bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 12069: Long-Term Trends in the Incidence and Outcome of Refractory and Non-Refractory Ventricular Fibrillation Cardiac Arrest
Authors: Nehme Ziad , Andrew Emily , Ball Jocasta , Smith Karen L
Published: December 2021

Introduction:
Although many developed countries are reporting temporal improvements in out-of-hospital cardiac arrest (OHCA) outcomes from initial shockable rhythms, trends in the incidence and outcome of refractory ventricular fibrillation are not well understood.

Methods:
Between 2010 and 2019, we performed a retrospective observational study of OHCA from a population-based registry in Victoria, Australia. We included all adult, non-traumatic OHCA with an initial shockable rhythm. Temporal trends in incidence and survival to hospital discharge were compared across non-refractory and refractory OHCA, defined as cases receiving 3 or more consecutive shocks for a persistent shockable rhythm. Risk-adjusted logistic regression models were used to describe the year-on-year change in the likelihood of refractory OHCA and survival to hospital discharge.

Results:
Of the 7,267 initial shockable OHCA with an attempted resuscitation, 4168 (57.4%) and 3,099 (42.6%) were non-refractory and refractory OHCA, respectively. The proportion of cases with refractory OHCA declined over the study period from 48.4% in 2010 to 40.2% in 2019 (p trend <0.001). Unadjusted survival to hospital discharge was higher in non-refractory OHCA (46.3% vs. 25.8%, p<0.001), although both populations experienced increases in survival over time (p trend <0.05 for both). After adjustment for arrest confounders, the likelihood of refractory VF decreased by 4.4% every year (adjusted odds ratio [AOR]: 0.96, 95% CI: 0.94, 0.97; p<0.001). Factors reducing the likelihood of refractory OHCA were female sex, bystander CPR, arrest witnessed by emergency medical services, and public location. In the survival model, refractory OHCA was independently associated with a reduction in survival to hospital discharge (AOR 0.50, 95% CI: 0.45, 0.56; p<0.001). Temporal improvements in survival were observed year-on-year (AOR 1.03, 95% CI: 1.02, 1.05; p<0.001) and this did not differ between non-refractory and refractory OHCA (group interaction, p = 0.51).

Conclusions:
The incidence of refractory OHCA is declining in our region and survival outcomes are improving. Further research identifying factors contributing to the decline in refractory OHCA may help to improve outcomes further.
Abstract 12097: The Impact of a High-Performance Cardiopulmonary Resuscitation Protocol on Survival From Out-of-Hospital Cardiac Arrests Witnessed by Paramedics
Authors: Nehme Ziad , Ball Jocasta , Villani Melanie , Stephenson Michael , Walker Tony , Stub Dion , Smith Karen L
Published: December 2021

Introduction:
Some emergency medical services (EMS) have shown increases in survival from out-of-hospital cardiac arrest (OHCA) following the implementation of a high-performance cardiopulmonary resuscitation (CPR) protocol. Despite this, little is known about the effect of high-performance CPR on OHCA witnessed by EMS personnel.

Methods:
We performed a retrospective cohort study of adult, EMS-witnessed OHCA patients of medical etiology from a population-based registry in Victoria, Australia. Patients treated after the introduction of a high-performance CPR protocol and training program between February 2019 and January 2020 were compared to historical controls between January 2015 and January 2019. The effect of the intervention on survival to hospital discharge was examined using logistic regression models adjusted for temporal and arrest factors.

Results:
A total of 1,561 and 420 EMS-witnessed OHCA patients were treated in the control and intervention periods, respectively. Baseline characteristics were similar across control and intervention periods, including the median age of cases (69 vs. 69 years, p=0.97), male sex (65.2% vs. 60.5%, p=0.08) and initial shockable arrests (33.7% vs. 29.3%, p=0.09). Resuscitation interventions were similar across groups, except for the use of mechanical CPR which declined during the intervention period (17.0% vs. 10.7%, p<0.001). Unadjusted survival to hospital discharge was similar across control and intervention periods for the overall population (29.4% vs. 32.1%, p=0.27), but significantly higher during the intervention period for initial shockable arrests (66.6% vs. 76.9%, p=0.03). After adjustment for confounders, cases in the intervention period were associated with a 43% increase (adjusted odds ratio [AOR] 1.43; 95% CI: 1.05, 1.94; p=0.02) in the risk-adjusted odds of survival to hospital discharge or a 79% increase (AOR 1.79, 95% CI: 1.09, 2.95; p=0.02) for initial shockable arrests.

Conclusions:
The implementation of a high-performance CPR quality improvement intervention was associated with significant improvement in survival from EMS witnessed OHCA. Efforts to monitor and improve CPR performance could yield further improvements in patient outcomes.
Abstract 12127: The Effect of Daylight Savings Time Transitions on the Incidence of Out-of-Hospital Cardiac Arrest: An Interrupted Time Series Analysis
Authors: Hook Jack , Smith Karen L , Andrew Emily , Ball Jocasta , Nehme Ziad
Published: December 2021

Introduction:
Many studies have reported increases in the risk of acute cardiovascular events following daylight savings time (DST) transitions. We sought to investigate the effect of DST transitions on the incidence of out-of-hospital cardiac arrest (OHCA) in Victoria, Australia.

Methods:
Between January 2000 and December 2020, we performed an interrupted time series analysis of the daily number of OHCA cases of medical etiology from the Victorian Ambulance Cardiac Arrest Registry. The effect of DST transition on OHCA incidence was estimated using negative binomial models and reported as either ‘immediate’ or ‘cumulative’ effects. Immediate effects were the average effects observed on the day of DST transition or each of the 6 days after DST transition. Cumulative effects were the sum of the average effects up to 6 days after the day of DST transition. Models were adjusted for population growth, temporal trends, and public holidays.

