bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 339: Quality of Physician Care Coordination During Inter-Facility Transfer for Cardiac Arrest Patients
Authors: Holby Stephen N , Munoz Daniel , Collins Sean P , Vogus Timothy J , Jenkins Cathy A , Liu Dandan , Ward Michael J
Published: June 2021

Objectives:
We sought to evaluate whether the quality of coordination between physicians transferring comatose cardiac arrest survivors to a high-volume cardiac arrest center for targeted temperature management (TTM) was associated with timeliness of care.

Methods:
We conducted a retrospective analysis of inter-facility transfers to Vanderbilt University Medical Center for TTM between October 2016 and October 2018. We examined the relationship between Relational Coordination (RC) - a validated measure comprised of 7 dimensions of communication (frequency, timeliness, accuracy, problem solving) and relationship quality (respect, knowledge sharing, shared goals) - during recorded phone conversations between transferring and accepting physicians and time-to-acceptance. Investigators listened to recorded phone conversations and used a scoring guide to assign a score between 1 and 100 for each of the 7 dimensions of RC.

Results:
We identified 18 patients meeting criteria. TTM was initiated or continued in 72% (13 of 18). Median time-to-acceptance was 2.77 (interquartile range [IQR] 2.0, 4.1) minutes, and duration of calls was 3.95 (IQR 2.7, 5.2) minutes. Inter-rater reliability for overall RC was high (rho=0.87). The correlation between RC and the time-to-acceptance was significant in univariate analyses (adjusted relative risk=0.96, 95%CI 0.93, 1.0, p=0.05). Secondary analyses did not find a significant relationship between RC and timeliness measures.

Conclusions:
In this sample of patients transferred for TTM, we found that RC had a high inter-rater reliability. We also found that higher quality care coordination for cardiac arrest survivors was associated with faster physician acceptance. To better understand how the quality of care coordination impacts timeliness of care and patient outcomes, future work using a larger cohort should examine whether higher RC among a broader set of stakeholders (physicians, emergency medical services, families, etc.) is associated with timeliness measures after adjusting for other factors.
Abstract 340: Effect of the 2015 CPR Guidelines for Patients With Out-Of-Hospital Cardiac Arrest Due to Non-Shockable Rhythm: Results From the All-Japan Utstein Registry
Authors: Yagi Tsukasa , Nagao Ken , Tachibana Eizo , Yonemoto Naohiro , Tahara Yoshio , Nonogi Hiroshi , Ikeda Takanori , Sato Naoki , Tsutsui Hiroyuki
Published: June 2021

Background:
The 2015 cardiopulmonary resuscitation (CPR) guidelines have stressed that high-quality CPR improves survival from cardiac arrest (CA). In particular, the guidelines recommended that it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120/min in adult CA patients. However, it is unknown whether the 2015 guidelines contributed to favorable neurological outcome in adult CA patients. The present study aimed to clarify the effects of the 2015 guidelines in adult CA patients, using the data of the All-Japan Utstein Registry, a prospective, nationwide, population-based registry of out-of-hospital CA (OHCA).

Methods:
From the data of this registry between 2011 and 2016, we included adult witnessed OHCA patients due to cardiac etiology, who had non-shockable rhythm, PEA and asystole, as an initial rhythm. Study patients were divided into two groups based on the different CPR guidelines; the era of the 2010 guidelines (2010G), and the era of the 2015 guidelines (2015G). The endpoint was the favorable neurological outcome at 30 days after OHCA.

Results:
The 109,175 patients who met the inclusion criteria comprised 18,764 who received CPR based on 2015G and 90,411 who received CPR based on 2010G. The figure showed favorable neurological outcomes at 30 days in the two groups. In the multivariate analysis, the adjusted odds ratio for 30-day favorable neurological outcome in 2015G patients as compared to 2010G patients was 1.28 (95%CI 1.11-1.46, p<0.001).

Conclusion:
In the OHCA patients with non-shockable rhythm, the 2015 guidelines were superior to the 2010 guidelines, in terms of neurological benefits.
Abstract 346: Cardiac Diagnoses and Initial Presentation to the Emergency Department May Be Associated With Hospital Mortality Among Hospitalized Pediatric Patients Who Experience Medical Emergency Team Events
Authors: Piasecki Rebecca J , Bahouth Mona N , Budhathoki Chakra , Newton Heather M , Duval-Arnould Jordan M , Dennison Himmelfarb Cheryl R , HUNT Elizabeth A
Published: June 2021

Introduction:
There is a paucity of data regarding the association of pediatric patient characteristics with hospital mortality and transfer to higher levels of care following medical emergency team (MET) events.

Objective:
To explore associations of patient characteristics with hospital mortality and transfer to higher levels of care among pediatric patients who experienced a MET event during an admission.

Methods:
This retrospective observational study included data from patients aged ≤17 years admitted to an urban, tertiary hospital who experienced a MET event between 2014 and 2017. Data specific to the initial MET event for a patient were included for analysis. Multiple logistic regression models were used to test associations between patient characteristics (age, race, sex, ethnicity, timing of MET event, primary admission diagnosis, receiving care on specialized units) and each outcome separately.

Results:
Of the 366 patients eligible for inclusion, 11% (41 of 366) experienced hospital mortality, and 59% (216 of 366) were transferred to higher levels of care following MET events. Hospital mortality was lower among those who received emergency department care within 24 hours before the MET event compared to patients who did not (OR=0.17; 95% CI=0.04-0.82). Hospital mortality was higher among those with cardiac-related primary admission diagnoses compared to patients with noncardiac-related diagnoses (OR=3.44; 95% CI=1.04-11.39), and among those of unknown race compared to white patients (OR=3.14; 95% CI=1.17-8.48). No patient characteristics were associated with transfers to higher levels of care.

