeleine , Guan Sally , Fahrenbruch Carol , Shigemura Mia , Rea Thomas
Published: November 2020

Background:
Bystander cardiopulmonary resuscitation (CPR) is a critical intervention to improve survival following out-of-hospital cardiac arrest (OHCA). We evaluated the quality of bystander CPR and whether performance varied according to the number of bystanders or provision of telecommunicator assistance (TCPR) to identify opportunities to improve care.

Methods:
We conducted a cohort investigation of non-traumatic cardiac arrest occurring in a large metropolitan EMS system during a 6-month period. Information about bystander care was ascertained through review of the 9-1-1 recordings in addition to EMS and hospital information to determine bystander CPR status (none vs TCPR vs unassisted), the number of bystanders on-scene, and CPR performance metrics of compression fraction and compression rate.

Results:
Of the 428 eligible OHCA, average age was 62.9 years (+/- 16.6), 31.5% (n=135) were female, and 76.4% (n=327) received bystander CPR. Of those receiving bystander CPR, 43.7% (n=143) received unassisted CPR and 56.3% (n=184) involved TCPR; 35.2% (N=115) had one bystander, 33.3% (N=109) had 2 bystanders, and 31.5% (n=103) had 3 or more bystanders. Overall CPR fraction was 59% with a compression rate of 88 per minute. CPR differed according to TCPR status (compression fraction=52% and rate=87 per minute for TCPR vs 69% and 102 for unassisted CPR, p<0.05 for each comparison) and the number of bystanders (compression fraction=55% and rate=87 per minute for 1 bystander, 59% and 89 for 2 bystanders, 65% and 97 for >=3 bystanders, test for trend p<0.05 for each metric). Additional bystander actions were uncommon to include rotation of compressors (3.1%) or application of an AED (8.0%).

Conclusion:
Overall bystander CPR quality as gauged by fraction and compression rate approached guideline goals though performance depended upon the type of CPR and number of bystanders. The findings suggest opportunities for how CPR quality and early defibrillation may be improved.
Abstract 237: Curriculum Development of Pitt Bystander Response Education: Developing "Caring Leaders" Through Early Exposure to Cpr Fundamentals
Authors: Hacker Emily , Ahrendt Gillian , Mitzner Jackson , Callaway Clifton W , Doshi Ankur A
Published: November 2020

Introduction:
Fewer than 25% of US adults feel trained in bystander CPR (bCPR). Barriers include the lack of social acceptance of bCPR, poor understanding of Good Samaritan laws, and inadequate knowledge of the steps needed to help a patient suffering out-of-hospital cardiac arrest.

Hypothesis:
We developed a novel, streamlined curriculum for children ages 11-13 to introduce the principles of bCPR and frame it as a shared social responsibility, hoping to increase bystander response and motivate young citizens to seek future CPR certification.

Methods:
The curriculum development process employed the Assess Design Develop Implement Evaluate (ADDIE) method of the Instructional System Design (ISD) model. We used an iterative approach where the novel curriculum was developed and then presented to stakeholders for review, editing and revision. Stakeholders included experts in CPR training, educational theory and elementary/middle school education. Pre- and post- survey tools were designed to evaluate curriculum outcomes, using the same process. Upon completing the iterative review, the curriculum and surveys were prepared for a pilot implementation in a middle school setting.

Results:
Using the ISD approach, we consulted with 9 experts to design the CPR curriculum. Three curriculum goals were identified: awareness, social responsibility and training. The novel curriculum will meet these goals through a single 50 minute in-class session of didactic, technique demonstration of compression-only CPR, and hands-on practice with manikins. Due to the present global pandemic, the curriculum has not yet been implemented as planned. Current efforts are being made to determine the feasibility of potential future implementation of the program and/or virtual options due to need for social distancing.

