bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 323: Time to Specialized Prehospital Care and Neurologically Favorable Survival After Traumatic Out-Of-Hospital Cardiac Arrest: Results From a Japanese Registry-Based Study
Authors: Fukuda Tatsuma , Ohashi-Fukuda Naoko , Kondo Yutaka , Sekiguchi Hiroshi , Kukita Ichiro
Published: June 2021

Introduction:
Specialized care is essential for successful resuscitation after traumatic out-of-hospital cardiac arrest (OHCA). However, the effect of early specialized care by healthcare professional for traumatic OHCA in the prehospital setting is unknown.

Hypothesis:
We sought to determine whether time to specialized prehospital care by healthcare professional is associated with a neurological status after traumatic OHCA.

Methods:
This was a nationwide population-based study of traumatic OHCA based on data from the All-Japan Utstein Registry. We included patients who experienced traumatic OHCA in Japan from 2013 to 2016. The primary outcome was 1-month neurologically favorable survival.

Results:
A total of 8,470 patients were included. Among these patients, 50 (0.6%) survived with a favorable neurological status one month after OHCA. The median time to specialized prehospital care by healthcare professional was 9 minutes (IQR, 7-13; mean [SD], 10.7 [6.3] minutes). Longer time to specialized prehospital care was associated with a decreased chance of neurologically favorable survival: 2.6, 1.2, 0.9, 0.5, 0.2, and 0.0%, respectively, when time to specialized prehospital care was treated as a categorical variable categorized into ≤2, 3-5, 6-8, 9-11, 12-14, and ≥15 minutes (P for trend <0.0001), and multivariable-adjusted OR per minute delay 0.79 (95%CI 0.70-0.89, P<0.0001) when time to specialized prehospital care was treated as a linear and continuous variable. In subgroup analyses, longer time to specialized care was associated with a decreased chance of neurologically favorable survival when ALS was provided in the prehospital setting (adjusted OR 0.73, 95%CI 0.61-0.87, P=0.0007), especially when prehospital ALS was performed by physician (adjusted OR 0.72, 95%CI 0.56-0.93, P=0.0119), whereas there was no significant association between time to specialized care and neurologically favorable survival when only BLS was provided in the prehospital setting (adjusted OR 0.86, 95%CI 0.74-1.01, P=0.0734).

Conclusion:
In traumatic OHCA, delayed specialized prehospital care by healthcare professional was associated with a decreased chance of neurologically favorable survival, especially when a physician was involved in prehospital ALS.
Abstract 324: Effect of Prehospital Use of Plasma and Erythrocytes on Crystalloid and Blood Product Requirements in Trauma
Authors: Truhlar Anatolij , Berkova Jana , Koci Jaromir , Seneta Libor , Rehacek Vit
Published: June 2021

Introduction:
Recent studies demonstrated positive effects of blood products (BP) administration by helicopter emergency medical services (HEMS) to trauma patients but most of them were limited to specific cohorts (e.g. mixture of primary and secondary transports, long prehospital times, high prevalence of penetrating injuries, military use). This study aimed to assess implementation of prehospital use of BP into a regional trauma system treating predominantly blunt injuries (>95 %) and achieving short prehospital times (first emergency call to handover at trauma center ~60 min).

Methods:
A prospective observational study in patients treated with prehospital plasma (1 unit) followed by erythrocytes (1 unit) during the initial 7 months of the RABBIT trial (Rapid Administration of Blood by HEMS in Trauma, ClinicalTrials NCT03522636). The treatment group was compared to a historical cohort treated with massive transfusion protocol but no BP available prehospitally. It was hypothesized that early transfusion was associated with lower severity of coagulopathy and lower requirements for crystalloids and BP within 24 hours. Data analysis was performed using Prism 6.0 (GraphPad, La Jolla, USA).

Results:
Twenty patients treated with prehospital BP (Jun-Dec 2018) were compared to 24 patients in a control group (Jun-Dec 2017). There were no secondary transports. No differences were found between groups in age (47.0 ± 4.1 vs. 46.1 ± 3.7 years, p=0.87), ISS (33.5 ± 3.7 vs. 35.8 ± 3.4, p=0.65), prehospital time (60.9 ± 3.8 vs. 63.8 ± 3.6 min, p=0.59), fibrinogen (2.6 ± 0.2 vs. 2.5 ± 0.2 g/L, p=0.74) and lactate on admission to trauma center (4.5 ± 0.7 vs. 4.4 ± 0.7 mmol/L, p=0.94). The treated patients had better INR (1.1 ± 0.1 vs. 1.4 ± 0.1, p=0.028), and required 14.5 ± 1.7 units of BP in 24 hours compared to 21.42 ± 4.0 units in a control group (p=0,15). Prehospital and emergency department (ED) dose of crystalloids was reduced from 1696 ± 161 mL to 1088 ± 137 mL (p=0.006). No colloids were given at any time. There were no transfusion related complications.

Conclusion:
Prehospital use of plasma and erythrocytes in a setting with short prehospital times was associated with lower need for crystalloids, better INR at admission, and a trend towards lower consumption of BP in a trauma center.
Abstract 341: Effect of Guideline Changes on Drug Administration in Pediatric In-Hospital Cardiac Arrest
Authors: Ross Catherine E , Moskowitz Ari , Yankama Tuyen , Holmberg Mathias Johan J , Andersen Lars , Grossestreuer Anne V , O’Halloran Amanda , Kleinman Monica E , Donnino Michael
Published: June 2021

Introduction:
Updates to PALS include modifications to recommendations and pictorial algorithms surrounding intra-arrest drug administration. These include: bicarbonate, which had been an option for prolonged arrests, was changed in 2010 to recommend against routine use; lidocaine was removed from the pictorial algorithm in 2010 and reintroduced in 2015, at which time the recommendation changed from it being 2
nd
-line to being equivalent to amiodarone as 1
st
line; and atropine for which text was added in 2010 stating there was insufficient evidence to support or refute routine use in pulseless cardiac arrest. Understanding the effects of these changes may be important in future guideline development.

