bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 246: Consumptive Coagulopathy is Associated With Poor Neurological Outcome in Patients With Refractory VT/VF Cardiac Arrest Requiring Extracorporeal Cardiopulmonary Resuscitation
Authors: Rojas-Salvador Nelly C , Kalra Rajat , Steiner Marie E , Marquez Alexandra M , Alexy Tamas , Elliott Andrea M , Yannopoulos Demetris , Bartos Jason , Gutierrez Alejandra
Published: December 2023

Introduction:
Post cardiac arrest syndrome is associated with altered hemostasis. This is aggravated further by the foreign surface in the extracorporeal circuit leading to a coagulofibrinolytic imbalance.

Aim:
We examined the serial changes of consumptive coagulopathy markers and their association with neurologic outcomes.

Methods:
A single-center, retrospective cohort study of consecutive patients with VT/VF cardiac arrest meeting criteria for ECMO-facilitated resuscitation (ECPR) between December 2015 and January 2023 were included. Consumptive coagulopathy markers (INR, D-dimer, platelet count, antithrombin III and fibrinogen) were obtained after VA ECMO cannulation and serially on day 1, 2 and 3. We compared the coagulation profiles of patients who had a neurologically favorable outcome (defined as Cerebral Performance Categories (CPC) 1-2) and those with a neurologically unfavorable outcome (CPC 3-5).

Results:
Of 258 patients, 82 (32%) survived to hospital discharge. Of these, 87% (71/82) survived with favorable neurological outcome. Prolonged INR, elevated D-dimer levels and decreased ATIII levels were associated (p<0.05) with neurologically unfavorable survival and decreased over time (p<0.05)(Figure1). Platelet count and fibrinogen levels were not associated with neurological outcomes. In adjusted analysis (including age, lactate, CPR time and use of dual antiplatelet therapy), each point increase in the INR on day 1, 2 and 3 was associated with neurologically unfavorable survival (OR 4.4, p=0.01; OR 7.14, p=0.04; OR 8.5, p=0.03 respectively).

Conclusion:
Markers of consumptive coagulopathy with a prolonged INR are associated with unfavorable neurological outcome.
Abstract 257: VIGAB-STAT- A Phase IIa Feasibility Trial of Irreversible GABA-Transaminase Inhibition as Adjunct Treatment of Status Epilepticus After Cardiac Arrest
Authors: Ahmad Bakhtawar , Maranchick Nicole F , Forero Daniela P , Busl Katharina M , Hirsch Lawrence , Bruzzone Maria , Eisenschenk Stephan , Peloquin Charles A , Maciel Carolina
Published: December 2023

Background:
Effective therapeutic interventions for post-anoxic status epilepticus (PASE) are lacking. Vigabatrin (VGB) could be an attractive adjunct drug in PASE by increasing GABA availability in inhibitory synapses; however, enteral malabsorption in the post-cardiac arrest (CA) period and difficulty enrolling in the FDA mandatory registry could hinder its use in this setting. We hypothesize that CA survivors absorb VGB despite vasopressor use, concurrent enteral feeding, and regardless of gastric or post-pyloric drug delivery.

Goals:
Prove feasibility and study pharmacokinetics of a single enteric VGB load within 48 hours of PASE onset.

Methods:
We administered a single load 1125-4500 mg VGB (based on creatinine clearance; CrCl) in adults with non-traumatic CA, with electrographic SE and gastric or duodenal access. Plasma samples were collected at 0, 0.5, 1, 2, 3, 6, 12, 24, 48, 72 and 168 hours.

Results:
Interim results from a cohort of 6 subjects comprised of 67% male (4 of 6), 83% White (5 of 6), with a median age 62 years 22-68), median BMI 30 Kg/m
2
(20-53), and median CrCl 44cc/min (22-186) are presented. All subjects received VGB within 48h window; median VGB dose was 2250 mg (1125-4500). The median time to peak (Tmax) was 2 h (1-3); median peak concentration (Cmax) was 38.1 mcg/ml (16.7 -91.8). Median 24h VGB concentration (C24) was 9.4 mcg/ml (3.4-14.2) and half-life (T1/2) was 16 h (10-24). The AUC 0-24 value was 318 mcg*h/ml (262-1012). No significant association was found between sex or BMI and Cmax. Three out of six patients achieved EEG response following VGB load; no association with dose or concentration was noted.

Conclusions:
All patients achieved detectable VGB levels with peak occurring between 1-3 hours post-administration. Enteric administration of VGB does not preclude phase IIb clinical trials of VGB in PASE.

Registration:
URL:
http://www.clinicaltrials.gov
; Unique identifier: NCT04772547
Abstract 278: Injuries and Outcomes Associated With Manual vs Mechanical CPR Post Out of Hospital Cardiac Arrest
Authors: Chen Connie , Sit Julian , Keeley Jacob , Swor Robert A
Published: December 2023

Objectives:
Mechanical CPR is increasingly being used for field out of hospital cardiac arrest (OHCA) care. However, existing literature does not identify a survival benefit of mechanical versus manual CPR. We hypothesized that CPR related injury may impact patient outcomes. For that reason, our primary objective is to compare mechanical and manual CPR-related injury in resuscitated OHCA patients. Our secondary objective is to compare hospital outcomes including length of stay (LOS) and survival between these two CPR methods.

Methods:
We performed a retrospective study of adult OHCA patients admitted to three teaching hospitals in Southeastern Michigan from 2017-2021. Resuscitated patients were matched to hospital electronic medical records (EMRs), included if they had CT imaging of chest or abdomen/pelvis, and then dichotomized by CPR method. Patients were excluded if no EMR match or CPR method was unknown. Hospital EMRs were queried for CT imaging results, LOS variables and survival to hospital discharge. Injuries are identified using hospital ICD-10 codes. Univariate statistics are reported.