Conclusions:
An iterative process can be used to bring together multiple stakeholders to design a novel, age appropriate CPR training curriculum. Another round of stakeholder review of the curriculum is planned post piloting prior to wider dissemination.
Abstract 243: Out-of-hospital Cardiac Arrest in the Outpatient Clinical Environment
Authors: Mitchell Oscar J , Wang Michael , Neefe Stacie , Lynch Michael , Schweickert William D , Shashaty Michael G , Abella Benjamin S
Published: November 2020

Background:
Out-of-hospital cardiac arrest (OHCA) remains a leading cause of death in the US, affecting over 400,000 annually. Although outcomes have improved, rates of return of spontaneous circulation (ROSC) and survival are lower from OHCA than from in-hospital cardiac arrest. Clinical emergencies, including OHCA, in outpatient clinical settings are often first attended by rapid response teams (RRT), but the causes and outcomes from OHCA in these environments has not been characterized. An understanding of this population is critical both for RRT quality improvement and resource allocation.

Objectives:
We aimed to describe OHCA that occurred in outpatient clinical environments. We hypothesized that OHCA in ambulatory settings would be uncommon and would be concentrated in a limited number of higher-risk outpatient areas.

Methods:
Retrospective analysis of all RRT calls for non-hospitalized adult outpatients occurring between 2012- 2020 at the Hospital of the University of Pennsylvania.

Results:
There were 7336 RRT calls;25 were for OHCA. Information was available for 24 of these. Mean age was 64 +/- 16.7 y, and 38% were female. Initial rhythm was pulseless electrical activity in 79%, ventricular fibrillation in 13%, asystole in 4%, and was not recorded in 4%. CPR was initiated in all cases prior to the arrival of the RRT. ROSC was obtained in 84%, extracorporeal membrane oxygenation (ECMO) was initiated in 8%, and 8% did not survive. ROSC was obtained within 5 min in 58% of cases. Of those that attained ROSC, 75% survived to discharge, 80% with good neurological status (CPC 1-2). Most events (54%) were judged to be iatrogenic. Of these, 54% were due to anaphylaxis, 15% were during cardiac stress testing, and 31% were peri-procedural. The most common causes of anaphylaxis were chemotherapeutics and radiographic contrast agents.

Conclusions:
OHCA events are uncommon in the outpatient clinical setting and are frequently iatrogenic. These events are associated with high rates of ROSC and neurologically intact survival. Iatrogenic OHCA occurred during a limited number of clinical settings, including outpatient procedural, , infusion, and stress test locations.. This finding suggests the need to focus resuscitation training in these specific environments.
Abstract 244: Preliminary Results on Angiotensin II as a Novel Vasopressor in Modeled Out-of-Hospital Cardiac Arrest and Cardiopulmonary Resuscitation
Authors: Neumann Tobias , Finke Simon-Richard , Assam Marlen , Emrich Jakob , Fuchs Alexander , Maul Alexandra C , Schroeder Daniel C , Annecke Thorsten
Published: November 2020

Introduction:
The PARAMEDIC2-trial reported a higher survival rate comparing standard epinephrine treatment with placebo, but severe neurologic impairment was found more often in patients who received epinephrine. Angiotensin II (AT2) has been recently authorized by FDA and EMA to treat distributive shock in adults. It is not approved as a vasopressor in the treatment of cardiac arrest (CA) and has not been studied in a standardized model of out-of hospital cardiac arrest with subsequent guideline-based cardiopulmonary resuscitation (CPR) before.

Hypothesis:
AT2 administration during CPR will 1. result in higher rates for return of spontaneous circulation (ROSC) after modeled out-of-hospital CA and 2. will achieve a greater increase in mean arterial blood pressure (MAP) compared to standard epinephrine bolus regimen.