Results:
A total of 89,409 adult OHCA of medical etiology were included. Following the spring DST transition (i.e. shorter day), there was an immediate 13% (IRR 1.13, 95% CI: 1.02, 1.25; p=0.02) increased risk of OHCA on the day of transition (Sunday) and the cumulative risk of OHCA remained higher over the first 2 days (IRR 1.17, 95% CI: 1.02, 1.34; p=0.03) compared to non-transitional days. Following the autumn (fall) DST transition (i.e. longer day), there was a significant lagged effect on the Tuesday following transition, with a 12% (IRR 0.88, 95% CI: 0.77, 0.99; p=0.04) reduced risk of OHCA. The autumn (fall) DST transition also showed a cumulative effect on OHCA incidence, with a 30% (IRR 0.70, 95% CI: 0.51, 0.96; p=0.03) reduction in the incidence of OHCA by the end of the transitional week. Subgroups aged > 65 years and cases with initial non-shockable rhythms were most vulnerable to DST transitions.

Conclusions:
This study showed that there is a modest increased risk of OHCA in the 2 days following the spring DST transition and a decreased risk of OHCA in the week following the autumn DST transition. These findings should promote further research exploring strategies to reduce the risk of OHCA in vulnerable populations.
Abstract 12233: Comparing EMS Witnessed Cardiac Arrest in Germany and Norway
Authors: Tjelmeland Ingvild B , Kramer-johansen Jo , Gräsner Jan-Thorsten , Seewald Stephan
Published: December 2021

Introduction:
Health registries are a unique source of information about current practice and can describe the burden of disease in a population. However, comparing data from different countries/states we are not always sure if we are comparing patients from similar populations.

Method:
The aim of this study was to gain a better understanding of the information in the German Resuscitation Registry (GRR) and the Norwegian Cardiac Arrest Registry (NorCAR) through a cross-sectional comparative-study of these two population-based public registries. We included all out-of-hospital cardiac arrest patients witnessed by ambulance personnel, between 1
st
January 2015 and 31
st
December 2019. Proportions were assessed with Chi-square tests.

Results:
A total of 3,688 cases from Germany and 2,016 cases from Norway were included in the analysis, resulting in an incidence of 8.6 ambulance witnessed cardiac arrests per 100,000 inhabitants in Germany and 7.8 in Norway. A higher proportion of patients had resuscitation terminated on scene in Norway, 43% vs 30% (p<0.01), while the proportion of patients arriving to hospital with spontaneous circulation was higher in Germany, 49% vs 40% (p<0.01). However, 24-hour survival and the overall survival was higher in Norway, with 24-hour survival of 36% vs 31% (p<0.01), and the overall survival of 28% vs 19% (p<0.01).

Conclusion:
The incidence of cardiac arrests observed by ambulance personnel was higher in Germany, but survival was higher in Norway. We speculate that the major difference between countries is in the post-resuscitation care after admission to hospital.
Abstract 12349: Rehabilitation Reduces Depression After Cardiac Arrest
Authors: Flickinger Katharyn L , Repine Melissa , Deliman Kara , Skidmore Elizabeth R , Rittenberger Jon , Ledyard Jonathan D , Frisch Adam N , CALLAWAY Clifton W , Elmer Jonathan
Published: December 2021

Introduction:
Over 70,000 Americans are discharged from the hospital after surviving cardiac arrest (CA) each year. CA survivors experience depressive symptoms that adversely affect quality of life. Exercise, facilitated through cardiac rehabilitation (CR), improves mood after traumatic brain injury. CR is inconsistently offered to CA survivors but may improve recovery.

Aims:
Determine if: 1) CA survivors receiving CR have less severe depressive symptoms than CA survivors who do not receive CR, and 2) CA survivors receiving CR have less severe depressive symptoms after CR than before.

Methods:
Chart review including CA survivors between 2016-2019 who received CR or were enrolled in the control arm of a randomized trial in which depression was assessed prospectively. Demographic and cardiac arrest characteristics were recorded for all patients. The Patient Health Questionnaire (PHQ-9) used to quantify depressive symptoms in CR participants at the beginning and end of 12-36 sessions of CR. PHQ-9 was also assessed 6 months after hospital discharge in control subjects. We compared PHQ-9 within and between groups using t-tests.

Results:
We included 25 patients (15 male), with mean age 54 (SD 17) years, 16 of whom CR and 9 of whom were enrolled in the trial’s control arm. In patients who received CR, PHQ-9 score decreased from a mean of 5 (SD 5) before CR to mean of 1 (SD 1) after CR [difference -4 (95% CI -4 to -1; p=0.01)]. Among patients who received CR, mean PHQ-9 after CR was lower than that of controls 6 months after discharge [control group mean 6 (SD 5); difference -5 (95% CI -9 to -2; p=0.001)].

Conclusions:
CR may improve depressive symptoms in CA survivors. Future studies should investigate other benefits, dose-response and optimal timing of CR.
Abstract 12356: Prevalence and Patterns of Injury Detected by Head-to-Pelvis Sudden Death Computed Tomography Following Cardiopulmonary Resuscitation
Authors: Karatasakis Aris , Sarikaya Basar , Liu Linda , Gunn Martin , Kudenchuk Peter J , Gatewood Medley , Sayre Michael R , Counts Catherine , Carlbom David , Edwards Rachel M , Branch Kelley R
Published: December 2021

Introduction:
Patients resuscitated from out-of-hospital cardiac arrest (OHCA) frequently have skeletal and visceral injuries identifiable by computed tomography, although the prevalence, types of injury, and potential effects on clinical outcomes are poorly characterized.

