The effect of the localisation of an underlying ST-elevation myocardial infarction on the VF-waveform: A multi-centre cardiac arrest study.

INTRODUCTION: In cardiac arrest, ventricular fibrillation (VF) waveform characteristics such as amplitude spectrum area (AMSA) are studied to identify an underlying myocardial infarction (MI). Observational studies report lower AMSA-values in patients with than without underlying MI. Moreover, experimental studies with 12-lead ECG-recordings show lowest VF-characteristics when the MI-localisation matches the ECG-recording direction. However, out-of-hospital cardiac arrest (OHCA)-studies with defibrillator-derived VF-recordings are lacking. METHODS: Multi-centre (Amsterdam/Nijmegen, the Netherlands) cohort-study on the association between AMSA, ST-elevation MI (STEMI) and its localisation. AMSA was calculated from defibrillator pad-ECG recordings (proxy for lead II, inferior vantage point); STEMI-localisation was determined using ECG/angiography/autopsy findings. RESULTS: We studied AMSA-values in 754 OHCA-patients. There were statistically significant differences between no STEMI, anterior STEMI and inferior STEMI (Nijmegen: no STEMI 13.0mVHz [7.9-18.6], anterior STEMI 7.5mVHz [5.6-13.8], inferior STEMI 7.5mVHz [5.4-11.8], p = 0.006. Amsterdam: 11.7mVHz [5.0-21.9], 9.6mVHz [4.6-17.2], and 6.9mVHz [3.2-16.0], respectively, p = 0.001). Univariate analyses showed significantly lower AMSA-values in inferior STEMI vs. no STEMI; there was no significant difference between anterior and no STEMI. After correction for confounders, adjusted absolute AMSA-values were numerically lowest for inferior STEMI in both cohorts, and the relative differences in AMSA between inferior and no STEMI was 1.4-1.7 times larger than between anterior and no STEMI. CONCLUSION: This multi-centre VF-waveform OHCA-study showed significantly lower AMSA in case of underlying STEMI, with a more pronounced difference for inferior than for anterior STEMI. Confirmative studies on the impact of STEMI-localisation on the VF-waveform are warranted, and might contribute to earlier diagnosis of STEMI during VF.

Resuscitation with an AED: putting the data to use.

The increased use of the automated external defibrillator (AED) contributes to the rising survival rate after sudden cardiac arrest in the Netherlands. When used, the AED records the unconscious person's medical data (heart rhythm and information about cardiopulmonary resuscitation), which may be important for further diagnosis and treatment. In practice, ethical and legal questions arise about what can and should be done with these 'AED data'. In this article, the authors advocate the development of national guidelines on the handling of AED data. These guidelines should serve two purposes: (1) to safeguard that data are handled carefully in accordance with data protection principles and the rules of medical confidentiality; and (2) to ensure nationwide availability of data for care of patients who survive resuscitation, as well as for quality monitoring of this care and for related scientific research. Given the medical ethical duties of beneficence and fairness, existing (sometimes lifesaving) information about AED use ought to be made available to clinicians and researchers on a structural basis. Creating a national AED data infrastructure, however, requires overcoming practical and organisational barriers. In addition, further legal study is warranted.

When is a bystander not a bystander any more? A European survey.

OBJECTIVE: There is international variation in the rates of bystander cardiopulmonary resuscitation (CPR). 'Bystander CPR' is defined in the Utstein definitions, however, differences in interpretation may contribute to the variation reported. The aim of this cross-sectional survey was to understand how the term 'bystander CPR' is interpreted in Emergency Medical Service (EMS) across Europe, and to contribute to a better definition of 'bystander' for future reference. METHODS: During analysis of the EuReCa ONE study, uncertainty about the definition of a 'bystander' emerged. Sixty scenarios were developed, addressing the interpretation of 'bystander CPR'. An electronic version of the survey was sent to 27 EuReCa National Coordinators, who distributed it to EMS representatives in their countries. Results were descriptively analysed. RESULTS: 362 questionnaires were received from 23 countries. In scenarios where a layperson arrived on scene by chance and provided CPR, up to 95% of the participants agreed that 'bystander CPR' had been performed. In scenarios that included community response systems, firefighters and/or police personnel, the percentage of agreement that 'bystander CPR' had been performed ranged widely from 16% to 91%. Even in scenarios that explicitly matched examples provided in the Utstein template there was disagreement on the definition. CONCLUSION: In this survey, the interpretation of 'bystander CPR' varied, particularly when community response systems including laypersons, firefighters, and/or police personnel were involved. It is suggested that the definition of 'bystander CPR' should be revised to reflect changes in treatment of OHCA, and that CPR before arrival of EMS is more accurately described.