Results:
There were 808 patients admitted after OHCA, with 235 (103 mechanical CPR, 132 manual CPR) meeting the inclusion criteria. Demographics between groups were similar in age, gender, or body mass index (BMI). There were no abdominal/visceral injuries and few patients (4) had a pneumothorax. CPR associated injury was more common with manual CPR (28.8% vs 15.5%, p=0.02) and an increased rate of rib(s), sternum, or thoracic spine fracture (27.3% vs 14.6%, p=0.02). . We identified no differences in survival to hospital discharge (39 (29.5%) vs. 29 (28.2%), p=0.8), median hospital LOS, ICU LOS, and ventilator time between groups. Paradoxically amongst survivors, mechanical CPR was associated with longer LOS (15.7 vs 11.0 days, p=0.012) and a non-significant increased ventilator time (143 vs 99 hours, p=0.23).

Conclusion:
We identified a higher rate of injury with manual CPR compared to mechanical CPR in resuscitated OHCA patients We also did not identify any association between CPR method and ICU LOS, ventilator time, and survival. Further work is needed to assess the impact on outcome of CPR method and injuries typically associated with resuscitation.
Abstract 287: Psychosocial and Functional Status Are Associated With Readiness for Hospital Discharge Among Cardiac Arrest Survivors
Authors: Presciutti Alexander M , Flickinger Kate , Coppler Patrick J , Ratay Cecelia , Doshi Ankur A , Perman Sarah , Vranceau Ana-Maria , Elmer Jonathan
Published: December 2023

Introduction:
Long-term cardiac arrest (CA) survivors have recounted feeling unprepared to confront the psychosocial, functional, and cognitive sequelae of CA, but this has not been assessed quantitatively.

Hypothesis:
Psychosocial, functional, and cognitive status are associated with readiness for discharge post-CA.

Methods:
We prospectively recruited CA survivors treated by the University of Pittsburgh Post-Cardiac Arrest Service (4/21-9/22) who completed study measures within 72 hours prior to hospital discharge. We used linear regression to examine unadjusted associations between potential covariates (sex, income, arrest location, Charlson Comorbidity Index, time to return of spontaneous circulation, initial rhythm), post-CA sequelae (emotional distress screen via PROMIS Depression and Anxiety Short Forms 4A or PTSD Checklist-5, functional status via modified Rankin Scale, cognitive status via Telephone Interview for Cognitive Status, and social support via ENRICHD Social Support Inventory) and our dependent variable (readiness for discharge assessed via Patient Readiness for Hospital Discharge Scale - Short Form). Covariates significant at p < 0.10 were included in a multivariable regression.

Results:
We included 110 grossly cognitively intact CA survivors (mean age 59 years, 64% male, 88% non-Hispanic White, 48% low income, 36.4% emotionally distressed, 21.9% functionally dependent, 24.5% cognitively impaired). Emotional distress, functional dependence, and lower social support were associated with lower readiness for discharge (β’s [absolute value]: 0.23-0.31, p < 0.01; R
2
= 0.34) after adjusting for CA location and Charlson Comorbidity Index. Cognitive status, demographic covariates, and other CA clinical characteristics were not associated with readiness for discharge.

Conclusion(s):
Psychosocial and functional status predict readiness for discharge in this sample of grossly cognitively intact CA survivors. Further research should focus on developing interventions targeted towards these domains prior to hospital discharge.
Abstract 290: Initial Engagement in a Novel Online Support Community for Cardiac Arrest Survivors, Co-Survivors, Lay Rescuers, and Advocates
Authors: Newman Mary M , Presciutti Alex , Farrell Joe , Lupton Joshua , Sanko Stephen , Perman Sarah
Published: December 2023

Background:
Cardiac arrest survivors often experience physical, cognitive, emotional, and social challenges that can linger for years. Co-survivors and lay rescuers can also experience distress. In 2023, Sudden Cardiac Arrest Foundation (SCAF) created the Cardiac Arrest Survivor Alliance™ (CASA), an online community to support these individuals. CASA offers evidence-based information about common challenges post-arrest, easy connection with peers, access to experts, and pathways to further clinical support. To measure early dissemination, we examined CASA’s community engagement and growth through the first 5 months.

Methods:
We built CASA using Mighty Networks (MN), assembled a leadership team including researchers and clinicians with expertise in post-resuscitation quality of life, and launched the community in mid-January 2023. We recruited members through SCAF’s Survivor Network and outreach via its website, newsletters, and social media. We obtained analytic reports to evaluate engagement and growth of CASA during the first 5 months of operation.

Results:
By mid-June 2023, there were 868 members from the U.S. and 21 other countries. Based on preliminary data, approximately 75% of members are survivors. Initial growth resulted from SCAF outreach and is continuing organically through internet searches and member outreach. During the 5-month period, there were: 6,829 contributions (sum of actions taken by hosts, moderators and members including posts, “cheers,” comments, chat messages, direct [private] messages [DMs], and RSVPs), 858 active members (total members who visited during the 5-month period), and 376 unique members providing contributions. Members are not only engaging publicly, but also privately; 344 members (40%) have sent 1,944 DMs. MN considers communities to be successful if 15% or more members send DMs. CASA also provides monthly webinars with guided discussions led by experts. Attendance has ranged from 22 to 47 participants.

Conclusion:
In the 5 months since its launch, the CASA community is engaged and continually growing. Future plans include providing additional evidence-based content, outreach to hospitals and targeted healthcare professionals, and collaboration with program partners to grow the CASA community.
Abstract 300: An Opportunity for Awareness: The International Academy of Emergency Medical Dispatch's Stroke Diagnostic Tool is Predictive, but Underutilized, for Hospital Confirmed Large Vessel Occlusion Strokes
Authors: Gorman Codee , Young Christian , Fanuel Eyobed , Familara Tiffany , Cox Derek , SLATTERY DAVID
Published: December 2023

Background:
Accurate identification of ischemic stroke from large vessel occlusion (LVO) by 9-1-1 professionals can facilitate prompt patient transfer to stroke centers that perform endovascular thrombectomy. We sought to determine the proportion of LVO stroke patients that were evaluated using the Medical Priority Dispatch System's (MPDS) Stroke Diagnostic Tool (SDxT).

