Feasibility of Pre-Hospital Resuscitative Endovascular Balloon Occlusion of the Aorta in Non-Traumatic Out-of-Hospital Cardiac Arrest.

Background Few patients survive after out-of-hospital cardiac arrest and any measure that improve circulation during cardiopulmonary resuscitation is beneficial. Animal studies support that resuscitative endovascular balloon occlusion of the aorta (REBOA) during cardiopulmonary resuscitation might benefit patients suffering from out-of-hospital cardiac arrest, but human data are scarce. Methods and Results We performed an observational study at the helicopter emergency medical service in Trondheim (Norway) to assess the feasibility and safety of establishing REBOA in patients with out-of-hospital cardiac arrest. All patients received advanced cardiac life support during the procedure. End-tidal CO2 was measured before and after REBOA placement as a proxy measure of central circulation. A safety-monitoring program assessed if the procedure interfered with the quality of advanced cardiac life support. REBOA was initiated in 10 patients. The mean age was 63 years (range 50-74 years) and 7 patients were men. The REBOA procedure was successful in all cases, with 80% success rate on first cannulation attempt. Mean procedural time was 11.7 minutes (SD 3.2, range 8-16). Mean end-tidal CO2 increased by 1.75 kPa after 60 seconds compared with baseline (P<0.001). Six patients achieved return of spontaneous circulation (60%), 3 patients were admitted to hospital, and 1 patient survived past 30 days. The safety-monitoring program identified no negative influence on the advanced cardiac life support quality. Conclusions To our knowledge, this is the first study to demonstrate that REBOA is feasible during non-traumatic out-of-hospital cardiac arrest. The REBOA procedure did not interfere with the quality of the advanced cardiac life support. The significant increase in end-tidal CO2 after occlusion suggests improved organ circulation during cardiopulmonary resuscitation. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT03534011.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) in non-traumatic out-of-hospital cardiac arrest: evaluation of an educational programme.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is a critical incident with a high mortality rate. Augmentation of the circulation during cardiopulmonary resuscitation (CPR) might be beneficial. Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) redistribute cardiac output to the organs proximal to the occlusion. Preclinical data support that patients in non-traumatic cardiac arrest might benefit from REBOA in the thoracic level during CPR. This study describes a training programme to implement the REBOA procedure to a prehospital working team, in preparation to a planned clinical study. METHODS: We developed a team-based REBOA training programme involving the physicians and paramedics working on the National Air Ambulance helicopter base in Trondheim, Norway. The programme consists of a four-step approach to educate, train and implement the REBOA procedure in a simulated prehospital setting. An objective structured assessment of prehospital REBOA application scoring chart and a special designed simulation mannequin was made for this study. RESULTS: Seven physicians and 3 paramedics participated. The time needed to perform the REBOA procedure was 8.5 (6.3-12.7) min. The corresponding time from arrival at scene to balloon inflation was 12.0 (8.8-15) min. The total objective assessment scores of the candidates' competency was 41.8 (39-43.5) points out of 48. The advanced cardiovascular life support (ACLS) remained at standard quality, regardless of the simultaneous REBOA procedure. CONCLUSION: This four-step approach to educate, train and implement the REBOA procedure to a prehospital working team ensures adequate competence in a simulated OHCA setting. The use of a structured training programme and objective assessment of skills is recommended before utilising the procedure in a clinical setting. In a simulated setting, the procedure does not add significant time to the prehospital resuscitation time nor does the procedure interfere with the quality of the ACLS. TRIAL REGISTRATION NUMBER: NCT03534011.

Emergency teams in Danish emergency departments.

INTRODUCTION: The use of designated emergency teams for cardiac arrest and trauma patients is widely implemented. However, the use of designated teams in Danish emergency departments (EDs) has not been investigated. Our aim was to investigate the use and staffing of emergency teams in Danish EDs. MATERIAL AND METHODS: A cross-sectional questionnaire study was sent to all 20 Danish EDs designated for emergency care. RESULTS: The response rate was 95% (n = 19). Three EDs were excluded due to incomplete data. All EDs (n = 16) received critically ill patients, cardiac arrests and trauma patients. In all EDs, a designated team responded to cardiac arrest (CAT) and trauma patients (TT). Only 31% of EDs had access to a designated medical emergency team (MET). CAT consisted of a median of six (range 5-10) different personnel groups. Of these, three (1-6) were physicians and only one (0-2) was a senior physician. TTs consisted of a median of nine (7-11) different personnel groups. Of these, four (2-6) were physicians, and three (2-4) were senior physicians. In 25% of the EDs, there was no access to a MET. In 31% of the EDs, an ad hoc-team was created. In 14%, a team was created by the attending emergency physician. The staffing of ad hoc-teams relied on diagnosis, symptoms and triage scores. CONCLUSION: Designated teams for patients in cardiac arrest and trauma patients are available in all Danish EDs. More senior staff form part of trauma teams than cardiac arrest teams. There is limited access to designated teams caring for critically ill medical patients in Danish EDs.