Methods:
After legal approval (81-02.04.2019A072) and in conformance with the AHA position statement (Circulation 1985; 71:849A), we conducted a prospective, randomized trial in 25 swine weighing 32 to 43.5 kilogram bodyweight (kgBW) under general anesthesia. In 22 swine randomized to intervention groups i) EPI or ii) AT2, ventricular fibrillation was induced electrically and mechanical ventilation was discontinued. After 10 minutes (min) of untreated CA, ventilation was resumed and CPR was performed adapted to current guidelines for up to 56 min. After the third unsuccessful defibrillation (6 min CPR), swine received either i) boluses of epinephrine 0.01 mg/kgBW every 4 min or ii) an initial bolus of AT2 (25 μg/kgBW) followed by continuous infusion at 1 μg/kgBW/min. Three animals served as sham controls and received identical treatment but neither CA nor CPR.

Results:
ROSC was achieved in 7/22 swine and in 5/20 requiring vasopressors (EPI 1/10 vs. AT2 4/10, n. s.). The initial vasopressor bolus increased MAP significantly more in AT2 compared to EPI (p = 0.03). However, this could not be maintained under continuous infusion of AT2.

Conclusions:
For the first time, we have demonstrated the feasibility of successful guideline-based CPR using AT2 as sole vasopressor. But still, questions such as the optimal dosage remain. We strongly encourage larger trials to investigate this newly available drug also for the treatment of CA.
Abstract 247: Cardiac Arrest Management in Rural Prehospital Care
Authors: Peters Gregory A , Ordoobadi Alexander , Cash Rebecca E , Panchal Ashish
Published: November 2020

Introduction:
Rural prehospital care settings are underrepresented in the out-of-hospital cardiac arrest (OHCA) literature. We analyzed a nationwide database of emergency medical services (EMS) incidents in the US to describe treatment patterns and the odds of return of spontaneous circulation (ROSC) among rural OHCA patients.

Methods:
Using the 2018 National EMS Informational System dataset, we analyzed OHCA incidents where CPR provided by EMS was documented. We excluded incidents in which trauma was involved, patient age <18 years, transport was not by completed by an advanced life support unit, or response time >60 minutes. The primary outcome was ROSC during the EMS incident. Multivariable logistic regression was performed comparing rural, suburban, and urban settings while controlling for age and gender, incident location type, response time, CPR prior to EMS arrival, arrest witnessed by EMS, initial rhythm, epinephrine administration, mechanical CPR, and advanced airway used.

Results:
A total of 60,281 OHCA incidents were identified for inclusion, including 5,013 (8.6%) in rural settings. Rural OHCA patients achieved ROSC in 28.8% of cases, compared to 33.0% in urban or suburban settings (p<0.001). Neither age nor gender significantly differed between settings (Table 1). Rural OHCA incidents had greater response times (7.5 vs. 5.9 minutes, p<0.001) and were less likely to receive epinephrine (71.6% vs. 74.9%, p<0.001). Further, EMS were more likely to use mechanical CPR (29.8% vs. 28.1%, p=0.01) and less likely to provide an advanced airway (56.3% vs. 50.5%, p<0.001) for rural OHCA. On multivariable logistic regression, rural OHCA patients had lower odds of achieving ROSC than urban OHCA patients after controlling for other factors (0.80, 95%CI: 0.75-0.86).

Conclusion:
In this national sample of EMS-treated OHCA, rural patients were less likely to achieve ROSC than patients in urban or suburban settings.
Abstract 249: Association of Diastolic Blood Pressure and Myocardial Perfusion Pressure with Survival During Pediatric Cardiopulmonary Resuscitation
Authors: Sorcher Jill L , Shaffner Donald H , OBrien Caitlin
Published: November 2020

Introduction:
Myocardial perfusion pressure (MPP), defined as the aortic diastolic pressure minus the central venous diastolic pressure, is an important determinant of return of spontaneous circulation (ROSC) in cardiac arrest. However, measuring MPP requires both arterial and venous catheters and is often not possible. When only invasive arterial monitoring is available, diastolic blood pressure (DBP) is suggested as a surrogate for MPP during resuscitation and is also associated with survival after cardiac arrest.