Hypotheses:
We hypothesized that use of bicarbonate, lidocaine and atropine would decrease after 2010, and use of lidocaine would increase after 2015.

Methods:
Index pulseless IHCA in children ≤18 years of age in the GWTG-R pediatric database between 2001 and 2017 were included. We performed interrupted time series analyses using segmented linear regression with GEE for each medication. Atropine was analyzed
post-hoc
.

Results:
A total of 4,806 index cases (698 shockable, 4108 non-shockable) were included. After 2010, bicarbonate had no changes in the intercept (-3.1% (95% CI, -7.5, 1.3%; p = 0.17) or slope (0.7% (95% CI, -1.0, 2.3%; p = 0.41). For lidocaine in shockable arrests there was no change in the intercept (-7.7%, 95% CI, -21.6, 6.1%; p = 0.27) or slope (-2.7%, (95% CI, -7.2, 1.8%; p = 0.24) in 2010 nor in 2015 (intercept: -0.2%; 95% CI, -32.1, 31.8%; p = 0.99; slope: -3.6%; 95% CI; -7.8, 15.0%; p = 0.53). For atropine, there was a 9.3% downward step change in the intercept (95% CI, 3.3-15.2%; p < 0.01) for all arrests and 11.7% (95% CI, 5.3-18.2%; p < 0.001) for initial PEA/asystole.

Conclusion:
Recommendation changes in the PALS text correlated with decreased use of atropine but not bicarbonate. This is especially interesting considering atropine had not previously been part of the PALS cardiac arrest algorithm. However, this update coincides with the removal of atropine from the ACLS PEA/asystole algorithm in 2010, which may have influenced some providers. Lidocaine use was not affected by changes to the pictorial algorithm nor by changes in the text.
Abstract 348: Laryngoscopy With Vallecula Blade Position is Associated With Higher Success in Tracheal Intubation for Critically Ill Children
Authors: Kharayat Priyanka , Nishisaki Akira , Laverriere Elizabeth , Donoghue Aaron
Published: June 2021

Introduction:
Classical teaching in pediatric laryngoscopy advocates the use of straight blades to be placed underneath the epiglottis, whereas curved blades are placed in the vallecula. Anesthesia studies suggest that straight blade positioning in the vallecula may be a satisfactory technique for small children. We sought to assess laryngoscope blade tip position during pediatric tracheal intubation (TI) and its association with intubation success.

Methods:
Observational single center study. Children undergoing TI from November 2017 until December 2018 in a pediatric emergency department (ED) and pediatric intensive care unit (PICU) using a CMAC video laryngoscope with recorded images available for review were eligible for inclusion. Patient and provider characteristics were obtained from quality improvement database. Each video was independently reviewed, and the blade tip position was determined by study personnel as ‘in vallecula’ or ‘under epiglottis’. TI success was defined as observation of the tube entering the trachea on video. Univariate analysis between blade tip position and success, as well as potential confounders, was performed by chi
2
testing. Multivariable logistic regression to determine the independent association between blade tip position and success while controlling for relevant confounders.

Results:
95 TI attempts were analysed. 58% of attempts were successful (14/35 in infants, 8/15 in 1-7 yr old, 33/45 in 8+ yr, p=0.01). Blade tip position was in the vallecula for 20/31 (65%) attempts with curved blades and 23/64 (36%) with straight blades. In univariate analysis, TI attempts with blade tip position ‘in vallecula’ were significantly more successful than attempts with ‘under epiglottis’ (37% vs. 84%, p<0.001). Median duration of laryngoscopy was 41 sec (IQR 27-59), not significantly different between two blade tip positions (p=0.06). After controlling for patient age and blade type (potential confounders), TI attempts with blade tip ‘in vallecula’ was independently associated with success (aOR 7.2, 95% CI 2.6 - 20.1).

Conclusion:
During pediatric TI, laryngoscope blade tip position in the vallecula was independently associated with success when compared with placement under the epiglottis.
Abstract 358: Three-Sided Chest Compression is Beneficial to Rats Suffering From Cardiac Arrest
Authors: Okuma Yu , Shinozaki Koichiro , Yagi Tsukasa , Saeki Kota , Yin Tai , Kim Junhwan , Becker Lance B
Published: June 2021

Objective:
Rat models are necessary to study targeted interventions to improve survivability in patients suffered from a cardiac arrest (CA). For translational researchers, increasing the rate of return of spontaneous circulation (ROSC) is important to reduce the number of rats being used to obtain sufficient data. Yet, few studies have demonstrated how to perform better chest compression on rats.

Methods:
Rats underwent 10 min of asphyxia to induce CA. All rats were placed in a supine position. Three types of chest compression were examined: 1-sided method (classic) with 2 fingers on the sternum; 2-sided method with 2 fingers on the chest from both sides; and the 3-sided method with 2 hands (2 fingers on the sternum and with 2 fingers on the chest). ROSC rates, cardiac function, arterial pressure(s), intrathoracic pressure, cerebral oxygenation, and end-tidal CO
2
(EtCO
2
) were measured. In addition, survival after 14-min asphyxia was assessed.

