The International Liaison Committee on Resuscitation-Review of the last 25 years and vision for the future.

2017 marks the 25th anniversary of the International Liaison Committee on Resuscitation (ILCOR). ILCOR was formed in 1992 to create a forum for collaboration among principal resuscitation councils worldwide. Since then, ILCOR has established and distinguished itself for its pioneering vision and leadership in resuscitation science. By systematically assessing the evidence for resuscitation standards and guidelines and by identifying national and regional differences, ILCOR reached consensus on international resuscitation guidelines in 2000, and on international science and treatment recommendations in 2005, 2010 and 2015. However, local variation and contextualization of guidelines are evident by subtle differences in regional and national resuscitation guidelines. ILCOR's efforts to date have enhanced international cooperation, and progressively more transparent and systematic collection and analysis of pertinent scientific evidence. Going forward, this sets the stage for ILCOR to pursue its vision to save more lives globally through resuscitation.

The role of opioid receptor agonists in ischemic preconditioning.

Opioids and their receptor agonists have been widely used because of their beneficial effects on pain management and control. Over the past decade, there has been an increasing interest on the experimental use of opioid agonists in the laboratory setting of ischemia and reperfusion; existing data suggest that there is a potential association between opioid agonism and the reduction of infarct size in several animal models of regional ischemia similar to that following ischemic preconditioning. Most of these studies seem to attribute these beneficial and cardioprotective effects to the stimulation of a specific opioid receptor type, the delta (δ) opioid receptor. This review focuses on the role of the delta opioid receptor agonism in several models of ischemia and reperfusion, as well as on hemorrhagic shock models, on the potential mechanisms of action following delta opioid receptor activation and on the time window for opioid administration in various animal studies.

Classification of comorbidity in trauma: the reliability of pre-injury ASA physical status classification.

BACKGROUND: Pre-injury comorbidities can influence the outcomes of severely injured patients. Pre-injury comorbidity status, graded according to the American Society of Anesthesiologists Physical Status (ASA-PS) classification system, is an independent predictor of survival in trauma patients and is recommended as a comorbidity score in the Utstein Trauma Template for Uniform Reporting of Data. Little is known about the reliability of pre-injury ASA-PS scores. The objective of this study was to examine whether the pre-injury ASA-PS system was a reliable scale for grading comorbidity in trauma patients. METHODS: Nineteen Norwegian trauma registry coders were invited to participate in a reliability study in which 50 real but anonymised patient medical records were distributed. Reliability was analysed using quadratic weighted kappa (κ(w)) analysis with 95% CI as the primary outcome measure and unweighted kappa (κ) analysis, which included unknown values, as a secondary outcome measure. RESULTS: Fifteen of the invitees responded to the invitation, and ten participated. We found moderate (κ(w)=0.77 [95% CI: 0.64-0.87]) to substantial (κ(w)=0.95 [95% CI: 0.89-0.99]) rater-against-reference standard reliability using κ(w) and fair (κ=0.46 [95% CI: 0.29-0.64]) to substantial (κ=0.83 [95% CI: 0.68-0.94]) reliability using κ. The inter-rater reliability ranged from moderate (κ(w)=0.66 [95% CI: 0.45-0.81]) to substantial (κ(w)=0.96 [95% CI: 0.88-1.00]) for κ(w) and from slight (κ=0.36 [95% CI: 0.21-0.54]) to moderate (κ=0.75 [95% CI: 0.62-0.89]) for κ. CONCLUSIONS: The rater-against-reference standard reliability varied from moderate to substantial for the primary outcome measure and from fair to substantial for the secondary outcome measure. The study findings indicate that the pre-injury ASA-PS scale is a reliable score for classifying comorbidity in trauma patients.

Abbreviated Injury Scale: not a reliable basis for summation of injury severity in trauma facilities?

