Comparison of out-of-hospital cardiac arrests during the COVID-19 pandemic with those before the pandemic: an updated systematic review and meta-analysis.

The coronavirus disease of 2019 (COVID-19) pandemic, directly and indirectly, affected the emergency medical care system and resulted in worse out-of-hospital cardiac arrest (OHCA) outcomes and epidemiological features compared with those before the pandemic. This review compares the regional and temporal features of OHCA prognosis and epidemiological characteristics. Various databases were searched to compare the OHCA outcomes and epidemiological characteristics during the COVID-19 pandemic with before the pandemic. During the COVID-19 pandemic, survival and favorable neurological outcome rates were significantly lower than before. Survival to hospitalization, return of spontaneous circulation, endotracheal intubation, and use of an automated external defibrillator (AED) decreased significantly, whereas the use of a supraglottic airway device, the incidence of cardiac arrest at home, and response time of emergency medical service (EMS) increased significantly. Bystander CPR, unwitnessed cardiac arrest, EMS transfer time, use of mechanical CPR, and in-hospital target temperature management did not differ significantly. A subgroup analysis of the studies that included only the first wave with those that included the subsequent waves revealed the overall outcomes in which the epidemiological features of OHCA exhibited similar patterns. No significant regional differences between the OHCA survival rates in Asia before and during the pandemic were observed, although other variables varied by region. The COVID-19 pandemic altered the epidemiologic characteristics, survival rates, and neurological prognosis of OHCA patients. Review registration: PROSPERO (CRD42022339435).

Airway management during cardiac arrest.

PURPOSE OF REVIEW: Despite improvements over time, cardiac arrest continues to be associated with high rates of mortality and morbidity. Several methods can be used to achieve airway patency during cardiac arrest, and the optimal strategy continues to be debated. This review will explore and summarize the latest published evidence for airway management during cardiac arrest. RECENT FINDINGS: A large meta-analysis of out-of-hospital cardiac arrest (OHCA) patients found no difference in survival between those receiving tracheal intubation and those treated with a supraglottic airway (SGA). Observational studies of registry data have reported higher survival to hospital discharge in patients receiving tracheal intubation or an SGA but another showed no difference. Rates of intubation during in-hospital cardiac arrest have decreased in the United States, and different airway strategies appear to be used in different centres. SUMMARY: Observational studies continue to dominate the evidence base relating to cardiac arrest airway management. Cardiac arrest registries enable these observational studies to include many patients; however, the design of such studies introduces considerable bias. Further randomized clinical trials are underway. The current evidence does not indicate a substantial improvement in outcome from any single airway strategy.

[Impact of the COVID-19 pandemic on basic resuscitation and success rate after sudden cardiac arrest]. / A COVID­19-pandémia hatása a hirtelen szívmegállást követo alapszintu újraélesztésre és annak sikerességére.

Since the onset of the coronavirus disease, infection-related mortality has been tracked worldwide and the number of deaths caused by the virus is counted daily. The coronavirus pandemic has not only transformed our daily life, but reorganized the whole healthcare system. In response to the increased demand for hospital admissions, leaders in different countries have implemented a number of emergency actions. The restructuring has had both direct and indirect negative effects on the epidemiology of sudden cardiac death, the willingness of lay rescuer to give cardiopulmonary resuscitation and the use of automated external defibrillators, but these negative effects vary widely across continents and countries. In order to protect lay people and health workers as well as to prevent the spread of the pandemic, the previous recommendations of the European Resuscitation Council on basic and advanced life support have undergone a few modifications. Orv Hetil. 2023; 164(13): 483-487.

Impact of COVID-19-adapted guidelines using different airway management strategies on resuscitation quality in out-of-hospital-cardiac-arrest - a randomised manikin study.