Results:
Male Sprague-Dawley rats were used and there were no differences in chest compression rates among the three groups. The ROSC rate was 100% (8/8) with the 3-sided method, 80% (4/5) with the 1-sided method, and 60% (3/5) with the 2-sided method. The 3-sided group showed significantly shorter time to ROSC (105.0±36.0 sec for the 1-sided method vs.141.0±21.7 sec for the 2-sided method vs. 57.8±12.3 sec for the 3-sided method, p<.05). The 3-sided method significantly increased the left ventricular stroke volume (the ratio of baseline: 1.2±0.6, 1.3±0.1, vs. 2.1±0.6, p<.05) and pressure (24.0±5.5, 19.8±3.4, vs. 29.4±1.8 mmHg, p<.05), the difference of common carotid arterial pressure to femoral artery pressure (4.0±2.5, 0.3±1.6, vs. 8.4±2.6 mmHg, p<.01), intrathoracic pressure (esophagus: 7.6±1.9, 7.3±2.8, vs. 12.7±2.2 mmHg, p<.01), cerebral oxygenation (the ratio of baseline: 1.4±0.1, 1.3±0.2, vs. 1.6±0.04, p<.05) and EtCO
2
(the ratio of baseline: 12.4±2.0, 14.2±1.9, vs. 17.5±1.7 mmHg, p<.05). The 3-sided chest compression achieved 75% (3/4) ROSC from 14-min asphyxia CA.

Conclusions:
The 3-sided chest compression was associated with the most successful ROSC. It is likely that the 3-sided method increased intrathoracic pressure and stabilized cardiac function, which might be beneficial to the brain.
Abstract 365: Percutaneous Ventricular Assist Devices Versus Intra Aortic Balloon Pump in Cardiogenic Shock
Authors: Janjua Muhammad Faisal Asad , Zubair Hafiz Muhammad , Shahbaz Amir
Published: June 2021

Introduction:
Cardiogenic shock (CS) is a condition of insufficient tissue perfusion due to cardiac dysfunction. Despite the improvement in prognosis due to aggressive reperfusion strategies, in-hospital mortality from CS is around 50%. Intra-aortic balloon pump (IABP) has been used for the management of CS. Percutaneous Ventricular Assist Devices (pVAD) such as the tandem heart and the Impella have been developed to treat CS. We carry out a meta-analysis comparing the IABP versus pVAD during CS.

Method:
Using PubMed, Cochrane Library, and EMBASE we searched for randomized clinical trials (RCTs) that compared pVAD versus IABP in patients CS.

Result:
We demonstrated no difference in short-term 30 days all-cause mortality (risk ratio [RR] 1.14 [CI: 0.70+/- 1.86]. The RR of acute kidney injury (AKI) for pVAD compared to IABP is 0.96 [CI: 0.46 +/- 2.00], for limb ischemia RR is 3.31 [CI: 1.04 +/- 10.51], for infection/sepsis 0.59 [CI: 0.19+/-1.80], for bleeding 2.41 [CI: 1.41+/- 4.13] and for vascular injury 3.75 [CI: 0.19 +/- 72.49]. Although pVAD provides superior hemodynamic support in patients with CS compared with IABP, the use of these more powerful devices did not improve early survival. The use of pVAD is associated with more adverse events compared with IABP.

Discussion:
The use of more vigorous hemodynamic support for CS does not associate with a 30 days survival benefit but could be associated with more adverse events. The reason for these findings is unclear but could be explained by the fact that decreased cardiac output seen in CS is only a single component of the multifaceted syndrome that involves several other molecular and hemodynamic mechanisms or merely because of the increase in the cardiac output by the IABP or the pVAD is inadequate to improve outcomes.

Conclusion:
Use of pVAD resulted in a better hemodynamic profile compared with IABP. However, this did not translate into improved 30-day survival. Also, patients treated with a pVAD have a higher risk of leg ischemia, AKI and, device-related bleeding.
Abstract 367: Ventricular Assist Device Association in Improving Outcomes in Patients Resuscitated From Out of Hospital Cardiac Arrest
Authors: Tram Julie , Pressman Andrew , Chen Nai-Wei , Berger David , Miller Joseph B , Welch Robert D , Reynolds Joshua C , PRIBBLE James M , Otero Ronny , SWOR Robert A
Published: June 2021

Introduction:
There has been continued debate and limited research on the efficacy of ventricular assist devices such as intra-aortic balloon pumps and Impella devices on improving survival outcomes in post cardiac arrest patients.

Objective:
The primary objective of this study is to assess whether the use of ventricular assist devices is associated with improved survival outcome in patients resuscitated from out-of-hospital cardiac arrest in Michigan.

Methods:
We matched cardiac arrest cases from 2014-2017 in the Michigan CARES Registry (CARES) and the Michigan Inpatient Database (MIDB) using probabilistic linkage. Ventricular assist devices (VAD) are defined as either Intra-aortic balloon pump (IABP) or Impella device identified using ICD-9 or 10 procedure codes. Multilevel, multivariable regression analyses were employed to evaluate the impact of device use on survival to hospital discharge, adjusting for variables normally predictive of cardiac arrest survival (age, location, witnessed, shockable rhythm).