Conclusions:
While MET events may cause concern about failures to triage patients to appropriate levels of care upon admission, we observed that patients admitted from the emergency department within 24 hours before their MET event were more likely to survive to discharge. Higher hospital mortality following MET events was observed among patients with cardiac diagnoses and those of unknown race; more research is needed to understand how processes and documentation of care are related to these patients. Further study of how these characteristics and other potential confounding factors are associated with MET events and outcomes is warranted.
Abstract 347: Sudden Cardiac Arrest Caused by Coronary Artery Disease in School Students
Authors: Ayusawa Mamoru , Kato Masataka , Komori Akiko , Abe Yuriko , Ichikawa Rie
Published: June 2021

Background:
To disclose coronary artery disease (CAD) in the young is difficult by electrocardiogram screening for school students before their first events.

Methods:
By reviewing all reports submitted to the Mutual Aid System for Schools between 1989 and 2015, we listed all cases of sudden cardiac arrest which were considered to be caused by CAD. Kawasaki disease sequela was excluded. Epidemiology, type of CAD, symptom before onset, the intensity of the exercise at onset were investigated.

Results:
Thirty cases were enrolled and 26 resulted in sudden deaths, 4 were resuscitated without unfavorable sequelae. Cardioverter-defibrillator were implanted in 2 cases. Twenty-eight were male. One student was in 6th grader of primary, 11 in junior high, 15 cases in high, and 3 cases in nursing schools. Before onset, 12 cases were diagnosed as normal by ECG screening, 1 case for each was diagnosed as premature ventricular contraction, Wolff-Parkinson-White syndrome, and past history of atrial flutter. Diagnosis of 15 cases was unknown. Types based on hospital or post-mortem records: Left coronary artery (LCA); LCA of two cases were originated from the pulmonary artery, 4 cases from right coronary cuspid (RCC), and 1 from an unknown site. Two cases with LCA malformation without detail description, 3 with left ostium stenosis, and 1 with a myocardial bridge. Right coronary artery (RCA); RCA of a student was from left coronary cuspid (LCC), 1 from unknown site, 4 cases were diagnosed as hypoplastic RCA. Three cases complicated with atherosclerotic stenosis, 2 with hypoplastic CA, a case with single CA, and 4 with vasospastic angina.The school grader at onset: All of 4 cases with LCA from RCC, 2/3 with the LCA ostium stenosis and 3/4 with RCA hypoplasia were junior high school cases. Exercise intensity (level 1 to 5: most strenuous): At the onset, 19 cases were at level 5, 7 at level 4, 1 at level 3, 3 at an unknown level. Exercise at onset; soccer in 6 cases, basketball in 5, long distance running in 4, swimming, baseball, tennis, rugby, kendo, and on the way to school were in 2 for each.

Conclusion:
Anomalous ostium and origin of CA from the opposite side cusp tend to cause cardiac arrest in younger cases. CA evaluation by CT angiogram, MRI, or myocardial perfusion imaging is desirable.
Abstract 355: Effect of Poloxamer 188 on Rat Brain Isolated Mitochondria After Exposure to Hydrogen Peroxide
Authors: Pille Johannes A , Salzman Michele M , Sonju Anna A , Lotze Felicia P , Hees Josephine E , Cleveland William J , Balzer Claudius , Riess Matthias L
Published: June 2021

Introduction:
In a pig model of myocardial infarction (MI), intracoronary delivered Poloxamer (P) 188 significantly reduces ischemia/reperfusion (IR) injury when given immediately upon reperfusion, with improved mitochondrial function as a predominant effect. As mitochondria are heavily damaged during IR, a direct effect of P188 on mitochondria may lead to better therapy options during reperfusion. To show not only a similar reduction of IR injury by P188 in the brain, but also a direct P188 effect on mitochondria, we established an in-vitro model of IR that consists of damaging isolated rat brain mitochondria with hydrogen peroxide (H
2
O
2
), one component of ischemia, then applying P188, and analyzing mitochondrial function.

Methods:
Male Sprague-Dawley rat brains were removed, and the mitochondria isolated by differential centrifugation and Percoll gradients, then kept on ice to slow their bioenergetics prior to any experimental treatments. Mitochondria were exposed to 200 μM H
2
O
2
for 10 min at room temperature with slight agitation; controls received no H
2
O
2
. Samples were then diluted ½ with buffer ± P188 (250 μM after dilution) to simulate reperfusion and treatment, and kept at room temperature for 10 further minutes. ATP synthesis was measured in a luminometer using a luciferase enzymatic assay. Oxygen consumption was measured by closed cell respirometry with an oxygen meter. In both assays, Complex I and Complex II were examined; Complex I substrates glutamate and malate, Complex II substrate succinate plus the Complex I inhibitor rotenone. Statistics: Data are expressed as mean ± SEM. One-Way ANOVA, SNK-Test; Kruskal-Wallis-Test; α=0.05, * vs control.

Results:
In both Complex I and II, mitochondrial function was significantly impaired by H
2
O
2
, with ATP synthesis affected more at Complex I and oxygen consumption affected more at Complex II. Addition of P188 did not provide any significant improvement in mitochondrial function.