BACKGROUND: Although airway management for paramedics has moved away from endotracheal intubation towards extraglottic airway devices in recent years, in the context of COVID-19, endotracheal intubation has seen a revival. Endotracheal intubation has been recommended again under the assumption that it provides better protection against aerosol liberation and infection risk for care providers than extraglottic airway devices accepting an increase in no-flow time and possibly worsen patient outcomes. METHODS: In this manikin study paramedics performed advanced cardiac life support with non-shockable (Non-VF) and shockable rhythms (VF) in four settings: ERC guidelines 2021 (control), COVID-19-guidelines using videolaryngoscopic intubation (COVID-19-intubation), laryngeal mask (COVID-19-Laryngeal-Mask) or a modified laryngeal mask modified with a shower cap (COVID-19-showercap) to reduce aerosol liberation simulated by a fog machine. Primary endpoint was no-flow-time, secondary endpoints included data on airway management as well as the participants' subjective assessment of aerosol release using a Likert-scale (0 = no release-10 = maximum release) were collected and statistically compared. Continuous Data was presented as mean ± standard deviation. Interval-scaled Data were presented as median and Q1 and Q3. RESULTS: A total of 120 resuscitation scenarios were completed. Compared to control (Non-VF:11 ± 3 s, VF:12 ± 3 s) application of COVID-19-adapted guidelines lead to prolonged no-flow times in all groups (COVID-19-Intubation: Non-VF:17 ± 11 s, VF:19 ± 5 s;p ≤ 0.001; COVID-19-laryngeal-mask: VF:15 ± 5 s,p ≤ 0.01; COVID-19-showercap: VF:15 ± 3 s,p ≤ 0.01). Compared to COVID-19-Intubation, the use of the laryngeal mask and its modification with a showercap both led to a reduction of no-flow-time(COVID-19-laryngeal-mask: Non-VF:p = 0.002;VF:p ≤ 0.001; COVID-19-Showercap: Non-VF:p ≤ 0.001;VF:p = 0.002) due to a reduced duration of intubation (COVID-19-Intubation: Non-VF:40 ± 19 s;VF:33 ± 17 s; both p ≤ 0.01 vs. control, COVID-19-Laryngeal-Mask (Non-VF:15 ± 7 s;VF:13 ± 5 s;p > 0.05) and COVID-19-Shower-cap (Non-VF:15 ± 5 s;VF:17 ± 5 s;p > 0.05). The participants rated aerosol liberation lowest in COVID-19-intubation (median:0;Q1:0,Q3:2;p < 0.001vs.COVID-19-laryngeal-mask and COVID-19-showercap) compared to COVID-19-shower-cap (median:3;Q1:1,Q3:3 p < 0.001vs.COVID-19-laryngeal-mask) or COVID-19-laryngeal-mask (median:9;Q1:6,Q3:8). CONCLUSIONS: COVID-19-adapted guidelines using videolaryngoscopic intubation lead to a prolongation of no-flow time. The use of a modified laryngeal mask with a shower cap seems to be a suitable compromise combining minimal impact on no-flowtime and reduced aerosol exposure for the involved providers.

An Intensivist-Led Extracorporeal Membrane Oxygenation Program: Design, Implementation, and Outcomes of the First Five Years.

We describe the development, implementation, and outcomes of an intensivist-led adult extracorporeal life support (ECLS) program using intensivists both to perform venovenous (V-V), venoarterial (V-A), and extracorporeal cardiopulmonary resuscitation (ECPR) cannulations, and to manage patients on ECLS throughout their ICU course. All adults supported with ECLS at the University of New Mexico Hospital (UNMH) from February 1, 2017 to December 31, 2021 were retrospectively analyzed. A total of 203 ECLS cannulations were performed in 198 patients, including 116 V-A cannulations (including 65 during ECPR) and 87 V-V cannulations (including 38 in patients with COVID-19). UNMH intensivists performed 195 cannulations, with 9 cannulation complications. Cardiothoracic surgeons performed 8 cannulations. Overall survival to hospital discharge or transfer was 46.5%. Survival was 32.3% in the ECPR group and 56% in the non-ECPR V-A group. In the V-V cohort, survival was 66.7% in the COVID-19-negative patients and 34.2% in the COVID-19-positive patients. This large series of intensivist-performed ECLS cannulations-including V-A, V-V, and ECPR modalities-demonstrates the successful implementation of a comprehensive intensivist-led ECLS program. With outcomes comparable to those in the literature, our program serves as a model for the initiation and development of ECLS programs in settings with limited access to local subspecialty cardiothoracic surgical services.

[Out-of-hospital adult basic life support: new guidelines and the involvement of bystanders]. / A kórházon kívüli felnott alapszintu újraélesztés új irányelvei és a laikusok bevonásának kérdései.