The challenges and possibilities of public access defibrillation.

Out-of-hospital cardiac arrest (OHCA) is a major health problem that affects approximately four hundred and thousand patients annually in the United States alone. It is a major challenge for the emergency medical system as decreased survival rates are directly proportional to the time delay from collapse to defibrillation. Historically, defibrillation has only been performed by physicians and in-hospital. With the development of automated external defibrillators (AEDs), rapid defibrillation by nonmedical professionals and subsequently by trained or untrained lay bystanders has become possible. Much hope has been put to the concept of Public Access Defibrillation with a massive dissemination of public available AEDs throughout most Western countries. Accordingly, current guidelines recommend that AEDs should be deployed in places with a high likelihood of OHCA. Despite these efforts, AED use is in most settings anecdotal with little effect on overall OHCA survival. The major reasons for low use of public AEDs are that most OHCAs take place outside high incidence sites of cardiac arrest and that most OHCAs take place in residential settings, currently defined as not suitable for Public Access Defibrillation. However, the use of new technology for identification and recruitment of lay bystanders and nearby AEDs to the scene of the cardiac arrest as well as new methods for strategic AED placement redefines and challenges the current concept and definitions of Public Access Defibrillation. Existing evidence of Public Access Defibrillation and knowledge gaps and future directions to improve outcomes for OHCA are discussed. In addition, a new definition of the different levels of Public Access Defibrillation is offered as well as new strategies for increasing AED use in the society.

Part 3: adult basic life support and automated external defibrillation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This review comprises the most extensive literature search and evidence evaluation to date on the most important international BLS interventions, diagnostics, and prognostic factors for cardiac arrest victims. It reemphasizes that the critical lifesaving steps of BLS are (1) prevention, (2) immediate recognition and activation of the emergency response system, (3) early high-quality CPR, and (4) rapid defibrillation for shockable rhythms. Highlights in prevention indicate the rational and judicious deployment of search-and-rescue operations in drowning victims and the importance of education on opioid-associated emergencies. Other 2015 highlights in recognition and activation include the critical role of dispatcher recognition and dispatch-assisted chest compressions, which has been demonstrated in multiple international jurisdictions with consistent improvements in cardiac arrest survival. Similar to the 2010 ILCOR BLS treatment recommendations, the importance of high quality was reemphasized across all measures of CPR quality: rate, depth, recoil, and minimal chest compression pauses, with a universal understanding that we all should be providing chest compressions to all victims of cardiac arrest. This review continued to focus on the interface of BLS sequencing and ensuring high-quality CPR with other important BLS interventions, such as ventilation and defibrillation. In addition, this consensus statement highlights the importance of EMS systems, which employ bundles of care focusing on providing high-quality chest compressions while extricating the patient from the scene to the next level of care. Highlights in defibrillation indicate the global importance of increasing the number of sites with public-access defibrillation programs. Whereas the 2010 ILCOR Consensus on Science provided important direction for the "what" in resuscitation (ie, what to do), the 2015 consensus has begun with the GRADE methodology to provide direction for the quality of resuscitation. We hope that resuscitation councils and other stakeholders will be able to translate this body of knowledge of international consensus statements to build their own effective resuscitation guidelines.

Electrocardiographic abnormalities in patients admitted for hip fracture.