Methods:
Structured, retrospective review of our institution’s stroke registry, EMS Records, and dispatch codes between January 1, 2019 and November 30, 2022.

Inclusion:
Adult (age >17), accessed the 9-1-1 system and transported by a ground EMS agency for an acute stroke.

Exclusion:
age <18, pregnant, incarcerated, cases with missing 9-1-1 data, and intracranial hemorrhage. Two trained/monitored abstractors, blinded to the study purpose, used a standardized data collection tool/dictionary to extract data. Data included MPDS codes, SDxT outcome, EMS care, demographics, hospital NIHSS score, advanced imaging, tPA administration, and mechanical thrombectomy.

Primary outcome:
the proportion of LVO cases that had an acute stroke (28 protocol) dispatch code.

Secondary outcome:
the proportion of LVO cases that that a SDxT score indicating “strong or clear evidence of a stroke”. We report proportions and 95% CI's as appropriate.

Results:
60 patients met inclusion/exclusion criteria. 11/60, 18.3 % (95%CI= 10.4, 30) of the patients had complete data and a LVO. 54% were male, the median (IQR) age was 69.5 (61.3-77.5), and the median (IQR) NIHSS was 16 (5-19.75).

Primary outcome:
45.5 % (95% CI= 21.3.72.0) of the LVO’s were coded as an Acute Stroke by the 9-1-1 center. Of those, 3/5 utilized the stroke diagnostic tool, all 3 of these were determined to have "Clear Evidence of Stroke".

Limitations:
Retrospective, unlinked data, small number of LVO's.

Conclusion:
When utilized, the SDxT correctly identified all LVO’s. There is an opportunity to increase awareness and utilization of the SDxT by 9-1-1 centers. Future research should focus on identifying barriers to stroke recognition and provide additional tools to address the real-life challenges our 9-1-1 communications specialists face when rapidly assessing for an acute stroke over the phone.
Abstract 310: Impact of "Cognitive Aids" on Responder Performance During Pediatric Code Blue Simulations - Results From Performance Improvement Project at a Tertiary Care Center in Saudi Arabia
Authors: Noorani Muzammil M , Mehboob Naila , Hashmat Tahira , Asif Zaib , Alshehri Amjad , Alomani Hakem , Zaid Muhammad , Mohammed Viqaruddin , Aldawalibi Rana
Published: December 2023

Introduction:
Despite advances such as high-fidelity code blue simulations, pediatric In-Hospital Cardiac Arrest mortality rate has plateaued at 62% in the USA. It is expected to be higher in low-income countries. Studies show deviations from the PALS guidelines despite regular PALS training due to skills and knowledge decay. Use of simple, easily accessible resources as “Cognitive Aids”, that decrease reliance on memory during stressful events, however, has not been studied well.

Aim:
To evaluate impact of cognitive aids on resuscitative capabilities of code-blue responders during simulations.

Method:
Performance Improvement (PI) project by Pediatrics Department at King Faisal Specialist Hospital and Research Centre, Madinah, Saudi Arabia. Simulations were run by Consultant, Pediatric Intensivist and PICU nurse on regular pediatric floors. A performance assessment checklist and a scoring tool were designed to evaluate team members for responsiveness, effective resuscitation, effective communication and resource utilization.

Results:
A total of 94 responders participated multiple times in 35 simulations that were conducted in two phases: Codes 1 - 19 as the Pre-PI phase and Codes 20 - 35 as Post-PI phase. Cognitive aids were not utilized during the Pre-PI codes and based on the assessment scores, interventions were introduced in the form of A3 size PALS resuscitation cards, “Pediatric Cardiac Arrest Resuscitation Direction” document with prompts to facilitate smooth running of the code and SBAR notes. Based on the scores, improvement was observed in responsiveness by 27% (Pre-PI:192/262 vs. Post-PI:222/223), effective resuscitation by 38% (Pre-PI:293/511 vs. Post-PI:409/431), effective communication by 46% (Pre-PI:94/245 vs. Post-PI:173/207) and resource utilization by 56% (PrePI:37/94 vs. Post-PI:76/80). Total of 36 (38%) responders participated in actual pediatric cardiac arrests after project completion and 97% (35/36) reported higher confidence.

Conclusion:
Cognitive aids were helpful supportive tools in overcoming skills and knowledge decay and enhance team performance and quality of resuscitation during code blue simulations. We suggest use of such tools wherever high-fidelity simulation training may not be available.
Abstract 311: Accuracy of Automated External Defibrillator Pad Placement During Out-of-Hospital Cardiac Arrest Resuscitation Simulations
Authors: Missel Amanda L , Rizk Daniel , Dowker Stephen R , Scott Isabella G , Majhail Noor K , Hunt Nathaniel , Neumar Robert W
Published: December 2023

Introduction:
Out-of-hospital cardiac arrest (OHCA) victims receiving defibrillation from an automated external defibrillator (AED) placed early in the chain of survival are more likely to survive.

Aim:
We sought to explore the accuracy of AED pad placement for lay rescuers (LR) and first responders (FR).

Methods:
We conducted a secondary analysis of data collected during randomized OHCA simulation trials involving LR and FR. LR received hands-only CPR and AED guidance from a simulated 9-1-1 telecommunicator. FRs did not receive telecommunicator instruction. Participants were surveyed about medical training and experience. Correct AED pad placements (anterior: AP, lateral: LP) were individually determined from video abstraction based on manufacturer’s recommendations and distance to anatomical landmarks (mid, nipple, and naval lines). Incorrect AP placement was defined as more than 6 cm medial or 10 cm inferior. Incorrect LP placement was defined as more than 6 cm superior, 9 cm inferior, or 10 cm medial. We examined the association between correct pad placement and previous CPR training (current, expired, or never) for LR and correct pad placement and self-reported recent field experience (< 1 year) with AED application for FR using Chi-square tests.