Survival rate for out-of-hospital cardiac arrest remains low across Europe. In the last decade, involving bystanders turned out to be one of the most important key factors in improving the outcome of out-of-hospital cardiac arrest. Beside recognizing cardiac arrest and initiate chest compressions, bystanders could be also involved in delivering early defibrillation. Although adult basic life support is a sequence of simple interventions that can be easily learnt even by schoolchildren, non-technical skills and emotional components can complicate real-life situations. This recognition combined with modern technology brings a new point of view in teaching and implementation. We review the latest practice guidelines and new advances in the education (including the importance of non-technical skills) of out-of-hospital adult basic life support, also considering the effects of COVID-19 pandemic. We briefly present the Szív City application developed to support the involvement of lay rescuers. Orv Hetil. 2023; 164(12): 443-448.

Efficacy of distance training program for cardiopulmonary resuscitation utilizing smartphone application and home delivery system.

AIM OF THE STUDY: Community cardiopulmonary resuscitation (CPR) education is important for laypersons. However, during the COVID-19 pandemic, with social distancing, conventional face-to-face CPR training was unavailable. We developed a distance learning CPR training course (HEROS-Remote) using a smartphone application that monitors real-time chest compression quality and a home delivery collection system for mannikins. This study aimed to evaluate the efficacy of the HEROS-Remote course by comparing chest compression quality with that of conventional CPR training. METHODS: We applied layperson CPR education with HEROS-Remote and conventional education in Seoul during the COVID-19 pandemic. Both groups underwent a 2-min post-training chest compression test, and we tested non-inferiority. Chest compression depth, rate, complete recoil, and composite chest compression score was measured. Trainees completed a satisfaction survey on CPR education and delivery. The primary outcome was the mean chest compression depth. RESULTS: A total of 180 trainees were enrolled, with 90 assigned to each training group. Chest compression depth of HEROS-Remote training showed non-inferiority to that of conventional training (67.4 vs. 67.8, p = 0.78), as well as composite chest compression score (92.7 vs. 95.5, p = 0.16). The proportions of adequate chest compression depth, chest compression rate, and chest compressions with complete chest recoil were similar in both training sessions. In the HEROS-Remote training, 90% of the trainees were satisfied with CPR training, and 96% were satisfied with the delivery and found it convenient. CONCLUSION: HEROS-Remote training was non-inferior to conventional CPR training in terms of chest compression quality. Distance learning CPR training using a smartphone application and mannikin delivery had high user satisfaction and was logistically feasible.

An unbroken ring of the chain of survival.

This is a commentary on the study conducted by Kennedy et al. from Victoria, Australia, that analyzed the cohort of all adult EMS-witnessed out-of-hospital cardiac arrest (OHCA) patients in the region and compared patients treated during the COVID-19 period to a historical comparator period. The commentary summarizes the study findings and discusses the importance of the study in the context of the chain of survival and changes in airway management for OHCA patients during the COVID-19 pandemic.

In-hospital cardiac arrest.

PURPOSE OF REVIEW: To describe our knowledge about in-hospital cardiac arrest (IHCA) including recent developments. RECENT FINDINGS: Improving trends in IHCA outcomes appear to have stalled or reversed since the COVID-19 pandemic. There are disparities in care based on patient sex, ethnicity and socioeconomic status that need to be tackled. The increased use of emergency treatment plans that include do-not attempt cardiopulmonary resuscitation recommendations will help to decrease the number of resuscitation attempts. System approaches and strong local leadership through resuscitation champions can improve patient outcomes. SUMMARY: In-hospital cardiac arrest is a global health problem with a 25% survival in high-income settings. There remain significant opportunities to both decrease the incidence of, and outcomes from IHCA.

Factors associated with the arrival of smartphone-activated first responders before the emergency medical services in Out-of-Hospital cardiac arrest dispatch.