BACKGROUND: Injury severity is most frequently classified using the Abbreviated Injury Scale (AIS) as a basis for the Injury Severity Score (ISS) and the New Injury Severity Score (NISS), which are used for assessment of overall injury severity in the multiply injured patient and in outcome prediction. European trauma registries recommended the AIS 2008 edition, but the levels of inter-rater agreement and reliability of ISS and NISS, associated with its use, have not been reported. METHODS: Nineteen Norwegian AIS-certified trauma registry coders were invited to score 50 real, anonymised patient medical records using AIS 2008. Rater agreements for ISS and NISS were analysed using Bland-Altman plots with 95% limits of agreement (LoA). A clinically acceptable LoA range was set at ± 9 units. Reliability was analysed using a two-way mixed model intraclass correlation coefficient (ICC) statistics with corresponding 95% confidence intervals (CI) and hierarchical agglomerative clustering. RESULTS: Ten coders submitted their coding results. Of their AIS codes, 2189 (61.5%) agreed with a reference standard, 1187 (31.1%) real injuries were missed, and 392 non-existing injuries were recorded. All LoAs were wider than the predefined, clinically acceptable limit of ± 9, for both ISS and NISS. The joint ICC (range) between each rater and the reference standard was 0.51 (0.29,0.86) for ISS and 0.51 (0.27,0.78) for NISS. The joint ICC (range) for inter-rater reliability was 0.49 (0.19,0.85) for ISS and 0.49 (0.16,0.82) for NISS. Univariate linear regression analyses indicated a significant relationship between the number of correctly AIS-coded injuries and total number of cases coded during the rater's career, but no significant relationship between the rater-against-reference ISS and NISS ICC values and total number of cases coded during the rater's career. CONCLUSIONS: Based on AIS 2008, ISS and NISS were not reliable for summarising anatomic injury severity in this study. This result indicates a limitation in their use as benchmarking tools for trauma system performance.

Law, ethics and clinical judgment in end-of-life decisions--how do Norwegian doctors think?

AIM: According to Norwegian law, an autonomous patient has the right to refuse life-prolonging treatment. If the patient is not defined as dying, however, health personnel are obliged to instigate life-saving treatment in an emergency situation even against the patient's wishes. The purpose of this study was to investigate how doctors' attitudes and knowledge agree with these legal provisions, and how the statutory provision on emergency situations influences the principle of patient autonomy for severely ill, but not dying, patients. METHOD: A strategic sample of 1175 Norwegian doctors who are specialists in internal medicine, paediatrics, surgery, neurology and neurosurgery received a mail questionnaire about decisions on end-of-life care in hypothetical scenarios. The case presented concerns a 45-year-old autonomous patient diagnosed with end-stage ALS who declines ventilatory treatment. Recipients were randomly selected from the membership roster of the Norwegian Medical Association. 640 (54.5%) responded; of these, 406 had experience with end-of-life decisions. RESULTS: 56.1% (221/394) stated that ALS patients in such situations can always refuse life-prolonging treatment, and 42.4% (167/394) were of the opinion that the patient can normally refuse life-prolonging treatment. 1.5% (6/394) stated that the patient cannot refuse life-prolonging treatment. CONCLUSIONS: The answers indicate that the respondents include patients' refusal in an overall clinical judgement, and interpret patients' right to decline life-saving treatment in different ways. This may reflect the complex legal situation in Norway regarding patient autonomy with respect to the right of severely ill, but not dying, patients' right to decline acute life-saving treatment.

Dynamic effects of adrenaline (epinephrine) in out-of-hospital cardiac arrest with initial pulseless electrical activity (PEA).