Methods:
We assessed the prevalence of resuscitation-attributable injury in a prospective, observational diagnostic utility study of a head-to-pelvis sudden death computed tomography (SDCT) protocol after successful resuscitation from OHCA. SDCT was performed within six hours of arrival at two academic medical centers. CT data were independently analyzed by two blinded radiologists. Primary outcomes included total injuries and time-critical injuries (such as organ laceration). Exploratory outcomes were clinical associations with injury and survival to discharge.

Results:
Among 104 patients with OHCA (mean age 56 ± 15 years, 31% female), 59% of events were witnessed and 60% had bystander CPR. Initial rhythms were pulseless electrical activity (38%), ventricular tachycardia/fibrillation (29%), and asystole/unknown (33%). Mean CPR time was 15.4 ± 10.6 minutes; mechanical chest compression systems were used in 27% of cases. The prevalence of injury was high (80%; Table), including 19 patients (18%) with time-critical findings. Compared to patients without injury, patients with injury had numerically lower BMI (24.2 ± 7.7 vs. 26.7 ± 8.0), higher use of mechanical CPR (29% vs. 19%), longer CPR time (16.1 ± 11.0 vs. 12.3 ± 8.5 min), and lower survival to discharge (40% vs. 52%), although none were significant (p= NS for all).

Conclusion:
In patients resuscitated from OHCA, head-to-pelvis SDCT identified injury in most patients, with nearly one in five with time-critical findings and nearly one half with extensive ribcage injuries that may affect ventilation. These data suggest that SDCT has additional diagnostic utility and treatment implications beyond evaluating causes of OHCA.
Abstract 12464: Signs of Life as a Predictor of Survival in Patients With Out-of-Hospital Cardiac Arrest and Long Low-Flow Times
Authors: Moerk Sivagowry , Stengaard Carsten , Boetker Morten Thingemann , christensen steffen , Tang Mariann , Terkelsen Christian J
Published: December 2021

Introduction:
Long low-flow times in patients with out-of-hospital cardiac arrest (OHCA) are associated with poor outcome. Signs of life during cardiopulmonary resuscitation (CPR) is a simple method to evaluate in the field, but little is known about its impact on survival in patients with long low-flow times.

Hypothesis:
Thirty-day survival in OHCA patients with long prehospital low-flow times is higher in patients with signs of life during CPR than in patients with no signs of life during CPR.

Methods:
Observational, retrospective, single center study of OHCA patients referred to a tertiary cardiac arrest center in the Central Demark Region from 2015-2018. Risk factors were assessed by univariate logistic regression. Comparisons were made by Kaplan-Meier survival curves and log-rank test.

Results:
In a cohort of 807 patients with OHCA, 30-day survival was seen in 364 (45%). Among patients discharged from hospital, favorable neurological outcome with CPC 1-2 was observed in 93%. Signs of life during CPR was present in 315 (39%) patients. Risk of 30-day mortality was significantly reduced in patients presenting signs of life during CPR (RR 0.25, 95% CI [0.20-0.30]). Poor survival was seen in patients with low-flow times exceeding 30 minutes compared to patients with shorter low-flow times, (11% versus 66%, p < 0.001). In patients with low-flow times > 30 min, the survival rate increased to 33 % in the presence of signs of life during CPR compared to only 3% in patients without signs of life during CPR, p < 0.001.

Conclusions:
In OHCA patients, low-flow times > 30 minutes were highly associated with poor survival, however signs of life during CPR predicts higher survival both in the overall population and in patients with long low-flow times. Thus, resuscitation efforts may not be futile in patients with long low-flow times presenting signs of life during CPR.
Abstract 12494: The Disparities of Gender-Based Out of Hospital Cardiac Arrest Characteristics and Outcomes: Comparing Rural to Urban Vancouver Island
Authors: Al Assil Rahaf
Published: December 2021

Introduction:
The relationship between the “chain of survival” metrics of Out of Hospital Cardiac Arrest (OHCA) and survival rates in rural settings has not been fully examined. In previous studies, low survival rate was attributable to the modifiable prehospital metrics and Return Of Spontaneous Circulation (ROSC). We sought to examine the association of the modifiable and non-modifiable OHCA characteristics and patient outcomes with rural settings.

Methods:
We did a post-hoc analyses of data from the British Columbia cardiac arrest registry, which enrolled all emergency medical system (EMS)-treated OHCAs. All non-EMS-witnessed OHCAs on Vancouver Island from Jan. 2019 to Oct. 2020 were included. The independent variable of interest was rural versus urban settings. Rural areas were defined as all areas outside the urban clusters (population ≥ 1000 and a population density of ≥ 400/km2). Our outcomes were 1. Post resuscitation ROSC, and 2. Survival to hospital discharge. We reported gender-mediated measures and adjusted odds ratios using logistic regression models.

Results:
We included 1172 OHCA patients, with 23% in rural settings, 33% Female, 30% had ROSC, and 23% survived to hospital discharge. The median EMS response time, from 911-call to first EMS arrival, was prolonged [10.5 mins (IQR 7.5-15)] in rural settings compared to urban settings [6.5 mins (IQR 5-9)]
(p value<.001)
. Among females, rural settings were associated with higher odds of bystander CPR compared to males [(OR 1.86; 95% CI 1.04-3.35), (OR 1.42; 95% CI 0.95-2.13)], respectively. After adjusting for all covariates, rural settings were associated with lower odds of ROSC among males compared to females [(OR 0.53; 95% CI 0.31-0.90), (OR 0.70; 95% CI 0.34-1.41)], respectively; however, not associated with survival to hospital discharge.