Results:
LR correctly placed the AP in 30/38 (79%) and the LP 30/38 (79%) simulations. Application did not differ significantly based on previous CPR training (AP p= .187, LP p=.578). The most common incorrect placement was too low for both AP (5/8, 63%) and LP (4/8, 50%). FRs applied the AP correctly in 31/36 (86%) and the LP in 22/36 (61%) simulations. Among FRs, correct pad application did not differ significantly based on recent field experience (AP p=.29, LP p=.563). The most common incorrect placement was too low for both AP (5/5, 100%) and LP (12/14, 86%).

Conclusion:
Both LRs and FRs may not apply AEDs per manufacturer’s recommendations. Further research is needed to improve instructions and follow-up training to ensure appropriate placement of AEDs, and to understand how improper AED placement impacts the accuracy of rhythm analysis and defibrillation success.
Abstract 316: Reperfusion With Mild versus Moderate Hypothermia in a Swine Model of Extracorporeal Cardiopulmonary Resuscitation
Authors: Marquez Alexandra M , Kosmopoulos Marinos , Kalra Rajat , Jaeger Deborah , Gaisendrees Christopher , Ripeckyj Adrian , Gutierrez Alejandra , Alexy Tamas , Elliott Andrea M , Steiner Marie E , Bartos Jason , Seelig Davis , Yannopoulos Demetris
Published: December 2023

Background:
Targeted temperature management (TTM) at lower temperatures has shown variable neuroprotective benefits in clinical trials of cardiac arrest. We hypothesized that moderate hypothermia at the time of VA-ECMO reperfusion followed by early rewarming would reduce brain injury in a swine model of refractory VF, compared to mild hypothermia.

Methods:
Fourteen female pigs had electrically induced VF and conventional CPR for 30 minutes. Animals were cannulated to VA-ECMO and randomized to TTM to 34°C for 4 hours (mild hypothermia, n=7) or 24°C for 1 hour followed by early rewarming to 34°C over 3 hours (moderate hypothermia, n=7). Cooling was initiated upon ECMO reperfusion by circulating ice water through the oxygenator. Brain temperature and cerebral and systemic hemodynamics were continuously monitored. After four hours of post-arrest and ECMO care, brain tissue was obtained for examination. Groups were compared using paired t- and Wilcoxon rank sum tests.

Results:
The mean time to target brain temperature was 5 and 35 minutes in the mild and moderate groups, respectively (Panel, A). CPR hemodynamics were similar. Carotid blood flow (CBF) was higher in moderate hypothermia animals (79.0±1.56 vs 60.7±1.86% pre-arrest baseline,
P
<0.001) throughout the post-arrest period. There were no differences in ECMO flow, mean arterial pressure, vasopressor/fluid requirement, bleeding, or thromboelastography. No significant difference in histologic damage score was observed between groups (10.5 [7, 11.8] vs 13 [9, 20], with 24°C vs 34°C respectively
P
=0.25; Panel, B). Immunohistochemistry markers for white matter and neuronal injury also did not significantly diverge.

Conclusion:
In a swine model of refractory cardiac arrest treated with ECPR, moderate hypothermia initiated upon reperfusion followed by early rewarming did not appear to be neuroprotective. Histological brain injury at 4 hours post-resuscitation was not affected by the degree of hypothermia.
Abstract 317: Development of a Swine Model of Rapidly-Induced Septic Shock Using Single Lipopolysaccharide Infusion and Titratable Inhaled Nitric Oxide to Prevent Severe Pulmonary Vasoconstriction
Authors: Saeed Moaz B , Shahid Azib , Razi Armin , Ayoub Iyad , Baetiong Alvin , Laporte Regent , Pelletier Martin , Gazmuri Raul J
Published: December 2023

Objective:
A serious limitation of LPS-induced swine models of septic shock is severe pulmonary vasoconstriction triggered, in part, by the pulmonary release of thromboxane A2. Efforts to overcome this limitation have included a stepwise increase in LPS dosing, intravenous aspirin derivatives, and inhaled nitric oxide (NO). We studied the effects of titrated inhaled NO given coincident with rapid LPS-infusion aimed at inducing the key features of septic shock over a shorter time period.

Methods:
We developed a LabVIEW-controlled system for inhaled NO delivery and monitoring. Exploratory studies showed that an NO concentration of up to 300 ppm sufficed to prevent significant pulmonary vasoconstriction despite delivery of a full LPS dose (12.6 μg/kg) in 30 minutes. We used this approach in 6 male domestic pigs (39.2 - 41.1 kg) and assessed hemodynamic and metabolic effects over 6 hours. NO and LPS infusion were started concurrently. Fluid resuscitation and vasopressor therapy were guided by macrohemodynamic measurements using custom-developed LabVIEW-controlled closed-loop algorithms.

Results:
Shown are medians with IQ25 and IQ75. LPS infusion increased pulmonary vascular resistance from 112 [72, 127] at baseline to 213 [120, 313] dynes-sec/cm
5
after 20 minutes. NO (139 [131, 166] ml/min) rapidly blunted the effect preventing the mean pulmonary artery pressure from exceeding 30 mmHg, avoiding detrimental effects on right ventricular function throughout the experiment. NO was rapidly de-escalated over 30 minutes using a closed-loop algorithm developed to prevent the mean pulmonary artery pressure from exceeding 30 mmHg. Within 60 minutes of LPS infusion start, animals began to develop key features of septic shock including tachycardia, hypotension, and systemic vasodilation triggering fluid resuscitation and norepinephrine administration. Additionally, blood lactate increased from 1.06 [0.90, 1.45] at baseline to 4.14 [2.43, 8.78] mmol/l after 3 hours remaining stable for an additional hour and subsequently decreasing in 3 and increasing in the other 3 animals, with half of the animals surviving the 6-h period.