Conclusions:
Although P188 significantly reduced IR injury when given during reperfusion in a pig model of MI, it does not appear to provide direct protection to mitochondria in this in-vitro model. Whether the exposure to H
2
O
2
causes the appropriate injury for P188 to become effective remains to be elucidated.
Abstract 359: The Effect of BDNF on the Neuroprotection of Win55,212-2 Pharmacological Hypothermia After CPR in a Rat Cardiac Arrest Model
Authors: Song Fengqing , YU Tao , Fang Xiangshao , Jiang Longyuan , Yang Zhengfei , Tang Wanchun
Published: June 2021

Introduction:
Studies have demonstrated that Win55,212-2 induced pharmacological hypothermia and protected the neurological function after cardiopulmonary resuscitation (CPR) in a rat cardiac arrest (CA) model. However, the mechanism is still unclear. In this study, we hypothesized brain derived neurotrophic factor (BDNF) was involved in this mechanism.

Methods:
CA was induced by transoesophageal ventricular pacing in SD rats. 5min after onset of CA, CPR was started. After 30 min of ROSC, 30 animals were randomized into either Win55, 212-2 group (animals in drug groups were received continuous intravenous infusion of Win55,212-2 with 1 mg/kg/h for 4 h) or Normothermia group (animals were received 5% DMSO). Rats in normothermia group were maintained at 37°C with warming lamp though the whole experiment. Rats in drug group were warmed to 37°C increasingly after 4h of Win55,212-2 treatment. Brains of five animals in each group were harvested for detecting BDNF by RT-PCT and Westen blot at 24 h after ROSC respectively.

Results:
Temperatures of animals in Win55,212-2 group decreased to 34°C in 4 hours after ROSC, and the survival of which were longer than that of the control group. The expression of BDNF was significantly higher in the Win55, 212-2 group than that of control group.

Conclusions:
BDNF paticipated the neuroprotection of Win 55,212-2 after CPR in a rat CA model.
Abstract 366: Risk of Adverse Events With Left Ventricular Assist Devicein Cardiogenic Shock Patients
Authors: Louis Clauden
Published: June 2021

Study:
The aim of this single-center, a retrospective study was to evaluate early and long-term adverse events in advanced heart failure patients with cardiogenic shock who underwent ventricular assist device (VAD) implantation. We hypothesize that outcomes in patients implanted with LVAD with INTERMACS 1 have increased the risk of perioperative bleeding and infection.

Methods:
We evaluated outcomes in 191 patients with a HeartMate II LVAD implanted between May 2008 and June 2014 at the University of Rochester Medical Center, enrolled in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) Registry. Patients were divided into two groups: A) INTERMACS level 1 (cardiogenic shock) or B) INTERMACS level>1 (noncardiogenic shock). Preoperative characteristics, as well as post-surgical bleeding, infection and all-cause mortality, were assessed. The original LVAD database has received exempt status from the RSRB (RSRB00043111).

Results:
From 191 patients, there were 59 patients with INTERMACS level 1, and 132 with INTERMACS level greater than 1. Patients with INTERMACS level 1 at LVAD implantation were younger. Following LVAD implantation, INTERMACS level 1 patients had a trend towards bleeding and infection.
Abstract 369: Implantable Cardioverter Defibrillator Therapy in Patients With Vasospastic Angina After Sudden Cardiac Arrest
Authors: Tateishi Kazuya , Kondo Yusuke , Kitahara Hideki , Nakano Masahiro , Nakayama Takashi , Fujimoto Yoshihide , Kobayashi Yoshio
Published: June 2021

Introduction:
The prognosis of vasospastic angina (VSA) treated with optimal medication therapy is generally good. However, the patients resuscitated from sudden cardiac arrest (SCA) caused by lethal ventricular arrhythmias are at high risk of recurrent cardiovascular events. Moreover, little is known about the efficacy of implantable cardioverter defibrillator (ICD) therapy in this population The aim of this study is to evaluate the incidence of lethal arrhythmic events in VSA patients with secondary prophylaxis for SCA.

Methods:
Data from patients who received an ICD as a secondary prophylaxis in our institution between January 2012 and November 2018 were retrospectively analyzed. A total of 123 patients were enrolled in this study and divided into 16 patients with VSA (VSA group) and 107 patients without VSA (non-VSA group). VSA was diagnosed by acetylcholine provocation test or coronary angiography alone on arrival.

Results:
Current smoker was more prevalent and cardiac function was better in the VSA group. Diabetes mellitus was more prevalent in the non-VSA group. Although VSA patients were treated with calcium-channel blockers, with or without nitrates, 3 patients (18.8%) experienced appropriate ICD therapies due to lethal arrhythmias during a follow-up of 3.2 years. There were no significant differences in the proportion of appropriate and inappropriate therapy between 2 groups. (Table)

Conclusions:
Recurrent lethal arrhythmic events were common in patients with VSA after SCA. In addition to optimal medical therapy, ICD therapy should be aggressively considered in patients with VSA and a history of lethal arrhythmia.
Abstract 376: Confounders of Early Processed EEG to Stratify Neurological Injury After Cardiac Arrest
Authors: Seder David B , Bilkanovic Ameldina , Dziodzio John , Lucas Lee , Haxhija Zana , Denico Sadie , Ackert-Smith Lyn , Gagnon David , Ryzhov Sergey V , MAY Teresa , Riker Richard
Published: June 2021

Introduction:
Electroencephalographic suppression ratio (SR) measured six hours after resuscitation from cardiac arrest (SR6) can stratify risk of neurological-etiology death (NED) after cardiac arrest. Confounders of this tool for risk stratification have not been described.