Conclusions:
There are significant disparities in the modifiable prehospital OHCA characteristics, and post resuscitation ROSC between rural and urban Vancouver Island. An officially integrated rural CPR community-based program, and innovations focused on gender-based implementation may significantly improve OHCA survival rates and subsequent prognostication.
Abstract 12497: Long Transport Distances to a Tertiary Cardiac Arrest Center Does Not Affect Survival in Patients With Out-of-Hospital Cardiac Arrest
Authors: Moerk Sivagowry , Stengaard Carsten , Boetker Morten Thingemann , christensen steffen , Tang Mariann , Terkelsen Christian J
Published: December 2021

Introduction:
Patients with out-of-hospital cardiac arrest (OHCA) are increasingly transported to tertiary cardiac arrest centers, when the arrest is presumed to be of cardiac origin. For some patients, centralization has led to longer transport distances to advanced care resulting in prolonged prehospital system delays, which may affect outcome.

Hypothesis:
Longer transport distance to center for patients with OHCA reduces 30-day survival.

Methods:
Central Denmark Region covers rural and urban areas of 13 000 square kilometers and has a population of approximately 1.3 million inhabitants. Aarhus University Hospital functions as the tertiary cardiac care hospital with access to 24/7 cardiac catherization service and extracorporeal cardiopulmonary resuscitation. Distance to center varies greatly among citizens in the region; with longest distance exceeding 170 km. This observational retrospective study included all patients with OHCA referred to Aarhus University Hospital from 2015 to 2018. Kaplan-Meier curves were conducted to evaluate association between distance and mortality. The odds of 30-day mortality were generated using logistic regression.

Results:
A total of 807 patients with OHCA were referred to center. Distance to center was < 25km (22%), 25 to 50km (40%), 50 to 100km (20%) and > 100km (18%), respectively. The median prehospital system delay from collapse to arrival at center was 70 minutes [IQR, 55-90 minutes]. Logistic regression did not demonstrate an association between 30-day mortality and increasing distance to center (distance < 25 km as reference, 25 to 50km: OR 0.83, 95% CI [0.58-1.20], 50 to 100km: OR 0.96, 95% CI [0.62-1.47] and >100km: OR 1.20, 95% CI [0.77-1.88]).

Conclusions:
In OHCA patients with long transport distances to a tertiary cardiac center, survival was similar in patients with short distance to center. Centralization of post cardiac care is feasible in the setting of long transport distances.
Abstract 12508: Nicotinamide Restores Tissue NAD
+
and Improves Mouse Survival After Cardiac Arrest
Authors: Zhu Xiangdong , Li Jing , Gasior Filip , Wang Huashan , Lin Shaoxia , JUSTICE CODY , Odonnell J Michael , Vanden Hoek Terry L
Published: December 2021

Introduction:
Metabolic suppression in the ischemic heart is characterized by NAD
+
depletion. How nicotinamide (NAM) supplementation affects NAD
+
repletion and cardiac arrest outcomes is unknown.

Hypothesis:
We hypothesized that NAM supplementation restores tissue NAD
+
and promotes glucose oxidation and sorbitol clearance, resulting in improved cardiac function and survival in a mouse model of cardiac arrest.

Methods:
Adult C57BL6 mice were subjected to an established KCL-induced 8 min cardiac arrest, randomly assigned to receive saline (NS) or 100 mg/kg NAM during cardiopulmonary resuscitation (CPR). Survival, MAP, ETCO
2,
and ECG were monitored for 4 h after the return of spontaneous circulation (ROSC). Direct cardiac effects were assessed using a cardiomyocyte stunning model and an isolated rat heart Langendroff model to measure the contraction recovery and cardiac function, respectively. NAD
+
, lactate and ATP were measured by assay kits and AMPK phosphorylation was measured by Western blot.

Results:
Cardiomyocyte NAD
+
content decreased from 4.51 ± 0.03 nMol/g pre-ischemia to 2.69 ± 0.42 nMol/g at the end of ischemia. Treatment with 0.01 mM NAM completely restored the cellular level of NAD
+
and improved contractile recovery by 10 min reperfusion (58.1 ± 7.3% of baseline contractile velocity vs.18.5 ± 3.7% in control cells). NAM administered immediately after ROSC significantly improved mouse survival, with 10/10 survival at 4 h as compared to 5/10 in the NS group. NAM-treated mice displayed improved NAD
+
content in hearts obtained at 4 h post-ROSC compared to saline treated hearts (4.5 ± 0.1 nMol/g vs. 2.4 ± 0.1 nMol/g). NAM significantly reduced sorbitol accumulation in heart from saline control of 20.4 ± 2.7 μMol/g to 7.2 ± 1.5 μMol/g at 30 min post-ROSC, indicating less glucose shunting to polyol pathway. Cardiac contractile function was completely recovered with 1 mM NAM treatment in the isolated perfused rat heart. Compared with buffer control, NAM treatment increased heart content of NAD
+
, lactate, ATP and phosphorylated AMPK.

Conclusion:
NAM is efficacious for restoring cardiac NAD
+
and promotes metabolic and contractile recovery, with improved survival of cardiac arrest.
Abstract 12583: Low-Dose, High-Frequency Psychomotor CPR Skills Training Results in Improved and Sustained Performance of Optimal Adult/Child Ventilations in Fire-Based EMS Personnel
Authors: SLATTERY DAVID E , Hamilton Chase , Tran Khanhha , Singer Aaron
Published: December 2021

Background:
Hyper/over-ventilation (HOV) negatively effects cerebral blood and coronary artery flow during cardiac arrest. The resuscitation quality improvement (RQI) model of low-dose, high-frequency (LDHF) CPR training has been shown to improve CPR skills. Due to the deleterious impact of HOV on survival, our study seeks to determine if the RQI model improves ventilation skills for EMS personnel. We test the hypothesis that the RQI training results in improved and sustained ventilation performance.