BACKGROUND: Several risk factors for falls and hip fractures have been recognised, but controversy still exists regarding the importance of rhythm and conduction abnormalities as potentially modifiable risk factors for recurrent falls. The aim of this study was to determine the prevalence of clinically relevant ECG abnormalities in patients with a hip fracture versus controls. METHODS: The study was designed as a case-control study within consecutive hip surgery patients in an academic hospital. CASES: patients with traumatic hip fractures. CONTROLS: patients undergoing planned hip surgery (non-traumatic). CASES and controls were 1:1 matched for age and gender. INCLUSION CRITERIA: age ≥ 50 years. EXCLUSION CRITERIA: high-energy trauma, pathological and÷or previous hip fracture. ECGs were scored using predefined categories. Multivariate logistic regression was performed to calculate odds ratios (OR) and to correct for confounders. RESULTS: We included 888 patients (444 cases). Mean age was 70.9 years (SD 9.3), 70% were female. After correction for potential confounders we found the following associations between clinically relevant ECG abnormalities and hip fractures: atrial fibrillation OR 2.7 (95% CI 1.2-6.1), abnormal QTc prolongation OR 3.9 (2.2-6.8), sinus tachycardia OR 5.0 (2.1-11.8) and sinus bradycardia OR 0.3 (0.1-0.5). Univariately, several markers for decreased cardiac function were also associated with hip fractures. CONCLUSIONS: Hip fracture patients are at higher risk for ECG abnormalities than matched patients undergoing hip surgery for other indications. To potentially reduce the risk of future (injurious) falls, increased awareness of these ECG abnormalities is warranted to assess the need for further cardiovascular fall risk assessment.

Genetic, clinical and pharmacological determinants of out-of-hospital cardiac arrest: rationale and outline of the AmsteRdam Resuscitation Studies (ARREST) registry.

INTRODUCTION: Out-of-hospital cardiac arrest (OHCA) is a major public health problem. Recognising the complexity of the underlying causes of OHCA in the community, we aimed to establish the clinical, pharmacological, environmental and genetic factors and their interactions that may cause OHCA. METHODS AND ANALYSIS: We set up a large-scale prospective community-based registry (AmsteRdam Resuscitation Studies, ARREST) in which we prospectively include all resuscitation attempts from OHCA in a large study region in the Netherlands in collaboration with Emergency Medical Services. Of all OHCA victims since June 2005, we prospectively collect medical history (through hospital and general practitioner), and current and previous medication use (through community pharmacy). In addition, we include DNA samples from OHCA victims with documented ventricular tachycardia/fibrillation during the resuscitation attempt since July 2007. Various study designs are employed to analyse the data of the ARREST registry, including case-control, cohort, case only and case-cross over designs. ETHICS AND DISSEMINATION: We describe the rationale, outline and potential results of the ARREST registry. The design allows for a stable and reliable collection of multiple determinants of OHCA, while assuring that the patient, lay-caregiver or medical professional is not hindered in any way. Such comprehensive data collection is required to unravel the complex basis of OHCA. Results will be published in peer-reviewed journals and presented at relevant scientific symposia.

Reduced in-hospital survival rates of out-of-hospital cardiac arrest victims with obstructive pulmonary disease.

AIM: Out-of-hospital cardiac arrest (OHCA) due to sustained ventricular tachycardia/fibrillation (VT/VF) is common and often lethal. Patient's co-morbidities may determine survival after OHCA, and be instrumental in post-resuscitation care, but are poorly studied. We aimed to study whether patients with obstructive pulmonary disease (OPD) have a lower survival rate after OHCA than non-OPD patients. METHODS: We performed a community-based cohort study of 1172 patients with non-traumatic OHCA with ECG-documented VT/VF between 2005 and 2008. We compared survival to emergency room (ER), to hospital admission, to hospital discharge, and at 30 days after OHCA, of OPD-patients and non-OPD patients, using logistic regression analysis. We also compared 30-day survival of patients who were admitted to hospital, using multivariate logistic regression analysis. RESULTS: OPD patients (n=178) and non-OPD patients (n=994) had comparable survival to ER (75% vs. 78%, OR 0.9 [95% CI: 0.6-1.3]) and to hospital admission (56% vs. 57%, OR 1.0 [0.7-1.4]). However, survival to hospital discharge was significantly lower among OPD patients (21% vs. 33%, OR 0.6 [0.4-0.9]). Multivariate regression analysis among patients who were admitted to hospital (OPD: n=100, no OPD: n=561) revealed that OPD was an independent determinant of reduced 30-day survival rate (39% vs. 59%, adjusted OR 0.6 [0.4-1.0, p=0.035]). CONCLUSION: OPD-patients had lower survival rates after OHCA than non-OPD patients. Survival to ER and to hospital admission was not different between both groups. However, among OHCA victims who survived to hospital admission, OPD was an independent determinant of reduced 30-day survival rate.