Results:
A total of 3,790 CARES cases were matched with the MIDB of which 183 (4.8%) received IABP, 50 (1.3%) received impella devices, and 1,131 (29.8%) survived to hospital discharge. VAD use was associated with improved survival to discharge (OR=2.07, 95% CI 1.55, 2.77). IABP were used more frequently and associated with an improved outcome (OR=2.16, 95%CI 1.59, 2.93) compared to the Impella device (OR=1.72, 95% CI 0.96, 3.06). In a multivariable model, however, VAD use was no longer associated with an improved outcome (aOR =0.95, 95% CI 0.69, 1.31). In the subset of patients with a diagnosis of cardiogenic shock (n=725) we identified an improved survival to discharge with VAD use (OR= 1.84 95% CI 1.24, 2.73). IABP use was more frequent and associated with an improved outcome (OR=1.98, 95% CI 1.32, 2.98). After adjusting for patient characteristics, VAD use increased the odds of an improved outcome by 14% but was not statistically significant (aOR = 1.14, 95% CI 0.74, 1.77 ).

Conclusion:
Although limited by a low frequency of use, VAD or IABP alone was associated with improved outcome for post arrest care. However, in a multivariable analysis, VAD use was not associated with an independent improvement in post arrest survival.
Abstract 385: Family Presence During Resuscitation: A Needs Assessment
Authors: Tennyson Carolina
Published: June 2021

Introduction:
Evidence is mounting that appropriate family presence during resuscitation (FPDR) can be beneficial to patients and their families including lower rates of post-traumatic stress disorder after the event. Despite this, FPDR has not been widely adapted and continues to have legitimate barriers. Therefore, the focus of this quality improvement project was to conduct an organizational needs assessment at Duke University to create a systematic FPDR guideline that can be consistently implemented across the hospital.

Methods:
A 17-question survey tool was created using Ottowa Decision Making Framework and distributed to all members of a Cardiothoracic Intensive Care Unit code team including physicians, advanced practice providers, nurses, respiratory therapists, chaplains, perfusionists, pharmacists and social workers. The questions addressed FPDR experience, decision making influencers, situational comfort, and demographics.

Results:
There was a total of 200 responses. 46.6% Registered Nurses, 7.3% were Advanced Practice Providers, 7.8% Attending Physician, 6.2% Resident Physicians, 19.2% Respiratory therapists, 2.5% Chaplains. Four themes emerged - comfort based on experience, support for early chaplain involvement, need of family facilitator role, and absolute resistance. Multiple concerns were raised by the surveyed healthcare providers including logistics, risk for legal retribution, distraction from resuscitation, family suffering, and ill preparedness regarding FPDR. 72% of the respondents endorsed utilizing a family facilitator role to support the practice of FPDR. There was wariness regarding using the term ‘protocol’ for the guideline document.

Conclusions:
There are varying levels of comfort and support regarding the practice of FPDR amongst the resuscitation team. Many healthcare professionals acknowledge a need for family facilitation with a dedicated staff member, while others respond with a resolute unwillingness to practice FPDR. There is a need for education and publication of guidelines to assist staff in gaining consistency and confidence in the practice of FPDR.
Abstract 395: State-Level CPR Education Legislation Associated With Higher Survival After Out-Of-Hospital Cardiac Arrest in Older Adults
Authors: Buckler David G , Barnes Megan , Alexander Tyler D , Lang Marissa , Zebrowski Alexis M , Wiebe Douglas J , Abella Benjamin S , Carr Brendan G
Published: June 2021

Introduction:
State-level legislation requiring CPR education prior to high school graduation (CPR Legislation) is associated with an increased likelihood of community-level CPR training. CPR Legislation has also been shown to be associated with increased bystander CPR. We hypothesized that states with recent CPR Legislation would be associated with higher survival in older adults following out-of-hospital cardiac arrest (OHCA).

Methods:
Utilizing 2014 Medicare Claims data for emergency department (ED) visits and inpatient stays, we identified OHCA via ICD-9-CM code. CPR Legislation data was collected through online statute review. Exposure to CPR Legislation was assessed using the patient state of residence reported on the first claim. Patient dispositions were coded as home, SNF, death/hospice, rehab or other. All categories were considered survival to discharge except for death/hospice. Associations between categorical variables were assessed by chi-squared test. Multiple logistic regression was used to calculate the odds ratio associated with OHCA survival and CPR Legislation, controlling for patient age and sex.

Results:
In 2014, 256,277 OHCAs were identified. Mean age was 79 ±8 y, 48% were female, 23% were non-white, and survival to discharge was 22%. Prior to 2013, 4 states had passed CPR Legislation and 6 others passed legislation in 2013. These states account for 12% of OCHA for the study year. States that passed CPR Legislation in 2013 had the highest survival compared to states with earlier passage or no CPR Legislation (22.2% vs 20.6% vs. 21.8%, respectively, p < 0.001). Among those who survived to discharge, more patients were discharged home from states with 2013 CPR Legislation, than earlier or no legislation (50.8% vs. 41.3% vs. 42.8%, p <0.001). Results of the multiple logistic regression showed CPR Legislation passed in 2013 was associated with a 12% increase in the odds of survival to discharge compared to states with CPR Legislation prior to 2013 (OR: 1.12, p <0.001).

Conclusion:
States with CPR Legislation passed in 2013 were associated with higher survival to discharge and discharge to home, compared to earlier adopters and states with no legislation. Further work is needed to assess the mechanisms underlying this relationship.
Abstract 396: Successful Virtual Reality Cardiopulmonary Resuscitation Training in Schools: Digitally Linking a Physical Manikin to a Virtual Lifesaving Scenario
Authors: Gent Lana , Sarno David , Coppock Kent , Axelrod David M.
Published: June 2021

Introduction:
The AHA trains over 20 million people in CPR skills annually. Virtual Reality (VR) education may improve student engagement, but the efficacy of VR-CPR programs has not been adequately studied. We performed the largest study to-date evaluating the feasibility of VR-enhanced CPR training.