Methods:
In 2014, our department transitioned from traditional BLS/ACLS training to the RQI model. Performance metrics are captured automatically for each rescuer on a quarterly basis using high-fidelity mannequins. Inclusion: All data from adult RQI attempts by EMS personnel from 2015-2019. Exclusion: attempts by non-EMS personnel. The 1 outcome measure is the overall mean (95% CI) ventilation score (composite measure, range 0-100, derived from average volume/rate and % with correct volume). The 2nd outcome measure is the proportion (95%CI) of rescuers with ventilation scores >90%. Data were extracted from RQI and analyzed with Prism statistical software. Comparisons for the 1 outcome was performed using one-way ANOVA and we report mean and 95% CI and proportions and 95% CI as appropriate.

Results:
During the study period, 740 personnel completed 1,490 ventilation activities in the baseline period and 5,077 in the subsequent years. The mean (95% CI) composite ventilation scores for the baseline was 84.10 (83.09,85.10) vs 2016 = 83.13 (82.17,84.09), 2017=88.79 (87.91,89.66), 2018=90.36 (89.45, 91.27), 2019= 88.59 (87.37, 89.81) for years 2016-2019; F= 41.36, R2=0.024, p value <0.0001. 10outcome: In the baseline RQI year, there were 55.3 % (95%CI= 52.8,57.8) participants with composite ventilation scores >/=90% vs. 2016= 53.5% (51.2,55.8), 2017=65.2%(62.6,68.6), 2018= 71.7%(69.1,74.3) and 2019=69.3%(66.1,72.2) in subsequent years.
Limitations:
Individual performance not reported, single agency.

Conclusions:
LDHF CPR training improves proper, and exceptional, ventilation performance in fire-based EMS personnel. Our results may be useful for other EMS agencies who are considering transitioning to LDHF training such as the RQI system.
Abstract 12789: Development of the Tool to EMPOwer Surrogate Decision Makers of Comatose Survivors of Cardiac Arrest
Authors: Perman Sarah M , Siry-Bove Bonnie J , Abella Benjamin , Daugherty Stacie L , Havranek Edward , Matlock Dan D
Published: December 2021

Introduction:
Surrogate decision makers (SDMs) for comatose survivors of cardiac arrest are often charged with making time-sensitive complex decisions with regard to life-sustaining therapies in a sudden critical illness. We describe the development of a decision aid for SDMs of comatose survivors of cardiac arrest.

Methods:
Applying recommendations from the International Patient Decision Aid Standards, we developed this decision aid iteratively with the purpose to educate families on post-arrest care and evidence based decision-making. We obtained feedback from stakeholders, including surrogate decision makers, patients, caregivers, nurses and physicians, in focus groups and semi-structured interviews.

Results:
Informed by interviews with SDMs and the AHA Guidelines, we designed a prototype of the decision aid. Each iteration resulted in a refined version of the aid (Figure). Step 1 included feedback from the Shared Decision-Making Core at the Adult and Child Consortium on Outcomes Research and Delivery Science (ACCORDS). Step 2 incorporated feedback from the ACCORDS Community Engagement Stakeholder group. Step 3 consisted of 10 semi-structured interviews with informal caregivers and patient pairs within the Advanced Heart Failure or Seniors clinics. The document was then reviewed by a team of expert cardiac arrest stakeholders. The aid includes key definitions, a timeline of post-arrest care, factors that support decisions to discontinue or pursue life sustaining therapies, commonly asked questions and an illustration of a patient undergoing post-arrest treatment. The decision aid, entitled
T
ool to
EMPO
wer (TEMPO) Surrogate Decision Makers, is written at a 7
th
grade reading level.

Conclusions:
Through a robust iterative process, we designed a decision aid for SDMs of comatose survivors of cardiac arrest. The aid is intended to support the decision to pursue or forego further life-sustaining therapy and to be informative about post-arrest care.
Abstract 12792: Enhancing the Accuracy of Cardiac Rhythm Analysis in Automated External Defibrillators During Ongoing Cardiopulmonary Resuscitation by Applying a Deep Encoder-Decoder Filtering Model
Authors: Hajeb Mohammadalipour Shirin , Cascella Alicia , Valentine Matt , Chon Ki
Published: December 2021

Survival from out-of-hospital cardiac arrests depends on an accurate defibrillatory shock decision during cardiopulmonary resuscitation (CPR). Since chest compressions induce severe motion artifact in the electrocardiogram (ECG), current automatic external defibrillators (AEDs) do not perform CPR during the rhythm analysis period. However, performing continuous CPR is vital and dramatically increases the chance of survival. Hence, we demonstrate a novel application of a deep convolutional neural network encoder-decoder (CNNED) method in suppressing CPR artifact in near real-time using only ECG data. The encoder portion of the CNNED uses the frequency and phase contents derived via time-varying spectral analysis to learn distinct features that are representative of both the ECG signal and CPR artifact. The decoder portion takes the results from the encoder and reconstructs what is perceived as the motion artifact removed ECG data. These procedures are done via multitude of training of CNNED using many different arrhythmia contaminated with CPR. In this study, CPR-contaminated ECGs were generated by combining clean ECG with CPR artifacts from 52 different performers. ECG data from CUDB, VFDB, and SDDB datasets which belong to the Physionet’s Physiobank archive were used to create the training set containing 89,984 14-second ECG segments. The performance of the proposed CNNED was evaluated on a separate test set comprising of 23,816 CPR-contaminated 14-second ECG segments from 458 subjects. The results were evaluated by two metrics: signal-to-noise ratio (SNR), and Defibtech’s AED rhythm analysis algorithm. CNNED resulted in the increase of the mean SNR value from -3 dB to 5.63 dB and 6.3 dB for shockable and non-shockable rhythms, respectively. Comparing Defibtech’s AED rhythm classifier before and after applying CNNED on the CPR-contaminated ECG, the specificity improved from 96.57% to 99.31% for normal sinus rhythm, and from 91.5% to 96.57% for other non-shockable rhythms. The sensitivity of shockable detection also increased from 67.68% to 87.76% for ventricular fibrillation, and from 62.71% to 81.27% for ventricular tachycardia. These results indicate continuous and accurate AED rhythm analysis without stoppage of CPR using only ECG data.
Abstract 12933: Myocardial Dysfunction After In-Hospital Cardiac Arrest in COVID-19 Patients
Authors: Bhardwaj Abhishek , Alwakeel Mahmoud , Dugar Siddharth , krishnan sudhir , Wang Xiaofeng , Duggal Abhijit , Abi Fadel Francois , Abella Benjamin
Published: December 2021