Hypothesis:
Misclassification of risk of NED by SR6 is explained by characteristics of the patient, arrest, or treatment.

Methods:
Comatose patients prospectively enrolled in an IRB-approved cardiac arrest database were treated by protocol. Patients with brain death or death after withdrawal of life support measures (WLST) due to poor neurological prognosis were considered NED; neuroprognostication follows European Resuscitation Council guidelines. We analyzed patients misclassified by the SR6; high SR that did not suffer NED, or low SR6 that had NED. We reviewed factors associated with misclassification in bivariate analysis, and performed chart review for potential confounders of SR6.

Results:
Among 364 patients resuscitated from cardiac arrest and with complete data, SR6 predicted NED with AUC 0.89, and an optimal cutoff value of 55.5%. Forty (11%) patients with high SR6 and 17 (5%) with low SR6 were misclassified. In bivariate analysis, factors associated with high SR misclassification were older age 62.6(±14.9) vs. 56.4 (±16) p=0.02, prior neuropathology [20% vs 9.1%, p=0.049], and longer no-flow time (7 [4-9] vs 5 [2-7] minutes, p=0.01). Those associated with low SR misclassification were heart failure [29.4% vs 11.4%, p=0.045] hypertension [82.4% vs 44.6%, P=0.003], obesity [29.4% vs 10.7%, p=0.04], seizures [47.1% vs 21.5%, p=0.03], and higher BMI 33.9 [26.5-36.1] vs 27.8 [23.7-31.3], p=0.04. In chart review, misclassification was associated with early WLST due to family preference, drug or alcohol overdose, seizures, death due to non-neurological cause, preexisting neurological disease, and “favorable” SR6 trajectory.

Conclusion:
Age, seizures, drug overdose, and non-neurological causes of death may confound accurate neurological risk stratification using processed EEG very early after cardiac arrest. In addition to these “fixed” confounders, a few patients have dynamic SR that improves after 6 hours, and deserve further study.
Abstract 378: Diagnosing Pneumonia After Cardiac Arrest
Authors: Weissman Alexandra , Puyana Jacob S , Spencer David , Repine Melissa , Rittenberger Jon C , Callaway Clifton W
Published: June 2021

Introduction:
Post cardiac arrest syndrome, therapeutic hypothermia, and CPR confound the clinical diagnosis of pneumonia. Accurate pneumonia diagnosis is required to improve targeted antibiotic allocation and prevent sequelae of untargeted antibiotic therapy.

Hypothesis:
We can rigorously define pneumonia after cardiac arrest (CA) using accepted clinical parameters adapted from existing guidelines and innate immune system biomarkers Interleukin-17A (IL-17A), integrin α9β1, and CD11b specific to the response to pulmonary infection.

Methods:
A prospective cohort of consecutive OHCA patients surviving at least 72 hours from arrival was enrolled. IL-17A, integrin α9β1, and CD11b were measured daily at 4 timepoints from time 0 (arrival) through 72 hours. Chest radiography, pulmonary microbiology, temperature, and white blood cell count were recorded concurrently from the medical record. Pneumonia was defined narrowly (pna_narrow) by the presence of at least 2 of the following criteria in the initial 72 hours of presentation: fever ≥38°C; persistent infiltrate on chest radiography; positive sputum or bronchoalveolar lavage per the hospital microbiology laboratory. Broad criteria (pna_broad) also incorporated persistent leukocytosis ≥15,000 or leukopenia <3,000.

Results:
Of the 56 subjects with all data, 23% (13 of 56) met pna_narrow criteria while 43% (24 of 56) met pna_broad criteria. Positive clinical pulmonary microbiology was present in 62% (8 of 13) subjects meeting pna_narrow and 46% (11 of 24) subjects meeting pna_broad criteria. Antibiotics were given to 65% (28 of 43) subjects without pna_narrow and 63% (20 of 32) without pna_broad. Overall, 70% (39 of 56) subjects received antibiotics regardless of pneumonia status. Integrin α9β1 at Time 28 hours and Time 72 hours was associated with pna_narrow (p = 0.010, p = 0.049). CD11b at Time 0 and 72 hours was associated with pna_narrow (p = 0.03, p = 0.049). IL-17 at Time 28 and Time 72 was associated with pna_narrow (p = 0.04, p = 0.01).

Conclusions:
Pneumonia was rigorously defined in 23 to 43% of our sample, yet 70% of subjects received antibiotics. More rigorous definitions for pneumonia after CA, combined with pulmonary infection biomarkers, could be used to improve diagnosis and antibiotic allocation.
Abstract 379: Nursing Perspectives on Neuro-Prognostication for Post-Cardiac Arrest Patients and Their Integral Role in Supporting Surrogate Decision Makers
Authors: Perman Sarah M , Siry Bonnie J , Daugherty Stacie L , Havranek Edward
Published: June 2021

Introduction:
Post cardiac arrest patients frequently rely on surrogate decision makers (SDM) for critical decisions during their hospitalization. Our prior research has shown that bedside nurses are key resources for SDMs. Nurses’ understanding of post-arrest guidelines is therefore crucial if post-arrest care is to be concordant with guidelines.

Objective:
To explore critical care nurses familiarity with neuroprognostic guidelines and learn how they support families with decision making in the ICU.