Hypothesis:
We hypothesized that an immersive, VR-enhanced CPR training program, digitally linked to a physical manikin, can teach middle/high-school students Hands-Only CPR skills resulting in strong learner engagement.

Methods:
We linked a VR-enhanced CPR training program to a standard manikin with an optical “time of flight” sensor and hand-tracking gloves. Based on AHA’s Hands-Only CPR protocol, training included compression rate (100-120/min), depth (2-2.4”), hand position, and full chest recoil, with 124 students from 3 middle/high-schools in Florida (n= 38) and California (n=42, n=44). Iterations to streamline the user experience were implemented for Pilots 2 and 3.

Results:
VR-enhanced CPR training significantly improved compression rate, depth, and hand position; chest recoil was not statistically changed. Post-training, students were tested on CPR knowledge: 78% (96/124) were correct on nature of cardiac arrest, 88% (109/124) on compression rate, and 83% (103/124) on compression depth. Of students with prior CPR training, 79% stated VR-CPR training was more effective than prior training. Iterations in Pilots 2 and 3 were associated with additional learning gains at those sites.

Conclusions:
In this first-of-its-kind study, middle/high school students learned Hands-Only CPR skills and knowledge with a VR-enhanced CPR training program digitally linked to a physical manikin. Our VR-CPR training uniquely separates each of 4 Hands-Only CPR skills into separate training modules in which students receive instant feedback. Future study and development of VR-CPR is warranted, especially as learning gains were associated with user experience iterations.
Abstract 416: Four Score Remains Effective Prognostic Tool in Cardiac Arrest After Eliminating Respiratory Component
Authors: Duskin Jonathan , Liang Stephanie , Dam Katie , Spears William , Suchdev Kushak , Greer David M
Published: June 2021

Introduction:
The FOUR (Full Outline of UnResponsiveness) score was developed as a more effective alternative to the Glasgow Coma Scale for prognostication of critically-ill neurology patients. Current research on the FOUR score in cardiac arrest is limited, but suggests that it may be useful. Given that whether or not a patient over-breathes the ventilator can often be confounded by the set respiratory rate, hypocarbia, and other factors, we evaluated the FOUR score with and without the respiratory component (FOUR-).

Methods:
We retrospectively studied 83 cardiac arrest patients treated at an urban hospital from 2011-2018 from the Multimodal outcome characterization in comatose cardiac arrest (MOCHA) registry. FOUR and FOUR- score within first 24 hours (day 1) and 72-96 hours (day 4) after arrest were evaluated for ability to predict in-hospital mortality and survival to discharge.

Results:
Day 1 FOUR score
<
4 had 78% (67%-87%) sensitivity and 57% (29%-82%) specificity, while FOUR- score
<
4 had 84% (73%-92%) sensitivity and 50% (23%-77%) specificity for predicting in-hospital mortality. Day 4 FOUR and FOUR- scores
<
4 had higher specificities (both 94% [71%-100%]) but lower sensitivities (63% [45%-79%] and 69% [51%-83%], respectively) for mortality than day 1. With outcome changed to survival to discharge, day 1 FOUR score
>
8 had 29% (8%-58%) sensitivity and 97% (90%-100%) specificity, while FOUR-
>
8 had 21% (5%-51%) sensitivity and 100% (95%-100%) specificity. Day 4 FOUR and FOUR- scores
>
8 had lower specificities (89% [73%-97%] and 91% [77%-98%], respectively), but higher sensitivities (53% [28%-77%]) and 47% [23%-72%], respectively) than day 1. There were no differences in mortality between FOUR and FOUR-
<
4 on day 1 (p=0.89) or 4 (p=0.95), and no differences in survival between FOUR and FOUR-
>
8 on day 1 (p=0.26) or 4 (p=0.85).

Conclusions:
Both the FOUR and FOUR- scores had high specificity for mortality and survival, which is important given that incorrectly predicting a bad outcome could lead to premature withdrawal of life support. The absence of a significant difference between the FOUR and FOUR- and the stronger prognostic ability of the FOUR- suggest that the respiratory component may not provide additional prognostic utility in cardiac arrest.
Abstract 421: Point of Care Ultrasound Sonography (POCUS) in Cardiac Arrest: Predicting Survivorship
Authors: Wong Ada , Patail Hassan , Ahmad Sahar
Published: June 2021

Introduction:
Survival after in hospital (IH) cardiac arrest (CA) is at 17% suggesting that CA represents an arena of medical practice which deserves more attention. Ultrasound (US) may have a role in both intra-arrest management and peri-arrest prognosis. Very little is known about the role of ultrasound for IH CA.

Hypothesis:
Intra- arrest POCUS can provide prognostic value.

Methods:
This was a single center, prospective observational study and we included all IH CA which occurred when a provider was available to perform a standardized POCUS protocol. US and echocardiography imaging was collected during the intra- arrest period and compared with outcome measures of return of spontaneous circulation (ROSC) and survival to 24 hours post-ROSC.

Results:
Echocardiographic features which may reflect survivorship include cardiac standstill, right ventricle (RV) blood flow stasis, and the appearance of thrombus formation at or around the tricuspid valve. 10 of 16 (62.50%) patients with cardiac standstill alone and 1 of 3 (33.33%) RV stasis alone did not achieve ROSC. Of those that did achieve ROSC in these two groups, none of the patients survived beyond 24 hours of the CA. 11 of 19 (57.89%) patients with RV stasis in combination with cardiac standstill did not achieve ROSC, and of the remaining 8 patients that achieved ROSC, only 1 patient survived past 24 hours. The combination of cardiac standstill, RV stasis, and tricuspid valve thrombus had 2 of 3 (66.67%) patients fail to achieve ROSC, with the remaining 1 patient surviving only to 24 hours. The presence of cardiac standstill alone confers an association with death, with an odds ratio (OR) of 1.212. RV stasis plus cardiac standstill on intra-arrest POCUS confer a markedly higher OR 0.8250 in association with death.