BACKGROUND: In cardiac arrest, pulseless electrical activity (PEA) is a challenging clinical syndrome. In a randomized study comparing intravenous (i.v.) access and drugs versus no i.v. access or drugs during advanced life support (ALS), adrenaline (epinephrine) improved return of spontaneous circulation (ROSC) in patients with PEA. Originating from this study, we investigated the time-dependent effects of adrenaline on clinical state transitions in patients with initial PEA, using a non-parametric multi-state statistical model. METHODS AND RESULTS: Patients with available defibrillator recordings were included, of whom 101 received adrenaline and 73 did not. There were significantly more state transitions in the adrenaline group than in the no-adrenaline group (rate ratio = 1.6, p<0.001). Adrenaline markedly increased the rate of transition from PEA to ROSC during ALS and slowed the rate of being declared dead; e.g. by 20 min 20% of patients in the adrenaline group had been declared dead and 25% had obtained ROSC, whereas 50% in the no-adrenaline group have been declared dead and 15% had obtained ROSC. The differential effect of adrenaline could be seen after approx. 10 min of ALS for most transitions. For both groups the probability of deteriorating from PEA to asystole was highest during the first 15 min. Adrenaline increased the rate of transition from PEA to ventricular fibrillation or -tachycardia (VF/VT), and from ROSC to VF/VT. CONCLUSIONS: Adrenaline has notable clinical effects during ALS in patients with initial PEA. The drug extends the time window for ROSC to develop, but also renders the patient more unstable. Further research should investigate the optimal dose, timing and mode of adrenaline administration during ALS.

A field evaluation of real-life motor vehicle accidents: presence of unrestrained objects and their association with distribution and severity of patient injuries.

Moving objects may pose an added threat to car occupants in motor vehicle accidents (MVAs). However, to our knowledge, there have only been two case studies published on the subject. For the present study, accident reports and photo documentation from MVAs were collected on-scene by dedicated paramedics. Emergency medical service personnel on-scene were interviewed as necessary. Potentially harmful unrestrained objects in the involved motor vehicles (MVs) were identified and categorised by type, weight and hardness. Seatback offset by unrestrained objects was noted. The patient injury distribution (Abbreviated Injury Scale (AIS) body regions) and severity (AIS severity scores and New Injury Severity Score (NISS) scores) were retrospectively determined from hospital and autopsy records, and their potential relationship to unrestrained objects was explored. A total of 190 accidents involving 338 MVs and 618 individuals were included. In total, 327 individuals (53%) were injured, and 61 (10%) died. 37 of 61 were not autopsied. The mean NISS was 17 (median 8, interquartile range (IQR) 1-27). Unrestrained objects were reported for 133 motor vehicles (39%) involving 293 individuals. 35% of the unrestrained objects found in the passenger compartment weighed >2 kg. In the boot, 32% of objects weighed >20 kg. Seatback offset associated with unrestrained objects was found for 45 individuals (15%). Unrestrained objects originally located in the boot (heavy luggage, groceries and tyres were the most frequently reported) had moved into the passenger compartment on impact in 27 cases, 24 of which were associated with seatback offset. An in-depth analysis was performed on 24 patients whose injuries were highly likely to be associated with unrestrained objects, as indicated by accident reports and medical documentation. Nineteen (79%) were involved in frontal collisions, and 12 (50%) died on-scene. The mean NISS was 51.7 (median 51, IQR 27-75) in the 17 (71%) patients with seatback offset and 37.2 (median 41, IQR 22.5-50) in the 7 (29%) without seatback offset. Seatback offset was associated with more severe head and thoracic injuries and an increased incidence of abdominal and pelvic injuries. Patients injured by unrestrained objects while sitting in unharmed car seats predominantly suffered head, cervical spine and thoracic injuries. Our results indicate a need for public information campaigns. The development of car backseats that can better sustain hits from heavy objects in the cargo boot is an important area for the motor vehicle production industry to explore.

Outcome when adrenaline (epinephrine) was actually given vs. not given - post hoc analysis of a randomized clinical trial.