Conclusion:
We developed a swine model of rapidly-induced key features of septic shock useful to explore early septic shock management.
Abstract 320: Survival and Neurological Function With Rapid versus Delayed Automated Head-Up CPR in a Porcine Model of Prolonged Cardiac Arrest
Authors: Pourzand Pouria , Moore Johanna C , Metzger Anja , Salverda Bayert , Suresh Mithun , Arango Susana , Rosenhagen Henry , Kaizer Alex , Debaty Guillaume P , Lurie Keith G
Published: December 2023

Background:
Rapid Basic Life Support (BLS) treatment with controlled sequential elevation of the head and thorax, active compression-decompression CPR, and an impedance threshold device, collectively termed automated Head Up Position (AHUP)-CPR, is associated with better outcomes versus conventional CPR (C-CPR) in animal models and human observational studies.

Hypothesis:
Rapid AHUP-CPR should improve survival and neurological function vs rapid C-CPR followed by delayed AHUP-CPR.

Aim:
Determine if AHUP-CPR should be initiated as a BLS or ALS intervention.

Methods:
Male and female farm pigs (n=22) weighing~40kg were anesthetized and ventilated. Central venous and aortic pressures, as well as end-tidal CO2 (ETCO2) and cerebral oximetry (rSO2) were measured continuously. After 15 min of untreated VF, pigs were randomized to either rapid AHUP-CPR for 25 min or 10 min of C-CPR followed by 15 min of AHUP-CPR. Pigs received intravenous epinephrine and amiodarone after 24 min of CPR and were defibrillated 60 sec later. For the primary endpoint, 24-hour neurologic function, a veterinarian blinded to the CPR intervention assessed pigs using a Neurological Deficit Score (0 = normal and 260 = worst deficit score or death). Secondary outcomes included 24-hour survival rates and hemodynamic parameters. Data were expressed as mean ± SD. Statistical significance was determined by log-rank, Mann-Whitney-U and unpaired t-tests.

Results:
Sustained return of spontaneous circulation was achieved in 10/11 pigs with rapid AHUP-CPR vs 6/11 with delayed AHUP-CPR and cumulative 24-hour survival rates were 45.5% (5/11) vs 9.1% (1/11), respectively (p=0.01). Neurological Deficit Scores were 202.7 ± 80.3 with rapid AHUP-CPR vs 259.1 ± 3.0 with delayed AHUP-CPR group (p=0.04). Ten minutes after initiating CPR, ETCO2 (mmHg) was 45.0 ± 3.8 vs 26.9 ± 5.4 (p<0.001), and rSO2 (%) was 67.3 ± 3.9 vs 61.4 ± 6.3 (p=0.01) with rapid AHUP-CPR vs delayed AHUP, respectively.

Conclusion:
In a severe and prolonged model of porcine cardiac arrest, rapid AHUP-CPR, delivered as a BLS intervention, significantly improved the survival rate, neurological function and hemodynamics when compared with rapid C-CPR followed by delayed AHUP-CPR.
Abstract 339: Causes and Initial Cardiac Arrest Rhythms in a National Paediatric Cohort From Norway
Authors: Kelpanides Inga K , Katzenschlager Stephan , Skogvoll Eirik , Tjelmeland Ingvild B , Grindheim Guro , Alm-Kruse Kristin , Liberg John-Petter , Kristiansen Thomas , Wnent Jan , Grasner Jan-thorsten , Kramer-Johansen Jo
Published: December 2023

Background:
Mortality following paediatric out-of-hospital cardiac arrest (POHCA) is high. Registration of any resuscitation attempt is mandated by law in the Norwegian Cardiac Arrest Registry (NorCAR), providing an opportunity to study precipitating causes from a nationwide population perspective. Research questions and aims The study set out to investigate the precipitating causes and the presenting rhythms of OHCA in children; enabling a focused approach to prevention and treatment of cardiac arrest in children.

Methods:
NorCAR data for children aged 0-17 years was extracted for 2016-21. Cases of perinatal resuscitation and children not receiving ongoing cardiopulmonary resuscitation by ambulance personnel were excluded. Descriptive statistics were used to create age-stratified summaries for presumed causes of POCHA and presenting rhythms.

Results:
In total, 308 children were included. Presumed causes of cardiac arrest included choking (n=67), cardiac aetiology (n=55), respiratory failure (n=51), sudden infant death syndrome (n=51), and drowning (n=37). The presumed causes differed substantially according to age (Figure). Non-shockable rhythms dominated (87%, 250 of 287 with available rhythm data). The proportion of shockable rhythms increased with age to 15 % (19 of 127) in the 13-17 year age group.

Conclusion:
The causes of POHCA were diverse and highly age dependent. This knowledge may inform both parents and caretakers, health professionals, and the whole community with respect to effective prevention, proper first aid, and focused emergency medical treatment.
Abstract 350: Measuring the Return on Investment of an Artificial Intelligence (AI) Early Warning System
Authors: Edelson Dana P , Snyder Ashley , Knych Stephen , Thordarson Thor , Kuhlman Jeffrey , Marcus Stuart , Bordo David
Published: December 2023

Background:
The use of AI has been associated with decreased hospital mortality for at risk patients but the financial benefit is unknown.

Aims:
We sought to measure the change in mortality and cost in six priority clinical conditions following a multi-center phased implementation of eCART (AgileMD), an AI early warning system which utilizes electronic health record (EHR) data to predict clinical deterioration.

Methods:
eCARTv2 was integrated into the EHR (Oracle Cerner) at four Midwest hospitals in a rolling two-phase implementation. In Phase I, providers viewed scores on a stand-alone web dashboard. In Phase 2, the output was displayed in the EHR, linked to clinical pathways. Phase 0 consisted of a 12 month baseline. Mortality and inflation-adjusted direct variable cost data were compared across the phases in six predetermined diagnosis related group (DRG) conditions: sepsis, heart failure (HF), chronic obstructive pulmonary disease (COPD), stroke, acute myocardial infarction (AMI) and pneumonia.