Conclusions:
Our preliminary work brings to light the role of POCUS for predicting short term survivorship based on echocardiographic patient features. This may have implications for resource utilization in such events.
Abstract 426: Factors Contributing to Out-Of-Hospital Cardiac Arrest Mortality Trends in the City of Detroit (2014-2018)
Authors: Mathew Shobi , Paxton James H , Reed Brian , Miller Joseph B , Klausner Howard , Dunne Robert , O’Neil Brian
Published: June 2021

Introduction:
Survival with good neurologic outcome following out-of-hospital cardiac arrest (OHCA) requires intensive post-ROSC care. In response to a recent decline in OHCA survival rates in Detroit, we conducted an analysis to identify factors contributing to this regression.

Methods:
CARES data from Detroit EMS transports were analyzed, including adult non-traumatic OHCA patients treated from 2014-2018 at four hospitals. Patient demographics, conditions of the arrest, and post-ROSC interventions including left heart catheterization, (LHC) and targeted temperature management, (TTM), were correlated to survival to hospital discharge and discharge with CPC 1 or 2. We calculated crude and adjusted survival rates across sites. Survival rates were adjusted for Utstein criteria using multilevel multi-variable regression analyses.

Results:
A total of 5,175 CARES patients were included. There was no difference in Utstein criteria between years, other than a small increase in the rate of witnessed arrest. We noted a steady decrease in LHC, and steady increase in TTM rate over the 5 years. There was a system-wide decrease in survival to hospital discharge during 2018, though the percentage of patients discharged with CPC 1 or 2 was similar. We found a strong, though insignificant, trend for LHC rate and survival: 0.72 (p = 0.1057), R
2
: 0.88, Adjusted R
2
: 0.76; and for survival with CPC 1 or 2: 0.59 (p = 0.5172), R
2
: 0.72, Adjusted R
2
: 0.44. In 2018, the rate of patients with LHC and good CPC nearly doubled.

Conclusion:
During the study period, we found a steady increase in TTM rate and concomitant decrease in LHC rate. The rate of LHC correlated best with survival to hospital discharge. In 2018, an increase in the proportion of patients with CPC 1 or 2 receiving LHC occurred, despite a decline in the overall rate of LHC.
Abstract 431: Initial Nutrition Status is Associated With Neurologic Outcome in Post Cardiac Arrest Patients
Authors: Cho Sumin , Park Eunjung , Lee Sungeun , Chae Minjung K
Published: June 2021

Background:
Poor nutrition is associated with mortality in critically ill patients. Also overweight BMI, low albumin is known to be associated with poor neurologic outcome in post cardiac arrest patients. We aimed to assess the association between initial nutritional status and poor neurologic outcome in post cardiac arrest patients.

Methods:
The nutrition support team(NST) initially assesse all patients admitted to the ICU in 24 hours of admission. All patients are screened for initial nutrition status with age, height, weight, laboratory results, signs of poor nutrition, nutrition risk comorbidities into consideration. We retrospectively analyzed the nutrition risk from the initial nutrition risk record assessed by NST and compared the nutrition risk between outcome groups. Furthermore, we did a multivariate logistic regression correcting for confounding variables to investigate the association between the initial nutrition risk and neurologic outcome.

Results:
High nutrition risk was associated with poor neurologic outcome (OR 3.03 [1.25-7.33], p=0.01) compared to the low nutritional risk group after adjusting for age, sex, CPR duration and initial shockable rhythm.

Conclusion:
High initial nutrition risk was associated with poor neurologic outcomes in our study.
Abstract 455: A Comparison of CPR Quality Using an Augmented Reality Application versus a Standard Audio-Visual Feedback Manikin
Authors: McGovern Shaun K , Balian Steve , Bhardwaj Abhishek , Abella Benjamin , Blewer Audrey L , Leary Marion
Published: June 2021

Background:
The provision of high-quality cardiopulmonary resuscitation (CPR) is a significant predictor of survival from cardiac arrest, yet healthcare provider (HCP) CPR quality is known to be poor. Although refresher CPR simulation training has been shown to improve HCP CPR quality, no studies have compared an immersive augmented reality (AR) application to a standard audio-visual feedback (AVF) manikin (Laerdal ResusciAnne) as a refresher training modality.

Objectives:
We randomized HCPs to refresher CPR simulation training with either a novel AR CPR training application (CPReality, Figure 1) or a validated AVF manikin; both cohorts completed a post-simulation CPR quality evaluation with no feedback immediately following the intervention. We sought to assess the efficacy of AR as a CPR simulation modality compared with an AVF manikin. We hypothesized that the AR application would confer similar skills to the AVF manikin.

Results:
We enrolled 100 experienced HCPs (e.g. RN, MD, APP) between 1/19-5/19. Mean chest compression (CC) rate for the AR application compared with the AVF manikin was 114±1 vs 121±3 cpm (p<0.01) and CC depth was 52±1 vs 48±1 mm (p<0.01), respectively. Post-simulation mean CC rate for the AR application compared with the AVF manikin was 122±15 vs 117±11 cpm (p=ns), depth was 52±8 vs 49±8 mm (p=ns), and percent with complete recoil was 92±24 vs 88±28 (p=ns), respectively. More AR simulation subjects agreed that the AR simulation provided a realistic patient presence compared to AVF simulation subjects (79% vs. 59%, p=0.07). The majority of CPReality simulation participants agreed or strongly agreed that they would want to use AR modalities for future CPR training (95%).