PURPOSE OF THE STUDY: IV line insertion and drugs did not affect long-term survival in an out-of-hospital cardiac arrest (OHCA) randomized clinical trial (RCT). In a previous large registry study adrenaline was negatively associated with survival from OHCA. The present post hoc analysis on the RCT data compares outcomes for patients actually receiving adrenaline to those not receiving adrenaline. MATERIALS AND METHODS: Patients from a RCT performed May 2003 to April 2008 were included. Three patients from the original intention-to-treat analysis were excluded due to insufficient documentation of adrenaline administration. Quality of cardiopulmonary resuscitation (CPR) and clinical outcomes were compared. RESULTS: Clinical characteristics were similar and CPR quality comparable and within guideline recommendations for 367 patients receiving adrenaline and 481 patients not receiving adrenaline. Odds ratio (OR) for being admitted to hospital, being discharged from hospital and surviving with favourable neurological outcome for the adrenaline vs. no-adrenaline group was 2.5 (CI 1.9, 3.4), 0.5 (CI 0.3, 0.8) and 0.4 (CI 0.2, 0.7), respectively. Ventricular fibrillation, response interval, witnessed arrest, gender, age and endotracheal intubation were confounders in multivariate logistic regression analysis. OR for survival for adrenaline vs. no-adrenaline adjusted for confounders was 0.52 (95% CI: 0.29, 0.92). CONCLUSION: Receiving adrenaline was associated with improved short-term survival, but decreased survival to hospital discharge and survival with favourable neurological outcome after OHCA. This post hoc survival analysis is in contrast to the previous intention-to-treat analysis of the same data, but agrees with previous non-randomized registry data. This shows limitations of non-randomized or non-intention-to-treat analyses.

Patients Referred to a Norwegian Trauma Centre: effect of transfer distance on injury patterns, use of resources and outcomes.

BACKGROUND: Triage and interhospital transfer are central to trauma systems. Few studies have addressed transferred trauma patients. This study investigated transfers of variable distances to OUH (Oslo University Hospital, Ullevål), one of the largest trauma centres in Europe. METHODS: Patients included in the OUH trauma registry from 2001 to 2008 were included in the study. Demographic, injury, management and outcome data were abstracted. Patients were grouped according to transfer distance: ≤20 km, 21-100 km and > 100 km. RESULTS: Of the 7.353 included patients, 5.803 were admitted directly, and 1.550 were transferred. The number of transfers per year increased, and there was no reduction in injury severity during the study period. Seventy-six per cent of the transferred patients were severely injured. With greater transfer distances, injury severity increased, and there were larger proportions of traffic injuries, polytrauma and hypotensive patients. With shorter distances, patients were older, and head injuries and injuries after falls were more common. The shorter transfers less often activated the trauma team: ≤20 km -34%; 21-100 km -51%; > 100 km -61%, compared to 92% of all directly admitted patients. The mortality for all transferred patients was 11%, but was unequally distributed according to transfer distance. CONCLUSION: This study shows heterogeneous characteristics and high injury severity among interhospital transfers. The rate of trauma team assessment was low and should be further examined. The mortality differences should be interpreted with caution as patients were in different phases of management. The descriptive characteristics outlined may be employed in the development of triage protocols and transfer guidelines.

High school students as ambassadors of CPR--a model for reaching the most appropriate target population?

BACKGROUND: There is mismatch in age between those usually trained in CPR and those witnessing out-of-hospital cardiac arrest with mean age reported at 30 and 65 years old, respectively. Two tier mass CPR self-training with manikin-DVD sets using school children has been reported. We have studied high school students as first tier and encouraged them to train older people. METHODS: Four separate groups were tested: students before or after training and second tier adults before or after training with first tier students as facilitators. CPR performance was videotaped and electronically documented on a Skillmeter Anne manikin. RESULTS: Each student reported to train mean 2.8 extra persons, and 43% were aged 50 or older. Pre-training results were poor, while first and second tier persons performed equally well after training, and within ERC guideline recommendations. CONCLUSIONS: People trained at home with a manikin-DVD set and high school students as facilitators were able to perform CPR as recommended by ERC guidelines with a reasonable percentage aged 50 or older.

Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial.