Results:
Between 6/1/17 and 2/29/20, 15217 (20.3%) med-surg encounters met inclusion DRG criteria. eCART elevation was most common in sepsis (62.5%), followed by HF (47.4%), pneumonia (43.7%), AMI (39.0%), stroke (35.5%) and COPD (27.1%). Full eCART implementation was associated with significant cost reductions in sepsis, HF, pneumonia, COPD and AMI of $471-795 per encounter and mortality reductions in sepsis and HF (aOR 0.56 and 0.39, respectively).

Conclusions:
The mortality and cost benefits of eCART appear to be strongest for sepsis and heart failure, where eCART is most likely to be elevated. Savings for sepsis, HF, pneumonia and COPD are primarily driven by labor (ie LOS).
Abstract 358: Coronary Features in Different Subsets of Out-of-Hospital Cardiac Arrest
Authors: Franco Danilo , Goslar Tomaz , Radsel Peter , De Luca Nicola , Santoro Alessandro , Tesorio Tullio N , Barbato Emanuele , Noc Marko
Published: December 2023

Introduction:
Coronary artery disease (CAD) is the leading cause of out-of-hospital cardiac arrest (OHCA) which is usually triggered by acute coronary event.

Hypothesis:
CAD is more complex if acute coronary event is associated with OHCA. CAD complexity progressively increases from patients with reestablishment of spontaneous circulation (ROSC) to patients with refractory OHCA.

Aims:
To investigate CAD features in different subgroups of OHCA and compare them to patients with acute coronary syndrome without OHCA.

Methods:
Consecutive conscious and comatose OHCA with ST-elevation myocardial infarction (STEMI) after ROSC and patients with refractory OHCA undergoing veno-arterial extracorporeal membrane oxygenation (E-CPR OHCA) were compared to STEMI without OHCA (STEMI no OHCA).

Results:
Between 2016 and 2022, 71 conscious OHCA, 157 comatose OHCA, 50 E-CPR OHCA and 101 randomly selected STEMI no OHCA underwent immediate coronary angiography. Acute culprit lesion was documented less often in OHCA subsets (88.1% vs 97%; p=0.009) but complete occlusion was more prevalent (68.8% vs 58.4%; p=0.038)
(Figure A)
. Incidence of multivessel disease,
>
50% unprotected left main stenosis, and presence of
>
1 chronic total occlusion progressively increased from STEMI no OHCA to E-CPR OHCA. This was reflected in baseline SYNTAX score which was 5.6 in STEMI no OHCA,10.2 in conscious OHCA, 13.4 in comatose OHCA and 26.8 in E-CPR OHCA (p<0.001)
(Figure B)
. There was a linear correlation between SYNTAX score and delay to ROSC (r
2
=0.61; p<0.001)
(Figure C)
. Baseline and residual SYNTAX scores were among independent predictors of 5-year survival which was significantly decreased in comatose (56.1%) and E-CPR (36.0%) OHCA
(Figure D)
.

Conclusion:
OHCA is associated with increased incidence of acute coronary occlusion and progressive complexity of CAD from conscious OHCA to E-CPR OHCA. Severity of CAD is associated with increased delays to ROSC and decreased long-term survival.
Abstract 359: Temporal Trends in Perioperative Cardiac Arrest Rates Following Transcatheter Aortic Valve Replacement
Authors: Imburgio Steven , Akhlaq Hira , Johal Anmol , Pannu Viraaj , Udongwo Ndausung , Saybolt Matthew , Kiss Daniel , Heaton Joseph
Published: December 2023

Introduction:
Transcatheter aortic valve replacement (TAVR) procedural volume has continued to increase over the past decade, coinciding with expanded indications by the Food and Drug Administration. Despite advancements in TAVR safety, serious procedure-related complications including cardiac arrest are still a concern.

Aims:
This study aims to investigate temporal trends of in-hospital cardiac arrest rates and clinical outcomes following TAVR.

Methods:
In this large-scale, retrospective cohort study, admitted patients with a primary or secondary diagnosis of nonrheumatic aortic stenosis who underwent TAVR were identified from 2016 to 2020 using the National Readmissions Database. Diagnoses and procedures were classified using the International Classification of Diseases, 10th edition codes. The primary outcome was temporal trends in the rates of cardiac arrest with cardiopulmonary resuscitation during the perioperative period. Secondary endpoints assessed annual discharge survival rates and 30-day readmissions.

Results:
Of 31,621 total TAVR procedures, perioperative cardiac arrest occurred in 1.8% (n = 579) of cases. Baseline characteristics are described in Table 1. No statistically significant change in perioperative cardiac arrest rates was observed from 2016 to 2020 (p = 0.674). The average annual discharge survival rate was 97.7% which did not change significantly over the 5-year study period (p = 0.551). From 2016 to 2020, 30-day readmissions decreased from 13.6% to 10.1%, respectively (p = 0.028).

Conclusion:
While perioperative cardiac arrest is associated with high mortality, it still remains a relatively rare complication as operators have become more experienced and valve device technology has improved. An overwhelming majority of TAVR patients are successfully being discharged with improved rates of 30-day readmissions observed over recent years, indicating potential improvements in postoperative care.
Abstract 362: Multicenter, Retrospective Study of Ventricular Fibrillation Visualized by Echocardiogram With a Non-Shockable Elelctrocardiogram Following Out-of-Hospital Cardiac Arrest
Authors: Lindsay Robert , Kapoor Monica , Gleeson Timothy , Gaspari Romolo
Published: December 2023

Introduction:
Cardiac rhythm by ECG can be different from cardiac rhythm visualized by echocardiography (echo). Cardiac arrest interventions are largely based on the ECG rhythm and some patients with ventricular fibrillation (vfib) demonstrating a non-shockable ECG may not be rapidly defibrillated.

Hypothesis:
A significant percentage of out of hospital cardiac arrest (OHCA) with vfib are unrecognized by ECG.
Goals
- To measure the prevalence and survival outcomes for patients with a non-shockable ECG but vfib by echo.