Conclusions:
In a post-test scenario, the AR CPR simulation training produced similar CPR quality as the standard AVF manikin in refreshing CPR skills in HCP. Further studies should explore the use of innovative technologies for CPR training.
Figure 1
. CPReality (CPReality).
Abstract 457: Comparison of Effect of Audio-Instructed and Video-Instructed Dispatcher-Assisted Cardiopulmonary Resuscitation on Resuscitation Outcomes After Out-Of-Hospital Cardiac Arrest
Authors: Lee Sun Young , Song Kyoung Jun , Shin Sang Do , Hong Ki Jeong , Jong Hwan Kim , Pak Jieun
Published: June 2021

Introduction:
This study aimed to compare the effect of audio-instructed dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) and video-instructed DA-CPR on resuscitation outcome after out-of-hospital cardiac arrest (OHCA) in the real world.

Methods:
A cross-sectional study was conducted for resuscitation-attempted adult OHCAs of 2017 in Seoul, Korea. Seoul implemented video-instructed DA-CPR program in 2017. According to the protocol, when dispatcher detected OHCA, they checked two condition: 1) more than two bystanders were in the scene, 2) they could handle a video-call. If both conditions were met, dispatcher initiated the CPR instruction and called back a video-call to the caller for instructing CPR via video (video group). Unless, standard audio-instructed DA-CPR was provided (audio group). The primary outcome was survival to discharge. The secondary outcome was good neurological outcome at hospital discharge. The tertiary outcome was early instruction time interval (ITI, time from call to the initiation of CPR instruction≤ 90 seconds). The study outcomes were compared between audio and video group. A multivariable logistic regression analysis was performed and adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were calculated adjusting for potential confounders. Propensity score matching (PSM) method was used to increase comparability of two groups and same logistic regression model was analyzed for the PSM population.

Results:
A total of 1,720 eligible OHCA cases (1,489 in audio and 231 in video group) were evaluated. The median seconds of ITI was 136 seconds in audio group and 122 seconds in the video group (p=0.12). Survival to discharge was 8.9% in audio group and 14.3% in video group (p<0.01). Good neurological outcome was 5.8% in audio group and 10.4% in video group (p<0.01). Compared with audio group, the AORs (95% CIs) for survival to discharge, good neurological outcome and early ITI of the video group were 1.20 (0.74 to 1.94), 1.28 (0.73 to 2.26) and 1.00 (0.70 t0 1.43), respectively. PSM population showed similar results with original population.

Conclusion:
Compared with audio-instructed DA-CPR, video-instructed DA-CPR was not associated with survival improvement in the observational study.
Abstract 464: Improvement in Return of Spontaneous Circulation With a Cardiac Arrest Video Review and Team-Focused Mechanical CPR Program
Authors: Rolston Daniel M , Li Timmy , Owens Casey , Haddad Ghania , Palmieri Timothy J , Blinder Veronika , Wolff Jennifer L , Cassara Michael , Zhou Qiuping , Becker Lance B
Published: June 2021

Introduction:
Survival from cardiac arrest remains suboptimal. Pre-hospital studies demonstrate monitoring cardiopulmonary resuscitation (CPR) quality and utilizing team-focused resuscitation improve outcomes in cardiac arrest. Video review provides Emergency Departments (EDs) with the ability to monitor CPR quality and provide feedback to individuals and teams. We evaluated for improvement in the proportion of patients achieving return of spontaneous circulation (ROSC), survival-to-admission and discharge, pre and post-initiation of a cardiac arrest video review and team-focused mechanical CPR program.

Methods:
In 2018, our ED began a video review program of cardiac arrests, consisting of biweekly meetings with a multidisciplinary team; and mechanical CPR with the LUCAS
®
3. A revised team-focused approach to resuscitation was created using swim-lane diagrams and a priority payoff matrix. In-situ simulation was used to disseminate this new approach. Using data from 2017 as the pre-intervention group for comparison, we assessed for differences in outcomes after implementation of our intervention using χ
2
tests and multivariable logistic regression.

Results:
A total of 242 patients were analyzed; 106 (43.8%) pre-intervention and 136 (56.2%) post-intervention. Both groups were similar (Table). The proportion achieving ROSC increased from 26.5% to 41.6% post-intervention (p=0.019). There were non-significant increases in survival-to-admission (26.4% vs. 35.3%; p = 0.140) and survival-to-discharge (5.6% vs. 10.3%; p = 0.194) after our intervention. Controlling for age, sex, initial rhythm, witnessed arrest, and bystander CPR, the odds of ROSC were higher post-intervention (OR: 2.52; 95% CI: 1.08, 5.90).

Conclusions:
Implementation of a video review and team-focused mechanical CPR program increased ROSC in our ED. Our intervention may also improve survival-to-admission and discharge, but this study was underpowered to detect these differences.
Abstract 471: Barriers to Performing CPR in a Community With a Low Prevalence of Bystander CPR
Authors: Patel Parth , Smith Christina ,   EVMS Bystander CPR Service Learning Group, Knapp Barry , Lang Joseph , Stoner Julie
Published: June 2021

Introduction:
Sudden cardiac arrest is a leading cause of mortality in the United States, with over 475,000 people dying annually. Bystander CPR significantly improves the odds of neurologically intact survival, yet nationally is performed in only 46% of out of hospital cardiac arrests. Significant regional variation exists in the performance of bystander CPR, with our community performing lower than national norms (26%). We sought to assess our community’s awareness of current American Heart Association (AHA) recommendations and the perceived barriers to performing bystander CPR.