CONTEXT: Intravenous access and drug administration are included in advanced cardiac life support (ACLS) guidelines despite a lack of evidence for improved outcomes. Epinephrine was an independent predictor of poor outcome in a large epidemiological study, possibly due to toxicity of the drug or cardiopulmonary resuscitation (CPR) interruptions secondary to establishing an intravenous line and drug administration. OBJECTIVE: To determine whether removing intravenous drug administration from an ACLS protocol would improve survival to hospital discharge after out-of-hospital cardiac arrest. DESIGN, SETTING, AND PATIENTS: Prospective, randomized controlled trial of consecutive adult patients with out-of-hospital nontraumatic cardiac arrest treated within the emergency medical service system in Oslo, Norway, between May 1, 2003, and April 28, 2008. INTERVENTIONS: Advanced cardiac life support with intravenous drug administration or ACLS without access to intravenous drug administration. MAIN OUTCOME MEASURES: The primary outcome was survival to hospital discharge. The secondary outcomes were 1-year survival, survival with favorable neurological outcome, hospital admission with return of spontaneous circulation, and quality of CPR (chest compression rate, pauses, and ventilation rate). RESULTS: Of 1183 patients for whom resuscitation was attempted, 851 were included; 418 patients were in the ACLS with intravenous drug administration group and 433 were in the ACLS with no access to intravenous drug administration group. The rate of survival to hospital discharge was 10.5% for the intravenous drug administration group and 9.2% for the no intravenous drug administration group (P = .61), 32% vs 21%, respectively, (P<.001) for hospital admission with return of spontaneous circulation, 9.8% vs 8.1% (P = .45) for survival with favorable neurological outcome, and 10% vs 8% (P = .53) for survival at 1 year. The quality of CPR was comparable and within guideline recommendations for both groups. After adjustment for ventricular fibrillation, response interval, witnessed arrest, or arrest in a public location, there was no significant difference in survival to hospital discharge for the intravenous group vs the no intravenous group (adjusted odds ratio, 1.15; 95% confidence interval, 0.69-1.91). CONCLUSION: Compared with patients who received ACLS without intravenous drug administration following out-of-hospital cardiac arrest, patients with intravenous access and drug administration had higher rates of short-term survival with no statistically significant improvement in survival to hospital discharge, quality of CPR, or long-term survival. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00121524.

Out-of hospital advanced life support with or without a physician: effects on quality of CPR and outcome.

BACKGROUND: The presence of physicians is believed to facilitate optimal management of out-of-hospital cardiac arrest, but has not been sufficiently documented. METHODS: Adult non-traumatic cardiac arrests treated by Oslo EMS between May 2003 and April 2008 were prospectively registered. Patients were categorized according to being treated by the physician-manned ambulance (PMA) or by regular paramedic-manned ambulances (non-PMA). Patient records and continuous electrocardiograms (ECGs) with impedance signals were reviewed. Quality of cardiopulmonary resuscitation (CPR) and clinical outcomes were compared. RESULTS: Resuscitation was attempted in 1128 cardiac arrests, of which 151 treated by non-PMA and PMA together were excluded from comparative analysis. Of the remaining 977 patients, 232 (24%) and 741 (76%) were treated by PMA and non-PMA, respectively. The PMA group was more likely to have bystander witnessed arrests and initial VF/VT, and received better CPR quality with shorter hands-off intervals and pre-shock pauses, and having a greater proportion of patients being intubated. Despite uneven distribution of positive prognostic factors and better CPR quality, short-term and long-term survival were not different for patients treated by the PMA vs. non-PMA, with 34% vs. 33% (p=0.74) achieving return of spontaneous circulation (ROSC), 28% vs. 25% (p=0.50) being admitted to ICU and 13% vs. 11% (p=0.28) being discharged from hospital, respectively. CONCLUSIONS: Survival after out-of-hospital cardiac arrest was not different for patients treated by the PMA and non-PMA in our EMS system.