Quality management in resuscitation--towards a European cardiac arrest registry (EuReCa).

BACKGROUND: Knowledge about the epidemiology of cardiac arrest in Europe is inadequate. AIM: To describe the first attempt to build up a Common European Registry of out-of-hospital cardiac arrest, called EuReCa. METHODS: After approaching key persons in participating countries of the European Resuscitation Council, five countries or areas within countries (Belgium, Germany, Andalusia, North Holland, Sweden) agreed to participate. A standardized questionnaire including 28 items, that identified various aspects of resuscitation, was developed to explore the nature of the regional/national registries. This comprises inclusion criteria, data sources, and core data, as well as technical details of the structure of the databases. RESULTS: The participating registers represent a population of 35 million inhabitants in Europe. During 2008, 12,446 cardiac arrests were recorded. The structure as well as the level of complexity varied markedly between the 5 regional/national registries. The incidence of attempted resuscitation ranged between registers from 17 to 53 per 100,000 inhabitants each year whilst the number of patients admitted to hospital alive ranged from 5 to 18 per 100,000 inhabitants each year. Bystander CPR varied 3-fold from 20% to 60%. CONCLUSION: Five countries agreed to participate in an attempt to build up a common European Registry for out-of-hospital cardiac arrest. These regional/national registries show a marked difference in terms of structure and complexity. A marked variation was found between countries in the number of reported resuscitation attempts, the number of patients brought to hospital alive, and the proportion that received bystander CPR. At present, we are unable to explain the reason for the variability but our first findings could be a 'wake-up-call' for building up a high quality registry that could provide answers to this and other key questions in relation to the management of out-of-hospital cardiac arrest.

In vivo synthesis of meganuclease for generating transgenic zebrafish Danio rerio.

The authors show that co-injection at the one-cell stage of mRNA encoding a nuclear-targeted meganuclease I-SceI together with expression cassettes flanked by cognate restriction sites results in efficient stable transgenesis in zebrafish Danio rerio.

Burning issues: early cooling of the brain after resuscitation using burn dressings. A proof of concept observation.

AIM OF THE STUDY: Early cooling of resuscitated patients improves neurological outcome. Out-of hospital initiation of cooling is uncommon however for mainly practical reasons. Using burn dressings in the out-of-hospital care could initiate brain cooling in an early stage and therefore be of value; the method is easily adaptable by ambulance crews. The influence of burn dressings on brain temperature is however unknown. We determined tympanic temperature changes as proxy for brain temperature in healthy volunteers after the application of cooling dressings to face and neck as a proof of concept study. METHOD: In 10 healthy human volunteers tympanic temperatures were measured in 30s intervals before, during and after the application of burn-dressings, special trauma burn-care dressings that are designed for the acute treatment of skin burns (Burnshield emergency burn care sterile trauma burn dressings, Burnshield Ltd., Wadefield, South Africa) for the duration of 20min for each episode. RESULTS: In all study subjects the tympanic temperature was significantly lowered after 20min of the application of the burnshields. The mean difference between baseline and 2nd half of the exposure period was 0.43 degrees C (p<0.0001), ranging from 0.10 to 1.18 degrees C. CONCLUSION: Burn dressings could be of value in the early initiation of brain cooling in resuscitated patients. This study warrants further research to the effect of burnshield dressings on neurological activity and the effect on outcome after resuscitation.