Methods:
Adult study volunteers were recruited within the community (Norfolk, VA; pop. 244,703) and completed a 15-question anonymous survey that assessed knowledge of AHA recommendations, willingness to perform, and perceived barriers to performing CPR.

Results:
A total of 1,017 respondents completed all or part of the survey (40% male; 60% female). Knowledge of the importance of CPR was high. Of the respondents, 78% (n=708) indicated they would know if CPR was required, 84% (n=756) recognized the importance of performing CPR on a person who is unconscious and not breathing, and 89% (n=733) agreed CPR should not be delayed until the arrival of an ambulance. Though 70% (n=597) of respondents indicated they had been previously trained to perform CPR, only 44% (n=397) had been trained to perform “hands-only” CPR. Several barriers to performing CPR were identified. Forty-nine percent of respondents (n=402) believed they must perform “mouth to mouth” during CPR while 32% (n=284) were concerned they could catch a disease. Fear of doing something wrong while performing CPR was a concern for 28% (n=257). Twenty-six percent (n=237) reported concerns about the legal consequences of performing CPR.

Conclusions:
Though the importance of bystander CPR is well recognized in our community, misunderstandings regarding requirements and risks continue to exist. Education efforts should focus on increasing community awareness of current AHA recommendations.
Abstract 472: Organizations Unite in “Call-Push-Shock” Movement to Impact Public Understanding That Drives Action
Authors: Newman Mary M , Lopez-Anderson Martha E , Chap Jennifer F , Caramanis Carissa B , Legg Maureen , Graham Margaret
Published: June 2021

Introduction:
The incidence of OHCA in the U.S. is high (>350,000); the survival rate is low, about 1 in 10. Less than half of victims receive bystander CPR (39%) or treatment with an AED (6%) before EMS arrival. Consumer research indicates the public’s motivation to learn CPR/AED skills and help in emergencies increases with understanding of CA and the impact of bystander action. Two tested messages resonate most with the public: CPR/AED use can double or triple the chance of survival, and CA can happen to a loved one.

Hypothesis:
An inclusive national movement of organizations using unified, co-branded and tested messaging in a coordinated, multi-channel social media campaign could improve targeted reach and, over time, public understanding of CA and the importance of bystander action. Creating a gold standard for educational content on CA could improve message retention and motivation to act over time.

Methods:
We created a movement through consistent messaging in a user-friendly toolkit. We built a landing page (CallPushShock.org) and co-sponsored a social media campaign on CA and the importance of bystander action. We launched the campaign during CPR-AED Awareness Week (June 2018). We invited other organizations to join for SCA Awareness Month (Oct 2018), providing co-branded social media assets (Facebook/Twitter posts, videos, infographic) and posting schedules to all partners. Social media analytics were used to measure the reach of the campaign.

Results:
The campaign launched in June, attracting 20 partners by October. Combined co-sponsor results for June were: News release: 548,464 headline impressions (PR Web); hashtag (#callpushshock) impressions: 243,345 (Keyhole); FB reach: 86,134; Twitter impressions: 25,107; YouTube views: 351; e-news opens: 4,226 (MailChimp, Constant Contact); landing page: 1,291 users (Google). [
Oct 2018 and June 2019 results in development, reflecting extended partner reach.]

Conclusion:
A social media campaign, leveraging consumer-tested messaging used by multiple organizations in a unified, consistent movement can be effective in improving targeted reach and educational outcomes. A sustained effort is needed to determine campaign impact in improving public understanding of CA and bystander action over time.
Abstract 483: Out of Hospital Cardiac Arrest Outcomes After Transitioning to Pit Crew Model
Authors: Vindhyal Mohinder Reddy , Ndunda Paul M , Vindhyal Shravani , Duran Brent
Published: June 2021

Introduction:
One of the leading causes of untimely death as per the Resuscitation Outcomes Consortium Epistry for cardiac arrest is out of hospital cardiac arrest (OHCA). Adoption of the choreographed approach of the pit crew model resuscitation improved outcomes after OHCA in some previous studies.

Hypothesis:
Compare outcomes post OHCA before and after adopting a pit crew model approach in one of the largest counties in Kansas.

Methods:
The data was collected before (2010 – 2012) and after the pit crew (2013-2016) approach from 2010 to 2016. The patient demographics and resuscitation variables were similar and comparable including the emergency and fire department personnel. The primary outcome was the proportion of patients having sustained return of spontaneous circulation (ROSC). Secondary outcomes were average number of pauses >10 seconds, cerebral performance post return of spontaneous circulation, and average cardio-pulmonary resuscitation (CPR) cycles to ROSC.

Results:
The patients who had sustained ROSC post pit crew approach was 67.9% vs 32.1% (p=< 0.001). Average number of CPR pause time > 10 seconds post pit crew model was 1 vs 5 (p=0.01). Cerebral performance post return of spontaneous circulation using pit crew approach with good cerebral performance was 47% vs 56% (p=0.2), moderate cerebral disability was 17% vs 23% (p=0.19), severe cerebral disability was 8% vs 11% (p=0.44) and in coma/vegetative state was 8% vs 16% (p=0.001). Average CPR cycles to ROSC was 6.63.

Conclusion:
This focused model of high-quality CPR performance with individualized assigned tasks with minimal interruptions has shown increased numbers of sustained ROSC. The pit crew model approach also has showed decline in the rates of cerebral performance especially with moderate and severe cerebral performance including the patients in coma or vegetative state which is mainly through continuous cerebral perfusion pressures. More studies with better follow-up care in coordination with hospital outcomes will be key for the pit crew approach to be adopted.