Hypothesis:
We hypothesized that DBP measured during chest compression delivery would mirror MPP during resuscitation and both would be associated with survival.

Methods:
We performed a retrospective, secondary analysis of 102 swine resuscitations. Pediatric swine underwent asphyxial cardiac arrest and were resuscitated with predefined periods of basic and advanced life support (BLS and ALS). MPP and DBP were recorded every 30 s during chest compression delivery.

Results:
For both survivors and non-survivors, DBP mirrored MPP throughout resuscitation (
Figure 1A, B
). During BLS, both MPP and DBP were significantly greater in survivors (MPP: 8.5 0.6 vs. 1.1 0.5 mmHg;
p
< 0.0001; DBP 17.3 0.6 vs. 8.7 0.5 mmHg;
p
< 0.0001). During ALS, MPP and DBP were greater in survivors than non-survivors (MPP: 20.5 1.0 vs. 0.7 0.3 mmHg;
p
< 0.0001; DBP 32.3 0.9 vs. 8.8 0.2 mmHg;
p
< 0.0001). During ALS, the magnitude of change in both MPP and DBP after the first epinephrine administration in survivors was greater than in non-survivors (MPP: 24.4 3.3 vs. 4.8 0.9 mmHg;
p
< 0.0001; DBP: 24.5 3.1 vs. 5.4 0.8 mmHg;
p
< 0.0001).

Conclusion:
These observations confirm that both DBP and MPP are associated with survival in cardiac arrest and validate the use of DBP as a surrogate for MPP.

Figure 1:
Myocardial perfusion pressure (MPP) and diastolic blood pressure (DBP) during BLS and ALS in survivors (A) and non-survivors (B). Arrows indicate administration of epinephrine during ALS.
Abstract 252: Resuscitation in Prehospital Stage: Effectiveness and Influencing Factors
Authors: Abula Anita , Maca Aija , Kalejs Oskars
Published: November 2020

Background:
Sudden cardiac arrest or sudden cardiac death is one of the leading causes of death all over the world. Of particular importance is out-of-hospital cardiac arrest (OHCA) - an important overworld public health issue. In order to help these people and improve their chances of survival, it is necessary to provide assistance as soon as possible. Bystanders are usually non-medical persons why it is more complicated to implement. The objectives of the study were to research effectiveness and influencing factors of resuscitation in prehospital stage and create suggestions and methodical recommendations as possible.

Materials and Methods:
A retrospective study was developed, which summarizes and analyzes the electronic call cards (IEK) of the Emergency Medical service of Latvia (EMS) for 2018 and 2019. IEK were selected that identified “successful resuscitation” and “unsuccessful resuscitation” as a complication of diagnosis (classification developed and validated by EMS of Latvia).

Results:
Overall 2538 resuscitations were performed, of which 27,6% were successful resuscitation. About a quarter (24,2%) of all resuscitations happened in a public place. The increase in the number of successful resuscitations is observed for resuscitation events that happened in public places. In most of cardiac arrest cases, bystanders did not perform CPR (60,3%). Arrival time of EMS in 2018 was 7,52 - 8,44 minutes and in 2019 was 7,75 - 8,23 minutes. The research shows that approximately 23% of cases the first monitored rhythm by EMS were VF/pVT. There is a significant difference in the increase in successful resuscitations if EMS performed defibrillation during the call.

Conclusions:
The most important influencing factors in the outcome of resuscitation are the patient’s age, the location, the first aid provided by bystanders, the time until the arrival of EMS and the first observed heart rhythm in a patient with cardiac arrest. It is necessary to create a register of AED (automated external defibrillator) devices in Latvia and their locations, to ensure the availability of data to the EMS service and the public.
Abstract 253: Trajectory of Ventricular Fibrillation Prognostic Status During Cardiopulmonary Resuscitation
Authors: Coult Jason , Bhandari Shiv , Sashidhar Diya , Rea Thomas , Blackwood Jennifer E , Kudenchuk Peter , Kwok Heemun
Published: November 2020