Methods:
Analysis of echo images recorded during a previous multi-center, observational study of OHCA patients. ECG and echo during initial pause in CPR at arrival to the Emergency Department (ED) were reviewed. Echo imaging was reviewed for the presence of visible vfib blinded to all patient information. Image interpretation was performed by two experienced physicians with adjudication by a third. ECG interpretation was unblinded to patient information. Primary outcome was survival to hospital admission. Data is presented as mean (95%CI)
Results
- Vfib was unrecognized by ECG in 31% of patients in vfib at ED arrival (22 of 71). See Figure. Survival to hospital admission for patients with ECG vfib (18.2%, 95%CI 10.2-30.3) and echo vfib (18.2%, 95%CI 6.7-39.1) was similar. All 55 patients who presented in ECG vfib were defibrillated immediately, and 11 of 22 patients with a non-shockable ECG but echo vfib were defibrillated, but during a subsequent pause in CPR. Patients with ECG vfib had no echo before defibrillation. Patients with echo vfib demonstrated ECG PEA (n=9, 41%), asystole (n=7, 32%), or ECG vfib defibrillated to a non-shockable ECG with continued echo vfib that was not subsequently defibrillated (n=6, 11%).

Conclusion:
A significant percentage of OHCA vfib was not recognized at arrival to the ED, with 31% demonstrating a non-shockable ECG rhythm but vfib on echo. OHCA survival rate for echo vfib is similar to ECG vfib.
Abstract 381: Simultaneous Use of VA-ECMO and Impella (ECPELLA) Improves Mid-Term Mortality in Patients With Refractory Cardiac Arrest or Cardiac Shock Who Required VA-ECMO
Authors: Inamori Taiji , Unoki Takashi , Nakayama Tomoko , Fukuda Toshiki , Toyofuku Takaaki , Matsura Junya , Konami Yutaka , Suzuyama Hiroto , Inoue Masayuki , Horio Eiji , Kodama Kazuhisa , Taguchi Eiji , Sawamura Tadashi , Sakamoto Tomohiro , Nakao Koichi , Koyama Jyunjiro
Published: December 2023

Background:
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is an effective therapy to rescue patients with refractory cardiogenic shock, including cardiac arrest. VA-ECMO increase damaged left ventricular (LV) afterload. The intra-aortic balloon pump (IABP) has been often used as the additional circulatory support for LV unloading. However, the effectiveness of combining VA-ECMO with IABP has not been definitively established. The Impella , a percutaneous micro-axial pump, can reduce damaged LV preload with circulatory support, which may have significant effect on clinical outcome by concomitant use of VA-ECMO and Impella (ECPELLA).

Objective:
This single-site cohort study aimed to assess the impact of ECPELLA compared to VA-ECMO with or without IABP in patients with refractory cardiogenic shock who received VA-ECMO treatment.

Methods:
We retrospectively reviewed 275 consecutive patients who received VA-ECMO from January 2012 through December 2022 in our institute. The patients were divided into two groups, ECEPLLA (n = 81) and VA-ECMO with or without IABP (n = 194). The primary outcome of this study was the 180-day all-cause mortality rate.

Results:
There were no significant differences in age, gender ratio, prevalence of coronary risk factors, serum lactate levels at the emergency room (ER), the rate of extracorporeal cardiopulmonary resuscitation (E-CPR), and instances of out-of-hospital cardiac arrest between the groups. The ECPELLA groups had a significantly higher rate of acute coronary syndrome and a lower prevalence of chronic kidney disease. Kaplan-Meier analysis demonstrated that the 180-day all-cause mortality was significantly lower in the ECPELLA group compared to the VA-ECMO group (p < 0.001). Multivariate cox proportional hazard analysis revealed that age (hazard ratio [HR], 1.27 [10 years increase]; 95% confidence interval [CI], 1.13-1.42, p < 0.001), E-CPR (HR 1.43; 95% CI 1.02-2.00, p = 0.04), lactate level at ER (HR 1.07; 95% CI 1.04-1.10, p < 0.001), and ECPELLA (HR, 0.55, 95% CI, 0.40-0.76, p < 0.001) were significantly associated with the 180-day all-cause mortality.

Conclusion:
ECPELLA was associated with improvement of mid-term mortality in patients with refractory cardiogenic shock who received VA-ECMO.
Abstract 395: Outcomes Of Mechanical Circulatory Support for Cardiogenic Shock in the United States: An Analysis of the 2017-2020 National Inpatient Sample Database
Authors: Ramirez Claudia M , Alshami Abbas , Udongwo Ndausung , Ziad-M.Said Mohamed , Tavakolian Kameron , Mararenko Anton , Pannu Viraaj , Grzybacz David , Imburgio Steven , Varon Joseph , Almendral Jesus
Published: December 2023

Introduction:
Mechanical circulatory support devices, such as Extracorporeal membrane oxygenation(ECMO), Impella, and intra-aortic balloon pump(IABP), play a crucial role in managing patients with cardiogenic shock(CS). This study aimed to compare the outcomes and patient characteristics of different mechanical circulatory support modalities.

Methods:
We utilized the National Inpatient Sample Database(NIS) data from 2017 to 2020 to identify patients with the diagnosis of CS who received mechanical circulatory support. The study population was categorized into six groups: ECMO, Impella, IABP, ECMO + Impella, and ECMO + IABP. The groups were compared based on patient characteristics, length of stay(LOS), complications, need for a heart transplant, mortality, and total charges.