Which factors influence spontaneous state transitions during resuscitation?

BACKGROUND: The clinical state (i.e. ventricular fibrillation/tachycardia: VF/VT, asystole: ASY, pulseless electrical activity: PEA, or return of spontaneous circulation, ROSC) during cardiopulmonary resuscitation determines patient management. We investigate how spontaneous transitions (i.e. not forced by DC shock) between these states are influenced by factors like age, gender, bystander CPR, CPR quality, proportion of time spent in a state, or the number of state transitions. METHODS: Detailed recordings from CPR attempts in 304 out-of-hospital cardiac arrests in Akershus (Norway), Stockholm (Sweden), and London (UK) were obtained from modified Heartstart 4000 defibrillators. Spontaneous state transitions were studied using a non-parametric intensity regression method that can handle dynamic factors like the state history properly. RESULTS: The initial state tended to preserve itself, as did cumulative time in any state. Recent DC shock, bystander CPR, location, response time, gender, compression depth, and ventilation rate were important for some transitions. More ventilation during PEA might possibly avert development to ASY and favour ROSC; otherwise observed variations in CPR quality had little impact. CONCLUSION: Using a novel intensity regression approach we studied the influence of various factors on spontaneous (i.e. non-shock) state transitions during CPR. State development was largely determined by the initial state, the proportion of time spent in a state, and the transition frequency; all probably reflecting the underlying aetiology.

The effect of transport on quality of cardiopulmonary resuscitation in out-of-hospital cardiac arrest.

INTRODUCTION: Most manikin and clinical studies have found decreased quality of CPR during transport to hospital. We wanted to study quality of CPR before and during transport for out-of-hospital cardiac arrest patients and also whether quality of CPR before initiation of transport was different from the quality in patients only receiving CPR on scene. MATERIALS AND METHODS: Quality of CPR was prospectively registered with a modified defibrillator for consecutive cases of out-of-hospital cardiac arrest in three ambulance services during 2002-2005. Ventilations were registered via changes in transthoracic impedance and chest compressions were measured with an extra chest compression pad placed on the patients' sternum. Paired t-tests were used to analyse quality of CPR before vs. during transport with ongoing CPR. Unpaired t-tests were used to compare CPR quality prior to transport to CPR quality in patients with CPR terminated on site. RESULTS: Quality of CPR did not deteriorate during transport, but as previously reported overall quality of CPR was substandard. Quality of CPR performed on site was significantly better when transport was not initiated with ongoing CPR compared to episodes with initiation of transport during CPR: fraction of time without chest compressions was 0.45 and 0.53 (p<0.001), compression depth 37 mm and 34 mm (p=0.04), and number of chest compressions per minute 61 and 56 (p=0.01), respectively. CONCLUSION: CPR quality was sub-standard both before and during transport. Early decision to transport might have negatively affected CPR quality from the early stages of resuscitation.

Using ontologies to integrate and share resuscitation data from diverse medical devices.

OBJECTIVE: To propose a method for standardised data representation and demonstrate a technology that makes it possible to translate data from device dependent formats to this standard representation format. METHODS AND RESULTS: Outcome statistics vary between emergency medical systems organising resuscitation services. Such differences indicate a potential for improvement by identifying factors affecting outcome, but data subject to analysis have to be comparable. Modern technology for communicating information makes it possible to structure, store and transfer data flexibly. Ontologies describe entities in the world and how they relate. Letting different computer systems refer to the same ontology results in a common understanding on data content. Information on therapy such as shock delivery, chest compressions and ventilation should be defined and described in a standardised ontology to enable comparison and combining data from diverse sources. By adding rules and logic data can be merged and combined in new ways to produce new information. An example ontology is designed to demonstrate the feasibility and value of such a standardised structure. CONCLUSIONS: The proposed technology makes possible capturing and storing of data from different devices in a structured and standardised format. Data can easily be transformed to this standardised format, compared and combined independent of the original structure.