Background:
Resuscitation from out-of-hospital cardiac arrest (OHCA) due to ventricular fibrillation (VF) typically involves continuous CPR cycles interrupted every 2 minutes for rhythm analysis and potential defibrillation. Quantitative measures of the VF ECG waveform have been proposed to guide therapy for VF arrest because they are associated with myocardial energetics, are dynamic over the course of resuscitation, and predict outcome. However, while VF waveform measures have until recently have required CPR interruption to accurately gauge prognostic status, CPR interruptions are associated with a lower chance of survival. We used a novel waveform measure previously-validated during active CPR to estimate the course of VF status through the 2-minute CPR cycle between consecutive shocks.

Methods:
We conducted an observational study of patients with VF OHCA who experienced recurrent VF for at least 90 seconds following initial shock. We used the continuous defibrillator ECG to calculate the VF waveform measure as a function of predicted probability of survival-with-intact-neurologic-status at 1-s intervals over the course of resuscitation between shocks.

Results:
We collected 499 VF ECG segments (≥90 seconds) during CPR from 313 patients. The trajectory of the average prognostic VF measure had a 3-phase time-dependent pattern (Fig. 1). During CPR, the slope of the measure decreased during the initial 25 s of VF (slope = -12%/min) and was relatively flat during the subsequent 65-s interval of VF (slope = +1%/min). Furthermore, slope decreased sharply following the cessation of CPR for rhythm analysis, charge, and shock (slope = -23%/min).

Conclusion:
On average, a novel VF waveform measure assessed during the scheduled cycle of CPR and rhythm analysis between consecutive shocks was characterized by a period of decline, stabilization, and then decline. Whether these changes in VF status can be used to improve care for individual patients is uncertain.
Abstract 259: Outcomes of Targeted Temperature Management in Patients with Out-of-hospital Refractory Ventricular Fibrillation/ventricular Tachycardia Cardiac Arrest
Authors: Albrecht Kellen , Bartos Jason , Yannopoulos Demetris
Published: November 2020

Background:
Current guidelines recommend use of targeted temperature management (TTM) with goal between 32 and 36°C for all comatose adult patients with ROSC after cardiac arrest. However, refractory cardiac arrest with prolonged hypoperfusion, may cause passive cooling below goal temperature. The impact of this passive cooling and subsequent cooling strategies remains unknown. This study aims to describe the association between passive intra-arrest cooling and survival in patients suffering refractory VF/VT cardiac arrest treated with the University of Minnesota extracorporeal cardiopulmonary resuscitation (ECPR) protocol.

Methods:
Between December 2015 and October 2019, consecutive adult patients with refractory VF/VT arrest requiring ongoing CPR were transported by EMS to the CCL where ECPR, coronary angiography, and PCI were performed, as appropriate. TTM was initiated with goal temperature of 34°C unless clinically significant bleeding occurred, where a goal of 36°C was used. Patient and arrest characteristics, temperature data, and survival were collected retrospectively.

Results:
Data was gathered for 153 consecutive patients transferred for ECPR; 12 were excluded due to death in CCL prior to TTM. Of the remaining patients, 63 (41%) survived to discharge, where 55 (36%) had CPC scores of 1-2. Among deceased patients, 25 died from acute brain death while 47 died from other causes. Patients with CPC 1-2 had an initial temperature of 34.1°C versus 32.7°C in patients developing acute brain death (p=0.002). Survivors had shorter (p=0.0001) CPR time (52 minutes) versus deceased patients (65 minutes). If the initial temperature was below goal, patients were actively warmed to goal due to bleeding risk with ECPR. Survival to hospital discharge with CPC 1-2 was associated with lower peak warming rate compared with acute brain death (0.37°C/hr vs 0.69°C/hr; p=0.014)