Results:
A total of 715,470 patients were identified with CS, 17%(122,100) received mechanical circulatory support, 5,675 had ECMO therapy, 33,360 Impella, 79,540 IABP, 1,890 cases ECMO+Impella, and 1,635 cases ECMO+IABP. Age significantly differed, with ECMO patients being the youngest 54[36-65] years. There were higher proportions of females in the ECMO-only(37.4%) and males in the ECMO+Impella(76.7%). LOS was prolonged in the ECMO group(14 [5-28] days) compared to other groups(p<0.001). Mortality rates were higher in the ECMO group(47.1%), followed by ECMO+Impella(45.8%) and ECMO+IABP (40.1%) (p<0.001). Higher rates of stroke, disseminated intravascular coagulation, and continuous renal replacement therapy requirements were observed in the ECMO group. Bleeding requiring transfusion was more frequent with ECMO+IABP, and limb ischemia was more common in the ECMO+Impella group (p< 0.001). Heart transplant rates were highest after ECMO+IABP therapy. Over the years, ECMO utilization increased, while Impella and IABP utilization remained stable. Notably, the ECMO+IABP had the highest total charges among all the therapy modalities evaluated (p < 0.001).

Conclusions:
The rising utilization of ECMO and ECMO-IABP therapies indicates a changing treatment landscape. However, these approaches exhibit lower survival rates, potentially due to the severity of CS, heightened complications, and increased costs compared to standalone IABP or Impella therapies.
Abstract 429: The Association Between Naloxone Administration and Outcomes for Out-of-Hospital Cardiac Arrest Due to Suspected Overdose
Authors: Strong Nathan , Daya Mohamud R , Neth Matthew R , Noble Matt , Jui Jonathan , Lupton Joshua R
Published: December 2023

Background:
Opioid overdose is increasingly implicated in the development of out-of-hospital cardiac arrest (OHCA) and is a leading cause of death for adults 25 to 64 years old.

Aim:
Evaluate the association between naloxone use and outcomes after OHCA due to suspected overdose.

Methods:
This study was a secondary analysis of data collected in the Portland Cardiac Arrest Epidemiologic Registry, a database containing details of Emergency Medical Services (EMS)-treated cases of cardiac arrest around Portland, OR. Eligible patients had non-traumatic OHCA due to presumed overdose with naloxone (exposed) or without naloxone administration (control). We excluded patients with return of spontaneous circulation (ROSC) before the first dose of naloxone. The primary outcome was ROSC at emergency department (ED) arrival. Secondary outcomes included survival to admission; survival to hospital discharge; and cerebral perfusion category score ≤2 at discharge (functional survival). We performed multivariable logistic regressions adjusting for age, sex, arrest location, witness status, bystander interventions, initial EMS rhythm, time from 911 call to EMS arrival, and year of arrest. We separately assessed the subgroup with non-shockable initial rhythms.

Results:
Of 3,942 OHCA from 2018-2021, EMS documented an overdose etiology in 249. Of these, 236 (94.8%) had all variables and 18 were excluded for achieving ROSC prior to naloxone, resulting in 218 cases for analysis (171 receiving naloxone). Patients receiving naloxone had no difference in adjusted odds (aOR [95% CI]) of ROSC at ED arrival (1.43 [0.64-3.20]), survival to admission (1.87 [0.85-4.10]), survival to discharge (1.99 [0.39-10.30]) and functional survival (1.99 [0.34-11.55]). The subgroup with non-shockable rhythms showed higher odds of survival to admission (2.55 [1.09-5.92]) but not ROSC at ED arrival (1.60 [0.68-3.75]), survival to discharge (8.43 [0.84-84.20]), or good neurologic outcomes (7.26 [0.75-70.42]).

Conclusions:
For OHCA due to suspected overdose, those with initial non-shockable rhythms who received naloxone had higher adjusted odds of survival to admission than those who did not. Larger studies are necessary to evaluate the impact of naloxone on OHCA outcomes.
Abstract 430: Impact of the COVID-19 Pandemic on Out-of-Hospital Cardiac Arrest (OHCA) in Wayne County, Michigan
Authors: Almri Yasin , Klausner Howard A , Ball Matthew , Dunne Robert B , Rosenthal Marc , Miller Joseph B , Gunaga Satheesh , Brent Christine , Hunt Nathaniel R , Reece Ryan , Chien Christine , Page Brandon , Evans Hannah , Shields Teri
Published: December 2023

Background:
The COVID-19 pandemic has affected the incidence, presentation, care, and survival of OHCA. Early in the pandemic, healthcare systems were challenged by work force reduction due to illness and supply chain disruptions. We hypothesize there was an increase in the number of OHCA and a decrease in patient survival during the COVID-19 pandemic.

Methods:
We analyzed data from the Michigan Cardiac Arrest Registry to Enhance Survival (CARES) from 2018-2022 in Wayne County from two systems of care, Health Emergency Medical Services (HEMS) and Detroit East Medical Control Authority (DEMCA). We compared patient arrests and response characteristics during time periods: 2018-2019 (pre COVID-19), 2020-2021 (COVID-19), and 2022. Descriptive statistics were utilized for this retrospective review.

Results:
40 EMS agencies are included, and 12,695 OHCA cases were identified. HEMS and DEMCA recorded a total of 2,262 OHCA in 2018 and 2,401 in 2019. OHCA increased to 2,797 in 2020, 2,652 in 2021, and to 2,583 in 2022. There was a 6.1% increase in OHCA from 2018 to 2019, and a 16.5% increase in 2020, with a decrease of 6.4% in both 2021 and 2022. This trend is similarly observed in the rate of asystole as presenting rhythm. In 2018 and 2019, an average of 46.8% of patients were pronounced in the emergency department (ED) or on scene. This average rose to 56.8% in 2020 and 2021 and was 47.9% in 2022. There was also a decline in the average percentage of patients surviving until hospital admission, 23.3% in 2018 and 2019 and decreased to 18.4% in 2020 and 2021, and 22.5% in 2022. (
Figure 1.
)

Conclusion:
The COVID-19 pandemic may have impacted pre-hospital mortality and morbidity. There was an increase in OHCA and asystole as a presenting rhythm. The percentage of patients pronounced in the ED or on scene also increased. This data demonstrates that as a region, we have not returned to pre-pandemic levels and survivability for OHCA.

Figure 1.
Comparison of OHCA EMS Runs from 2018-2022
in Wayne County, MI