BACKGROUND: First responder programs were developed to speed up access to cardiopulmonary resuscitation and defibrillation for out-of-hospital cardiac arrest (OHCA) victims. Little is known about the factors influencing the efficiency of the first responders arriving before the EMS and, therefore, effectively contributing to the chain of survival. OBJECTIVES: The primary objective of this retrospective observational study was to identify the factors associated with first responders' arrival before EMS in the context of a regional first responder program arranged to deliver automated external defibrillators on suspected OHCA scenes. METHODS: Eight hundred ninety-six dispatches where FRs intervened were collected from 2018 to 2022. A robust Poisson regression was performed to estimate the role of the time of day, the immediate availability of a defibrillator, the type of first responder, distances between the responder, the event and the dispatched vehicle, and the nearest available defibrillator on the probability of responder arriving before EMS. Moreover, a geospatial logistic regression model was built. RESULTS: Responders arrived before EMS in 13.4% of dispatches and delivered a shock in 0.9%. The immediate availability of a defibrillator for the responder (OR = 3.24) and special categories such as taxi drivers and police (OR = 1.74) were factors significantly associated with the responder arriving before EMS. Moreover, a geospatial effect suggested that first responder programs may have a greater impact in rural areas. CONCLUSIONS: When dispatched to OHCA scenes, responders already carrying defibrillators could more probably reach the scene before EMS. Special first responder categories are more competitive and should be further investigated.

Effects of the 2020 COVID-19 pandemic on outcomes of out-of-hospital cardiac arrest and bystander resuscitation efforts: a nationwide cohort study in Japan.

Background and importance There is limited knowledge about the nationwide impact of the 2020 COVID-19 pandemic in Japan on out-of -hospital cardiac arrest (OHCA) outcomes.Objectives The aim of this study was to investigate the impact of the 2020 COVID-19 pandemic on OHCA outcomes and bystander resuscitation efforts in Japan. Design Retrospective analysis of a nationwide population-based registry of OHCA cases. Settings and participants To conduct this study, we created a comprehensive database comprising 821 665 OHCA cases by combining and reconciling the OHCA database for 835 197 OHCA cases between 2017 and 2020 with another database, including location and time records. After applying exclusion and inclusion criteria, we analysed 751 617 cases.Outcome measures and analysis The primary outcome measure for this study was survival with neurologically favourable outcome (cerebral performance category 1 or 2). We compare OHCA characteristics and outcomes between prepandemic and pandemic years, and also investigated differences in factors associated with outcomes. Results We found that survival with neurologically favourable outcome and the rates of bystander cardiopulmonary resuscitation (CPR) slightly increased in the pandemic year [2.8% vs. 2.9%; crude odds ratio (OR), 1.07; 95% confidence interval (CI), 1.03-1.10; 54.1% vs. 55.3%, 1.05 (1.04-1.06), respectively], although the incidence of public access defibrillation (PAD) slightly decreased [1.8% vs. 1.6%, 0.89 (0.86-0.93)]. Calls for hospital selection by emergency medical service (EMS) increased during the pandemic. Subgroup analysis showed that the incidence of neurologically favourable outcome increased in 2020 for OHCA cases that occurred on nonstate of emergency days, in unaffected prefectures, with noncardiac cause, nonshockable initial rhythm, and during daytime hours. Conclusions During the 2020 COVID-19 pandemic in Japan, survival with neurologically favourable outcome of OHCA patients and bystander CPR rate did not negatively change, despite the decrement in PAD incidence. However, these effects varied with the state of emergency, region, and characteristics of OHCA, suggesting an imbalance between medical demand and supply, and raising concerns about the pandemic.

Impact of COVID-19 on Out-of-Hospital Cardiac Arrest in Korea.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a global public health crisis that has had a significant impact on emergency medical services (EMS). Several studies have reported an increase in the incidence of out-of-hospital cardiac arrest (OHCA) and a decreased survival due to COVID-19, which has been limited to a short period or has been reported in some regions. This study aimed to investigate the effect of COVID-19 on OHCA patients using a nationwide database. METHODS: We included adult OHCA patients treated by EMS providers from January 19, 2019 to January 20, 2021. The years before and after the first confirmed case in Korea were set as the non-COVID-19 and COVID-19 periods, respectively. The main exposure of interest was the COVID-19 period, and the primary outcome was prehospital return of spontaneous circulation (ROSC). Other OHCA variables were compared before and after the COVID-19 pandemic and analyzed. We performed a multivariable logistic regression analysis to understand the independent effect of the COVID-19 period on prehospital ROSC. RESULTS: The final analysis included 51,921 eligible patients, including 25,355 (48.8%) during the non-COVID-19 period and 26,566 (51.2%) during the COVID-19 period. Prehospital ROSC deteriorated during the COVID-19 period (10.2% vs. 11.1%, P = 0.001). In the main analysis, the adjusted odds ratios (AORs) for prehospital ROSC showed no significant differences between the COVID-19 and non-COVID-19 periods (AOR [95% confidence interval], 1.02 [0.96-1.09]). CONCLUSION: This study found that the proportion of prehospital ROSC was lower during the COVID-19 period than during the non-COVID-19 period; however, there was no statistical significance when adjusting for potential confounders. Continuous efforts are needed to restore the broken chain of survival in the prehospital phase and increase the survival rate of OHCA patients.