Methods:
This inductive qualitative study consists of interviews with critical care nurses at an urban academic hospital. Subjects were identified by reviewing the care team of recent cardiac arrest patients. Nurses were invited by email to participate. Using a standardized interview guide, one on one interviews were conducted, audio recorded, and transcribed. Transcripts were read in entirety and thematically coded by two investigators.

Results:
Seven critical care nurses participated in this study. The participants were predominately female (6/7), mean age 32.4 years and had worked in critical care nursing from 1 year to 16 years. The nurses interviewed were based in the medical (3), cardiac (2) and neuro (2) ICUs. Major themes identified were: 1) discussion regarding prognosis is a team approach; 2) interpretation of neuroprognostic guidelines by nurses is variable; 3) communicating uncertainty to families and setting expectations is challenging. Excerpts to support these themes are identified in the table.

Conclusion:
Nurses are critical stakeholders in supporting surrogate decision makers in their decision-making. Ensuring that they are supported in relaying similar messages as the physician team, provided with more information regarding neurologic prognostication and supported in how to communicate uncertainty/set expectations will assist nurses in the integral and unique roll they play at the bedside of the post-cardiac arrest patient.
Abstract 387: Awareness and Cognitive Activity During Cardiac Arrest
Authors: Parnia Sam , Keshavarz Tara , McMullin Meghan , Williams Tori
Published: June 2021

Background:
While 50% of cardiac arrest (CA) survivors report negative psychological outcomes including post-traumatic stress disorder (PTSD), depression, and anxiety, 10% report a positive transformational outcome associated with recall of cognitive activity and 2-3% report external awareness during CPR. Though, often referred to using the poorly defined term of near-death experiences (NDE), this aspect of CA survivorship remains ill understood.

Methods:
In an ongoing prospective study (AWARE-II) we piloted methods to administer audiovisual stimuli to test implicit and explicit memories using a tablet computer with images and sounds delivered during on-going CPR.

Results:
Among 465 in-hospital CA lasting >5 min, 44 (9%) survived and 21 were interviewed. Of these, 4 (19%) reported explicit memories, including (internal) cognitive processes such as feeling peace, joy, and a perception of seeing relatives, while other memories were suggestive of (external) awareness e.g. hearing people talking, drugs given. One of 19 correctly recalled the audio stimuli given during CPR, but none identified the visual test. In this limited sample, there were no signs of implicit learning. We then compared these to 22 self-reported memories from a registry of CA survivors, Additional themes emerged as follows: 1) a sense of joy and peace (95%), perception of a light (86%), a tunnel (59%), a review and judgment of major life events including a person’s own actions and intentions (54%), and an overall feeling of positive transformation after the event (95%).

Conclusion:
External awareness and internal cognitive activity may occur during CA. However, it is unclear whether explicit recall sufficiently describes the entirety of cognitive processes during CA, or whether implicit memories may also form. In some survivors, memories lead to greater life-meaning and a positive transformation, which contrasts with negative psychological outcomes such as PTSD. In this context, in place of NDE a more appropriate term might be transformative experience of death (TED). Further studies, are needed to delineate the role of implicit and explicit learning and how cognitive activity during CPR may relate to brain resuscitation quality and overall psychological outcomes.
Abstract 388: Long-Distance Running Races Supported by Running Doctors Provide Better Clinical Outcomes for Runners With Cardiac Arrest
Authors: Kuroki Norihiro , Abe Daisuke , Suzuki Kou , Yuba Takao , Yui Yoshiaki , Takayama Akira , Ohashi Koichi , Hirano Hitoshi , Aoyama Takunori , Mukaida Takuto , Kimura Yumi , Okouchi Mikiko , Kato Taichi , Nagatomo Riki , Hamabe Yuichi
Published: June 2021

Background:
Approximately 10million people enjoy running in Japan annually. It is reported that the risk of an out-of-hospital cardiac arrest (OHCA) is temporarily increased during running. Several races in Japan supported by Running Doctors (RD) respond to runners with OHCA. The RDs are doctors who belong to the Japan Medical Joggers Association. The RDs participate in running races as general runners, perform medical monitoring from the inside of the running course, and if they encounter a serious health problem, especially OHCA, with a runner, they cancel their race and make an initial response. For example, 49 RDs cooperated in Tokyo Marathon 2019. However, the effectiveness of their activities is unclear. We investigated whether their activities were effective.

Methods:
A cohort of 8,884 patients with OHCA were admitted with return of spontaneous circulation (ROSC) or on-going resuscitation at our hospital arrival from 2006 to 2018. The 13 runners with OHCA which occurred during long distance running races were analyzed from the medical records and interviews of survivors and relatives. We divided runners into two groups depending on whether RD responded: RD group (n=7) and non-RD group (n=6). The clinical outcome was 30-day survival with minimal neurologic impairment.

Results;
Overall, the 12 (92%) runners were male. The RD group was older than Non-RD group (RD vs. Non-RD, 52±9 vs. 35±17 years old; P=0.04). The time interval between collapse and starting cardiopulmonary resuscitation (0.4±0.5 vs. 4.2±3.6 min; P=0.02) and between collapse and ROSC (6.6±2.9 vs. 23.3±19.3 min ; P=0.04) were significantly shorter in RD group. On Kaplan-Meier analysis, runners with OHCA in RD group were better clinical outcome than Non-RD group (100% vs. 67%; P=0.11; log-rank test). (Figure)

Conclusion;
The long-distance running races supported by running doctors provided early response to runners with OHCA. This might lead to better clinical outcomes for runners with OHCA.
Abstract 390: Automating a Cardiac Arrest Registry: Challenges and Opportunities
Authors: Idris Ahamed H , Owens Pamela , McDonald Samuel , Fowler Raymond , Herren Heather , May Susanne
Published: June 2021

Introduction:
A registry for out-of-hospital cardiac arrests facilitates cardiac arrest research, and emergency medical services (EMS) and community health quality improvement programs. Maintaining a cardiac arrest registry is labor intensive and costly, both of which could be reduced through automation.