Conclusions:
Survivors with CPC 1-2 after refractory VF/VT cardiac arrest and ECPR have preserved initial temperatures compared to more severe passive cooling in patients with acute brain death. This may be due to shorter duration of CPR. However, patients with acute brain death were noted to have higher peak rate of rewarming during TTM.
Abstract 263: The Relationship Between Time to Extracorporeal Cardiopulmonary Resuscitation and Coronary Reperfusion and Short-term Outcome in Out-of-hospital Cardiac Arrest Patients Due to Acute Coronary Syndrome
Authors: Kawakami Shoji , Tahara Yoshio , Noguchi Teruo , Inoue Shujiro , Yasuda Satoshi
Published: November 2020

Background:
In out-of-hospital cardiac arrest (OHCA) patients due to acute coronary syndrome (ACS), the association between time to extracorporeal cardiopulmonary resuscitation (ECPR) or coronary reperfusion and clinical outcome has yet to be well-known.

Methods:
Between June 2014 and 2017, we enrolled a total of 34,754 OHCA patients in multicenter, prospective fashion (JAAM-OHCA registry). Following exclusion criteria, 254 OHCA patients with underwent ECPR and emergent PCI were eligible for this study (59±12 years-old; 92% male). We investigated the association between call-to-ECPR or call-to-reperfusion and the survival at 30 days.

Results:
The survival patients were 85 (33%). Figure shows the numbers of patients according to call-to-ECPR interval. The call-to-ECPR interval and call-to-reperfusion interval in survival patients were significantly shorter than those in non-survival patients (51±16 vs 61±16 min, p<0.01; 123±50 vs 157±133 min, p=0.03, respectively). Receiver operating curve analysis indicated call-to-ECPR interval cutoff point of 46 min (area under the curve 0.70, sensitivity 48%, specificity 84%) and call-to-reperfusion interval cutoff point of 92 min (0.61, 37% and 81%, respectively) for predicting survival at 30 days. Multivariate logistic regression analysis revealed call-to-ECPR interval and call-to-reperfusion as the independent predictors of survival (OR 0.96, 95%CI 0.94-0.98, p<0.01; OR 1.00, 95%CI 0.99-1.00, p=0.03, respectively).

Conclusion:
The call-to-ECPR interval and call-to-reperfusion interval are independent predictors of survival at 30 days in OHCA patients due to ACS.
Abstract 265: Extracorporeal Cardiopulmonary Resuscitation for Acute Aortic Dissection During Cardiac Arrest: A Nationwide Retrospective Observational Study
Authors: Ogura Takayuki , Ohbe Hiroyuki , Yasunaga Hideo
Published: November 2020

Aim:
Acute aortic dissection has been considered a contraindication for extracorporeal cardiopulmonary resuscitation (ECPR). However, studies are lacking regarding the epidemiology and effectiveness of ECPR for this condition. We aimed to examine whether ECPR for acute aortic dissection during cardiac arrest is effective or not.

Methods:
Using the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2018, we identified all emergently hospitalized adults who received ECPR on the day of admission. ECPR was defined as receiving both chest compressions and percutaneous extracorporeal membrane oxygenation on the day of hospital admission. In-hospital mortality and neurological outcomes were compared between patients with and without acute aortic dissection. We also calculated the incremental cost-effectiveness ratio of ECPR for acute aortic dissection.

Results:
We identified 10,238 patients who received ECPR on the day of admission. Of these, 398 patients (3.9%) had acute aortic dissection. In-hospital mortality was 98% in the acute aortic dissection group and 79% in the non-acute aortic dissection group. Seven patients (1.8%) in the acute aortic dissection group survived to discharge after ECPR; of these, six patients had good neurological outcomes at discharge. The incremental cost-effectiveness ratio of ECPR for patients with acute aortic dissection was estimated at 159,337 US dollars per quality-adjusted life year gained.

Conclusion:
ECPR successfully rescued a small number of acute aortic dissection patients with cardiac arrest; however, the cost burden of ECPR for acute aortic dissection patients was unacceptably high.