The effect of the COVID-19 pandemic on the incidence and survival outcomes of EMS-witnessed out-of-hospital cardiac arrest.

AIM: We sought to examine the impact of the COVID-19 pandemic on the incidence and survival outcomes of emergency medical service (EMS)-witnessed out-of-hospital cardiac arrest (OHCA) in Victoria, Australia. METHODS: We performed an interrupted time-series analysis of adult EMS-witnessed OHCA patients of medical aetiology. Patients treated during the COVID-19 period (1st March 2020 to 31st December 2021) were compared to a historical comparator period (1st January 2012 and 28th February 2020). Multivariable poisson and logistic regression models were used to examine changes in incidence and survival outcomes during the COVID-19 pandemic, respectively. RESULTS: We included 5,034 patients, 3,976 (79.0%) in the comparator period and 1,058 (21.0%) in the COVID-19 period. Patients in the COVID-19 period had longer EMS response times, fewer public location arrests and were significantly more likely to receive mechanical CPR and laryngeal mask airways compared to the historical period (all p < 0.05). There were no significant differences in the incidence of EMS-witnessed OHCA between the comparator and COVID-19 periods (incidence rate ratio 1.06, 95% CI: 0.97-1.17, p = 0.19). Also, there was no difference in the risk-adjusted odds of survival to hospital discharge for EMS-witnessed OHCA occurring during COVID-19 period compared to the comparator period (adjusted odd ratio 1.02, 95% CI: 0.74-1.42; p = 0.90). CONCLUSION: Unlike the reported findings in non-EMS-witnessed OHCA populations, changes during the COVID-19 pandemic did not influence incidence or survival outcomes in EMS-witnessed OHCA. This may suggest that changes in clinical practice that sought to limit the use of aerosol generating procedures did not influence outcomes in these patients.

Amplitude Spectrum Area of ventricular fibrillation to guide defibrillation: a small open-label, pseudo-randomized controlled multicenter trial.

BACKGROUND: Ventricular fibrillation (VF) waveform analysis has been proposed as a potential non-invasive guide to optimize timing of defibrillation. METHODS: The AMplitude Spectrum Area (AMSA) trial is an open-label, multicenter randomized controlled study reporting the first in-human use of AMSA analysis in out-of-hospital cardiac arrest (OHCA). The primary efficacy endpoint was the termination of VF for an AMSA ≥ 15.5 mV-Hz. Adult shockable OHCAs randomly received either an AMSA-guided cardiopulmonary resuscitation (CPR) or a standard-CPR. Randomization and allocation to trial group were carried out centrally. In the AMSA-guided CPR, an initial AMSA ≥ 15.5 mV-Hz prompted for immediate defibrillation, while lower values favored chest compression (CC). After completion of the first 2-min CPR cycle, an AMSA < 6.5 mV-Hz deferred defibrillation in favor of an additional 2-min CPR cycle. AMSA was measured and displayed in real-time during CC pauses for ventilation with a modified defibrillator. FINDINGS: The trial was early discontinued for low recruitment due to the COVID-19 pandemics. A total of 31 patients were recruited in 3 Italian cities, 19 in AMSA-CPR and 12 in standard-CPR, and included in the data analysis. No difference in primary outcome was observed between the two groups. Termination of VF occurred in 74% of patients in the AMSA-CPR compared to 75% in the standard CPR (OR 0.93 [95% CI 0.18-4.90]). No adverse events were reported. INTERPRETATION: AMSA was used prospectively in human patients during ongoing CPR. In this small trial, an AMSA-guided defibrillation provided no evidence of an improvement in termination of VF. TRIAL REGISTRATION: NCT03237910. FUNDING: European Commission - Horizon 2020; ZOLL Medical Corp., Chelmsford, USA (unrestricted grant); Italian Ministry of Health - Current research IRCCS.