Objective:
To determine the feasibility of automating data population of a cardiac arrest registry and to identify the components needed for and barriers to automation.

Methods:
This is a prospective feasibility study at the Dallas Fort-Worth (DFW) Center for Resuscitation Research. Our cardiac arrest registry was part of the multi-center Resuscitation Outcomes Consortium (ROC) Epistry from 2006 to 2016. Since 2016, we modified and maintained it separately from the ROC and over 20,000 cases have been enrolled. We identified the following critical elements necessary for automated data population of the registry: Create a registry dataset; create Business Associate Agreements with EMS agencies and hospitals; identify EMS and hospital electronic health record programs; develop a search strategy; search for appropriate cases in city servers where EMS patient care reports (PCRs) are stored and download data; move EMS data through our institutional firewall to a secure server; perform the same steps for hospital medical records; match EMS cases with hospital medical records, and automatically populate the registry with EMS and hospital data on a regular basis.

Results:
At the DFW site, EMS agencies use five different PCR programs and hospitals use two different electronic health record programs. A combination of 13 search terms captured 90% to 100% of appropriate cardiac arrest cases across six EMS agencies. Two different strategies can be used for streaming data across our firewall: A proprietary program entitled “Move-It” or a university generated file transfer protocol. We used a probabilistic logical approach for matching EMS cases with hospital cases.

Conclusions:
Automating a cardiac arrest registry is feasible. A cardiac arrest registry has many elements that must be considered to accomplish automation. The authors found that the most time consuming element is establishing Business Associate Agreements with all parties that provide data.
Abstract 391: Variation in Time to Notification After Enrollment in Trials Conducted Under Exception From Informed Consent for Emergency Research
Authors: Nichol Graham , Zhuang Rui , Aufderheide Tom P , Bulger Eileen , Callaway Clifton W , Christenson Jim , Daya Mohamud R , Idris Ahamed H , Kudenchuk Peter , Morrison Laurie J , Schreiber Martin A , Sopko George , Sugarman Jeremy , Vaillancourt Christian , Wang Henry E , Weisfeldt Myron , May Susanne
Published: June 2021

Context:
Research in an emergency setting is challenging because the window of opportunity to treat may be short, and preclude time to obtain informed consent from the patient or their representative. Such research can be conducted under exception from informed consent (EFIC) if specific criteria are met. In the United States, this includes notification of an enrolled subject or their representative as soon as feasible after enrollment so that they have autonomy to opt out from ongoing study participation. To date, there is limited empiric information about time to notification (TTN).

Objective:
To describe variation in TTN among sites participating in randomized trials conducted under exception from informed consent for emergency research.

Methods:
Notification strategies were determined at each site prior to initiation of subject enrollment, and approved by a local institutional review board or equivalent. TTN was summarized overall, as well as stratified by site and clinical outcome among patients enrolled in multiple trials conducted by the Resuscitation Outcomes Consortium (ROC).

Results:
Included were 34,868 patients enrolled in four trials. Of these, 33,805 had with out-of-hospital cardiac arrest; and 1,063 had life-threatening traumatic injury. TTN varied (Table).

Conclusions:
There is large variation in TTN in trials conducted under EFIC for emergency research. Early notification is difficult; delayed notification may reduce the autonomy of patients or their representative.
Abstract 400: Advanced Cardiac Life Support Taught in a Transitional Medical School Course Improves Retention: A Prospective Cohort Study
Authors: Mitrani Lindsey R , Sanderson Lauren J , Gordon Rachel J , Iyasere Julia E
Published: June 2021

Introduction:
Advanced cardiac life support (ACLS) is taught in a two-day course. Studies show decay in retention of ACLS starting at 3 months, while repeat simulation may improve performance.

Hypothesis:
We hypothesize that teaching ACLS using a low-dose, spaced curriculum will improve retention of knowledge and skills.

Methods:
In March and April 2018, we collaborated with the AHA to incorporate ACLS training into Ready 4 Residency (R4R), a month-long course for 4
th
year medical students meeting course completion requirements for ACLS. In September 2018, we consented interns, who completed traditional ACLS or ACLS in R4R. Interns completed 20 multiple-choice questions, two minutes of compressions, and one minute of ventilations for a 20-dollar gift card. Student’s t-test, chi-squared, and Fisher’s exact tests were used for statistical analyses.

Results:
Of 28 participants, 18 had completed traditional ACLS, and 10 had completed ACLS in R4R. For the 20-question exam, the results were 13.90 +/- 2.81 in ACLS in R4R compared to 13.83 +/- 2.38 in traditional ACLS (p = 0.95). Interns who completed ACLS in R4R performed an average rate of compressions at 111 +/- 10.3 compared to traditional ACLS for a rate of 122.89 +/- 11.05 (p=0.013), table 1. For interns who completed ACLS in R4R, 50% completed rescue breaths in range compared to 0% interns who completed traditional ACLS (p = 0.002), table 2.