Introduction:
Post resuscitation myocardial dysfunction (PRMD) is common after out-of-hospital cardiac arrest. While PRMD is a known cause of post-resuscitation circulatory failure, few studies have reported associations between PRMD and neurologic outcome or survival. Further, little is known about PRMD after in-hospital cardiac arrest (IHCA) nor on the incidence and prognosis of PRMD in COVID-19 IHCA. We sought to evaluate the incidence of PRMD in a multicenter cohort of resuscitated COVID-19 IHCA patients.

Study Population and Methods:
We included adult patients (≥18 y) admitted to multiple hospitals of Cleveland Clinic Health System. Patients who attained ROSC with an initial echocardiogram (EC) in the 72 hours post-arrest were included. Data were extracted from a data registry and electronic medical records.

Results:
From 03/2020-10/2020, 58 patients with COVID-19 had IHCA. ROSC was noted in 35 patients (60.3%), 27 (46.6%) were alive at 24 h and 13 patients (22.4%) survived to hospital discharge. Of the 35 patients who had ROSC, 14 patients (40%) had an EC within 72 h. The median age of this cohort was 67 y (IQR 47 - 73); 71% were male, and median BMI of 28 (IQR 27 - 34), and admission APACHE II score was 13 (IQR 11 - 19). One third of the patients (36%) were mechanically ventilated before arrest and 43% were on vasopressors. Initial arrest rhythms were: PEA/Asystole, 79%; and VF/VT, 21%. Most patients (93%) received manual chest compression with median CPR duration of 5 min (IQR 2 - 10). The median time of obtaining first EC post-ROSC in these 14 patients was 22 hours (IQR 6 - 62). 7/14 (50%) of the patient had systolic dysfunction on initial EC (6 had global dysfunction, 1 with regional wall motion abnormality, and 4/7 had combined LV and RV systolic dysfunction). 5/14 patients had a follow up EC with a median time of 43 days. 2/5 had normal initial EC and 3 out of these 5 patients who initially had PMRD showed complete recovery in their LV and RV systolic function.

Conclusion:
We report a case series of PRMD in COVID-19 patients who experienced IHCA. We found that PMRD is seen in half of the patients. Most patients with PMRD recovered to normal RV and LV function, consistent with prior studies of non-COVID-19 arrest EC.
Abstract 12971: Positive Psychological Growth Post Cardiac Arrest Survivorship: A Pilot Study
Authors: AlQaqaa Rakan , Keshavarz Shirazi Tara , Jaffe Ian , Gonzales Anelly , Parnia Sam
Published: December 2021

Background:
Cardiac arrest (CA) has an annual US incidence of >500,000 with survival rates ~10%. Although most studies focus on survival and neurological outcomes, understanding long-term psychological consequences is of equal importance. Some have reported negative psychological outcomes such as anxiety, depression, and PTSD; however, since survivors of other adverse life-threatening disorders, including cancer, report positive psychological growth, we sought to test the hypothesis that CA survival may also be associated with growth of positive psychological traits.

Method:
Invitations were sent to CA survivors through their local hospitals or national registries to participate in an online pilot cross sectional study. Overall, 47 agreed and were given a series of standardized questionnaires to assess the following positive personality traits: empathy, compassion, forgiveness, altruism, optimism, gratitude, positivity, spirituality, consideration for others’ needs, and happiness. Using a 5-point Likert scale, they then estimated the relative change in these traits since their CA event, where 1=significant decrease, 2=moderate decrease, 3=no change, 4 =moderate increase, and 5=significant increase.

Results:
Overall 42 of 47 (89%) reported a return to their daily functional activities. Personality trait ratings were analyzed using a sign test relative to a population median score of 3 (i.e. no change) for statistical analysis. Participants showed statistically significant differences in all the assessed personality traits: gratitude (median=4, p<0.0001), compassion (median=4, p= p<0.0001), altruism (median=4, p<0.0001), empathy (median=4, p<0.0001), spirituality(median=4, p<0.0001), consideration for others’ needs (median=4, p<0.0001), forgiveness(median=4, p<0.0005), optimism (median=4, p<0.001), positivity (median=4, p<0.005), and happiness(median=4, p<0.05).

Conclusions:
Long-term psychological sequelae of CA survivorship remains ill understood. However, some CA survivors may develop greater positive psychological traits following CA. Further studies are required to assess the relationship between CA and long-term positive changes and quality of life, as well as possible therapeutic interventions.
Abstract 13076: Refractory Out-of-Hospital Cardiac Arrest in Patients With Pulmonary Embolism and Use of Extracorporeal Membrane Oxygenation: Prague OHCA Study Subanalysis
Authors: Pudil Jan , Smalcova Jana , Smid Ondrej , Rob Daniel , Hronova Michaela , Huptych Michal , Franek Ondrej , Kavalkova Petra , Milan Dusík , Belohlavek Jan
Published: December 2021

Introduction:
Refractory out-of-hospital cardiac arrest (r-OHCA) in patients with pulmonary embolism (PE) has poor outcome. Data about use of extracorporeal membrane oxygenation (ECMO) in PE are heterogenous and there is minimal evidence for its use in patients presenting with r-OHCA.