Conclusions:
Integration of low-dose, spaced ACLS training for 4
th
year medical students may improve retention of skills. Since interns are frequently ‘first-responders’ during in-hospital arrest, improved ACLS skills may improve resuscitation outcomes.
Abstract 409: Predictive Value of ’OHCA’ and ’C-GRApH’ Score to Predict Neurological Outcome in Cardiac Arrest Patients Treated With Targeted Temperature Management
Authors: Kim Hyun Soo , Park Kyu Nam , Kim Soo Hyun , Oh Sang Hoon , Youn Chun Song
Published: June 2021

Introduction:
Despite recent advances in critical care, out-of-hospital cardiac arrest (OHCA) patients still have a low probability of survival. For the purpose of an objective assessment of a patient’s risk of death or neurological deficits, several clinical tools have recently been developed.

Hypothesis:
The first hypothesis is that OHCA and C-GRApH score could predict neurologic outcome after OHCA patients treated with targeted temperature management (TTM). The second hypothesis is that adding neurologic examination to those scores could further improve outcome prediction after OHCA.

Methods:
This retrospective study included OHCA patients treated with TTM from 2009 to 2017 in a tertiary teaching hospital in Seoul, Korea. We calculated two cardiac arrest specific risk scores (OHCA and C-GRApH) at the time of admission. Initial neurologic examination (Full Outline of UnResponsiveness Brainstem reflexes (FOUR_B) score and Glasgow Coma Scale motor score (GCS_M)) was also evaluated. The primary outcome was neurological outcome at 6 months after CA.

Results:
Of 311 subjects, 100 (32.2%) had a good neurologic outcome at 6 months after CA. OHCA score had AUC of 0.843 (95% CI 0.797 - 0.888) and C-GRApH score had AUC of 0.774 (95% CI 0.717 - 0.830). Addition of FOUR_B or GCS_M to OHCA score improved prediction of poor neurologic outcome (AUC 0.891, p = 0.001 for FOUR_B and AUC 0.878, p=0.004 for GCS_M). Results were similar for C-GRApH score to predict poor neurologic outcome.

Conclusions:
This study confirms the good prognostic performance of cardiac arrest specific scores to predict neurological outcomes in OHCA patients treated with TTM. Addition of neurologic examination variables further improved prognostication for neurologic outcome.
Abstract 411: Location of Collapse is Independently Associated With Initial Rhythm and Survival in Out-Of-Hospital Cardiac Arrest
Authors: Oving Iris , Hulleman Michiel , Homma Paulien C , Beesems Stefanie G , Tan Hanno L , Koster Rudolph W , Blom Marieke T
Published: June 2021

Introduction:
Out-of-hospital cardiac arrest (OHCA) at a home location is associated with lower rates of shockable initial rhythm (SIR) and survival than OHCA at a public location. While this is generally attributed to unfavourable resuscitation characteristics, it might also be explained by differences in pre-existing disease or medication use between patients with OHCA at home and those in public. We compared medical history and medication use between home and public OHCA patients, and determined whether these factors explain the association between OHCA location and SIR or survival.

Methods:
Data from ARREST, an OHCA registry in the Netherlands, were used (Jan 2009 - Dec 2012). We assessed the association between OHCA location and a) presence of SIR and b) survival to hospital discharge in a multivariable regression analysis taking medical history, medication use, resuscitation characteristics and demographics into account. Next, the relative contribution of the abovementioned variables to variance in both outcome measures was estimated using the Nagelkerke test.

Results:
In total, 1724 patients were included (1278 [74.1%] home OHCA, 446 [25.9%] public OHCA). OHCA location was significantly associated with rates of SIR (home 39.1%, public 75.1%;
P
<0.01) and survival to hospital discharge (home 17.2%, public 47.3%;
P
<0.01). Adding resuscitation characteristics to models of SIR rate and survival rate resulted in the largest increase in explained variance (Figure 1A and 1B), whereas adding pre-existing disease or medication use to the models resulted in only a limited increase in explained variance (Figure 1A and 1B).

Conclusions:
Location of OHCA remains significantly associated with lower rates of SIR and survival, even when adjusted for medical history, medication use, resuscitation characteristics and demographics; an unexplained gap remains. Both medical history and medication use only explain a modest proportion of the variance of SIR and survival.
Abstract 419: Admission to Hospital With Ongoing Resuscitation - Are There Survivors?
Authors: Seewald Stephan , Wnent Jan , Gräsner Jan-Thorsten , Bohn Andreas , Fischer Matthias , Jakisch Barbara
Published: June 2021

Introduction:
The Emergency Medical Service Systems (EMS) in Germany are physician-based and provided by a two-tier system: One unit comprises physician staffing, and the second paramedics. Both units are simultaneously dispatched for a CPR call and are to arrive on scene at the same time. The physicians are allowed to terminate resuscitation efforts on scene or to indicate a transport to hospital under ongoing resuscitation.The aim of this study was to find out which patient survived after hospital admission with ongoing resuscitation.

Materials and Methods:
Data from the German Resuscitation Registry from the period 2014-2018, which have documented a hospital admission under ongoing resuscitation, will be examined. We excluded all patients without information on hospital outcome.