Hypothesis:
To describe in detail profile, initial settings of cardiac arrest (CA) and clinical course of patients with PE presenting with r-OHCA and its specifics in comparison to patients with r-OHCA of other cause. The special attention was paid to the use of ECMO and its potential benefit for patient prognosis.

Methods:
We reanalyzed subgroup of patients with PE from Prague OHCA study - a randomized control trial evaluating the effect of hyperinvasive approach including the use of ECMO in r-OHCA. Patients characteristics, the specifics of CA settings and the outcome were compared to the patients with other cause of r-OHCA. The neurologically favorable survival was then compared between PE patients randomized to Hyperinvasive and Standard arm of the study.

Results:
The PE was identified as a cause of CA in 24 (9.4 %) patients in Prague OHCA study. PE patients were more likely women (12 [50 %] vs 32 [13.8 %]) with non-shockable initial rhythm (23 [95.8 %] vs 77 [33.2 %]; P < 0.0001). The CA occurs more frequently after arrival of emergency medical service (14 [58.3 %], vs 22 [9.5 %]; P < 0.0001), had shorter time to hospital admission (median in minutes [IQR], 40 [34.5-57.8] vs 54 [46-64]; P = 0.01) with more severe acidosis at admission (median pH [IQR]; 6.83 [6.75-6.88] vs 6.98 [6.82-7.14] P = 0.0008). The primary outcome of patients with PE - CPC 1 or 2 at 180 days - was significantly worse (2 [8.3 %] vs 66 [28.4 %]; P = 0.049). There was non-significant difference in primary outcome - CPC 1 or 2 at 180 days - between PE patients in Hyperinvasive (12 [50%]) and Standard arm of the study (2 [16.7 %] vs 0; P = 0.24).

Conclusion:
The initial profile of patients and the settings of CA in patients with r-OHCA and PE differs from patients with other CA cause and their prognosis is significantly worse. The Hyperinvasive approach did not improved outcome in this subgroup of patients.
Abstract 13102: Outcomes of Primary and Secondary Pulseless Electrical Activity During In-Hospital Cardiac Arrest
Authors: Unneland Eirik , Norvik Anders , McGovern Shaun , Buckler David , Irusta Unai , Bhardwaj Abhishek , Aramendi Elisabete , Nordseth Trond , Abella Benjamin , Edelson Dana P , Kvaloy Jan Terje , Skogvoll Eirik
Published: December 2021

Background:
Pulseless Electrical Activity (PEA) is common during in-hospital cardiac arrest. We investigated the development of four types of PEA: PEA as presenting clinical state (primary) and PEA secondary to transient return of spontaneous circulation (ROSC), ventricular fibrillation/tachycardia (VF/VT), or asystole (ASY).

Methods:
We analyzed 660 episodes of cardiac arrest at one Norwegian and three U.S. hospitals. ECG, chest compressions and ventilations were recorded by defibrillators during CPR. Clinical states were annotated using a graphical application. We quantified the transition intensities from PEA to ROSC (i.e. the immediate probability of a transition), and the observed half-lives for the four types of PEA (i.e. how quickly PEA develops into another clinical state), using Aalen’s additive model for time-to-event data.

Results:
The transition intensities to ROSC from primary PEA (n=386) and secondary PEA after ASY (n=226) were about 0.08 per minute, peaking at 6 and 9 min, respectively (figure, left). Thus, an average patient in these types of PEA has about 8% chance to achieve ROSC in one minute. Much higher transition intensities to ROSC of about 0.20 per min were observed for secondary PEA after transient ROSC (n=209) or VF/VT (n=225), peaking at 10 and 5 min, respectively. Half-live times for the four types of PEA (figure, right) were 8.5 min, 6.8 min, 4.6 min and 1.6 min, for primary PEA, and secondary PEA after ASY, transient ROSC and VF/VT, respectively.

Discussion:
The observed clinical development of PEA in terms of intensity, peak intensity and half-lives during resuscitation differs substantially between the four types of PEA. The chance of obtaining ROSC is considerably lower in primary PEA or PEA after ASY, compared to PEA following transient ROSC or after VF/VT. This may increase understanding of the nature of PEA and the process leading to ROSC; and allow for simple prognostic assessments during a resuscitation attempt.
Abstract 13110: Novel Application of Thoracic Impedance to Characterize Ventilations During Cardiopulmonary Resuscitation in the Pragmatic Airway Resuscitation Trial
Authors: Nassal Michelle , Jaureguibeitia Xabier , Aramendi Elisabete , Irusta Unai , Panchal Ashish R , Wang Henry , Idris Ahamed
Published: December 2021

Introduction:
Controlled ventilation is important in OHCA resuscitation, but there are few validated methods for accurate detection of ventilations. We sought to utilize changes in thoracic impedance (TI) to characterize resuscitation ventilations in the Pragmatic Airway Resuscitation Trial (PART).

Methods:
We analyzed CPR process files collected from adult OHCA enrolled in PART. We limited the analysis to cases with simultaneous capnography ventilation recordings at the Dallas-Ft Worth site. We identified ventilation waveforms in the thoracic impedance signal by applying automated signal processing with adaptive filtering techniques to remove overlying artifacts from chest compressions. We correlated detected ventilations with the end-tidal capnography signal. We determined the amplitudes (Ai, Ae) and durations (Di, De) of both insufflation and exhalation phases of the ventilation impedance signal (Figure 1). We compared differences between laryngeal tube (LT) and endotracheal intubation (ETI) airway management during mechanical or manual chest compressions using Mann-Whitney U-test.

Results:
We included 303 CPR process cases in the analysis; 209 manual (77 ETI, 132 LT), 94 mechanical (41 ETI, 53 LT). Ventilation Ai and Ae were higher for ETI than LT in both manual (ETI: Ai 0.71Ω, Ae 0.70Ω vs LT: Ai 0.46Ω Ae 0.45Ω, p<0.01 respectively) and mechanical chest compressions (ETI: Ai 1.22Ω, Ae 1.14Ω VS LT: Ai 0.74Ω, Ae 0.68Ω, p<0.01 respectively). Ventilations per minute, duration of TI amplitude insufflation and exhalation did not differ among groups.

Conclusion:
Compared with LT, ETI thoracic impedance ventilation insufflation and exhalation amplitude were higher while duration did not differ. TI may provide a novel approach to characterizing ventilation during OHCA.
Abstract 13150: Racial/Ethnic Disparities of the Impact of the COVID-19 Pandemic Out-of-Hospital Cardiac Arrest (OHCA) in Texas
Authors: Chavez Summer , Huebinger Ryan , Schulz Kevin , Chan Hei Kit , Panczyk Micah , Villa Normandy W , Johnson Renee , Greenberg Robert , Vithalani Veer D , Bobrow Bentley
Published: December 2021

Introduction:
Prior research shows a greater disease burden, lower BCPR rates, and worse outcomes in Black and Hispanic patients after OHCA. The CDC has declared that the COVID-19 pandemic has disproportionately affected many racial and ethnic minority groups. However, the influence of the COVID-19 pandemic on OHCA incidence and outcomes in different races and ethnicities is unknown.

Purpose:
To describe racial/ethnic disparities in OHCA incidence, processes of care and outcomes in Texas during the COVID-19 pandemic.

Methods:
We used data from the Texas Cardiac Arrest Registry to Enhance Survival (CARES) comparing adult OHCA from the pre-pandemic period (March 11 - December 31, 2019) to the pandemic period (March 11- December 31, 2020). The racial and ethnic categories were White, Black, Hispanic or Other. Outcomes were rates of BCPR, AED use, sustained ROSC, prehospital termination of resuscitation (TOR), survival to hospital admission, survival to discharge and good neurological outcomes. We fit a mixed effect logistic regression model, with EMS agency designated as the random intercept to obtain aORs. We adjusted for the pandemic and other covariates.

Results:
A total of 8,070 OHCAs were included. The proportion of cardiac arrests increased for Blacks (903 to 1, 113, 24.9% to 25.5%) and Hispanics (935 to 1,221, 25.8% to 27.5%) and decreased for Whites (1 595 to 1,869, 44.0% to 42.1%) and Other (194 to 220, 5.4% to 5.0%) patients. Compared to Whites, Black (aOR = 0.73, 95% CI 0.65-0.82) and Hispanic patients (aOR = 0.78, 95% CI 0.68-0.87) were less likely to receive BCPR. Compared to Whites, Blacks were less likely to have sustained ROSC (aOR = 0.81, 95% CI 0.70-0.93%), with lower rates of survival to hospital admission (aOR = 0.87, 95% CI 0.75-1.0), and worse neurological outcomes (aOR = 0.45, 95% 0.28-0.73). Hispanics were less likely to have prehospital TOR compared to Whites (aOR = 0.86, 95% CI = 0.75-0.99). The Utstein bystander survival rate was worse for Blacks (aOR = 0.72, 95% CI 0.54-0.97) and Hispanics (aOR = 0.71, 95% 0.53-0.95) compared to Whites.

Conclusion:
Racial and ethnic disparities persisted during the COVID-19 pandemic in Texas.
Abstract 13228: Out-of-Hospital Cardiac Arrest Coverage by Volunteer Citizen Responders and Automated External Defibrillators in Denmark
Authors: Christensen Nanna B , Folke Fredrik , Jakobsen Louise Kollander , Jørgensen Anne J , Kjoelbye Julie , Gregers Mads Christian Tofte , Andelius Linn , Ringgren Kristian B , Torp-Petersen Christian , Hansen Carolina
Published: December 2021

Introduction:
High density of citizen responders (CR) and automated external defibrillators (AEDs) may increase chances for early bystander defibrillation in out-of-hospital cardiac arrest (OHCA). We aimed to assess coverage using current CR and AED positions applied on historical OHCAs in Denmark.

Methods:
Non-EMS witnessed OHCAs from the Danish cardiac arrest registry with known location (2016-2019) and AEDs registered with the Danish AED network (November 2020) were included. Locations of all CRs registered with the national CR program were identified (Wed, December 2, 2020) at 12pm (noon) and 12am (midnight). Since pilot data showed 25% of alerted CRs accepted the alarm, we investigated OHCA CR coverage defined ≥4 CR within <1800m (1969 yd), <500m (547 yd) and <200m (219 yd), and OHCA CR + AED coverage as ≥4 CR and 1 AED <1800m, <500m and <200m. We compared OHCA coverage during daytime and nighttime.

Results:
A total of 18,128 OHCAs (median age 73 years, 63.4% male) were included. A total of 22,418 AEDs (386/100,000 inhabitants) were available at 12pm, 65% were accessible 24/7. A total of 34,033 CR (586 CR/100,000 inhabitants) were available at 12am and 33,938 were available at12pm. During daytime, a median of 29 AEDs and 37 CRs were <1800m of historical OHCAs. Most OHCAs were covered by CRs and AEDs <1800m decreasing with shorter distances with little difference according to time of day (Figure 1).

Conclusion:
Following the implementation of a nationwide AED network and a citizen responder program, most historical OHCAs (85%) were < 1800m of CRs and AEDs at midnight with a slight decrease during daytime (82%). A decrease in CR and AED coverage were observed for 500m (59%) and 200 m (14%), with little difference according to time of day. During daytime a median of 29 AEDs and 37 CRs were < 1800m of historical OHCAs. Our results indicate successful implementation of a national AED registry and CR program with great potential for improving bystander defibrillation.