Results:
During the period, 7.146 patients were admitted to hospital under ongoing CPR. We included 2,884 patients with complete information on hospital outcome in this study. Of those, 73% were male and, on average, 62.2 years old. In 52% of all cases, mechanical chest compression devices were used. 12% of all patients admitted to hospital with ongoing resuscitation survived 24 hours and 4% can discharged alive, 2% with good neurological outcome (CPC ½). Patients survived to hospital discharge were younger (57.4 vs. 62.4 years), more male (79% vs. 73%) and have a shorter resuscitation free interval (3:49 vs. 4:53 min). If the patients can discharge alive, the initial rhythm were more often VF/pVT (71% vs. 30%) and more often the emergency physician presumed a cardiac cause of the arrest (79% vs. 67%). The rate of bystander resuscitation (39% vs. 36%) and telephone-guided CPR is similar between the two groups (18% vs. 16%).

Conclusions:
At all, 4% of all patients admitted to hospital under ongoing CPR can be discharged alive. The discharged patients are younger, more often male and have more often a cardiac cause of the arrest. More detailed analyses are necessary to define criteria for transport under ongoing resuscitation.
Abstract 420: Comparison of Prognostic Predictors After Return of Spontaneous Circulation Between Cardiac and Non-Cardiac Cardiopulmonary Arrest
Authors: Ohmure Kenta , Miyata Masaaki , Tagata Kento , Yokomine Tatsuo , Nomoto Yuutaro , Imamura Shunichi , Kawasoe Mariko , Chaen Hideto , Oketani Naoya , Ogawa Masakazu , Ohishi Mitsuru
Published: June 2021

Introduction:
Understanding the characteristics of survivor after return of spontaneous circulation (ROSC) in patients with cardiopulmonary arrest (CPA) may help us to select the optimal management.

Hypothesis:
We hypothesized that the prognosis and predictors of survivor after ROSC could be different between cardiac and non-cardiac CPA patients.

Method:
We retrospectively analyzed consecutive 85 patients with CPA and ROSC after cardiopulmonary resuscitation (CPR) in our hospital and divided them into cardiogenic (n=35) and non-cardiogenic (n=50) CPA. We analyzed age, gender, bystander CPR, duration of CPA, pupil diameter at admission, Glasgow coma scale, total protein (TP) level, creatinine level, pH of arterial blood and death in hospital.

Result:
The 17 patients died in cardiogenic CPA and 40 patients in non-cardiogenic CPA. The Kaplan-Meier curve demonstrated the better prognosis in cardiogenic CPA compared with non-cardiogenic CPA (Figure). In both CPA, duration of CPA was shorter and total TP level was higher in survival than those in dead group. In cardiogenic CPA, age was younger and creatinine level was lower in survival group compared with dead group (Table). In non-cardiogenic CPA, pupil diameter was smaller in survival group compared with dead group. Furthermore, in TP levels, the receiver operating characteristic (ROC) curve for survival after ROSC demonstrated that the area under curve (AUC) was 0.82 and provided an optimal cut-off value at 6.2 mg/dl of TP with 71% sensitivity and 83% specificity. In non-cardiogenic CPA, ROC curve demonstrated that AUC was 0.73 and 59% sensitivity, and 100% specificity at the optimal cut-off value of TP 6.0 mg/dl. Therefore, TP levels may be the better prognostic predictor in cardiogenic CPA compared with non-cardiogenic CPA.

Conclusion:
Although duration of CPA and TP levels were common predictor for survival after ROSC in CPA, there were different prognostic predictors in cardiogenic or non-cardiogenic CPA.
Abstract 428: Cause of Death Among Patients Resuscitated From Out-Of-Hospital Cardiac Arrest at a Single Urban Academic Hospital
Authors: Li Shu , Lazaridis Christos , Goldenberg Fernando D , Shah Atman , Beiser David , Sharp Willard W
Published: June 2021

Background:
Approximately 30% of patients resuscitated following Out of Hospital Cardiac Arrest (OHCA) survive to hospital admission, but only 10% of these patients survive to hospital discharge. Reasons for in hospital death of these patients is not well known or categorized. Understanding the principle reason for death among successfully resuscitated OHCA patients could guide the development of therapeutic and management strategies

Methods:
Using a retrospective OHCA cohort database at a single urban academic hospital, death of admitted adult OHCA patients from January 1, 2016 until June 30, 2019 was classified as primarily due to withdrawal of life-sustaining treatments (WOLST), in-hospital cardiac arrest, or formal declaration of death by neurologic criteria (brain death). Family/caregiver decisions to WOLST were categorized as occurring primarily in the setting of isolated severe neurological injury, multi-organ failure, in hospital cardiac arrest, severe hemodynamic shock, pre-existing comorbidities/terminal health condition, or prior unknown DNR status. Traumatic arrests were excluded.

Results:
During the study period there were 578 cardiac arrests brought to the emergency department; 291 (50%) patients survived to hospital admission. Of admitted patients, 95 patients (33%) survived to hospital discharge and 194 patients (67%) died. In non-surviving patients, death was attributable to WOLST (77%), brain death 25 (13%), in-hospital cardiac arrest (9%), and failure to achieve return of spontaneous circulation on ECMO 1 (1%). Decisions to WOLST by family members were complex and multi-factorial but were determined in the context of poor neurologic prognosis 93 (62%), multi-organ failure 27 (18%), in hospital cardiac arrest 11 (7%), severe shock 11 (7%), unknown prior DNR status 7 (5%), and pre-existing terminal illness 2 (1%).

Conclusion:
In this single center study, the majority of OHCA patients who survived to hospital admission from the emergency department subsequently died in the hospital due to the severity of their neurological injury in the context of WOLST. Death in the setting of multiorgan failure, re-arrest, or severe hemodynamic shock was less common.