Diagnostic test accuracy of point-of-care ultrasound during cardiopulmonary resuscitation to indicate the etiology of cardiac arrest: A systematic review.

AIM: Point-of-care ultrasound (POCUS) is used in cardiac arrest patients to assess for reversible causes. We aimed to conduct a diagnostic test accuracy systematic review of intra-arrest POCUS to indicate the etiology of cardiac arrest in adults in any setting. METHODS: This review is registered with PROSPERO (CRD42020205207) and reported according to PRISMA guidelines. We searched Medline, EMBASE, Web of Science, CINAHL, and Cochrane Library on October 6, 2021. Two investigators screened titles and abstracts, extracted data, and assessed risks of bias using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) template. We estimated sensitivity and specificity when feasible and evaluated the certainty of evidence with Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. RESULTS: Of 8,621 search results, 12 observational studies reported 26 combinations of index tests and reference standards to indicate six different etiologies of cardiac arrest. All studies had high risks of bias from subject selection, lack of blinding, reference standards susceptible to confounding, and/or differential verification. One study reported sufficient data to complete contingency tables for sensitivity and specificity of POCUS to identify myocardial infarction, cardiac tamponade, and pulmonary embolism as the etiology of cardiac arrest. Heterogeneity and risk of bias precluded meta-analysis and the certainty of evidence was uniformly very low. CONCLUSIONS: It is feasible to identify reversible causes of cardiac arrest with POCUS, but the current literature is heterogenous with high risks of bias, wide confidence intervals, and very low certainty of evidence, which render these data difficult to interpret.

Uses and pitfalls of measurement of end-tidal carbon dioxide during cardiac arrest.

PURPOSE OF REVIEW: To discuss recent studies relevant to the utility of measuring end-tidal carbon dioxide (ETCO2) during cardiopulmonary resuscitation (CPR) and its correlation with outcome in adults experiencing cardiac arrest. RECENT FINDINGS: Over the past couple of years, at least five studies have included measurement of ETCO2 in their methods. Two of these studies were prospective and two retrospective. All considered ETCO2 measurements after out-of-hospital cardiac arrest, either in the prehospital setting, or after arrival in the emergency department. All assessed for an association between ETCO2 measurement and return of spontaneous circulation (ROSC). However, the timing of measurement, whether a one-off value or a trend and the cut-off values used to determine whether or not there was an association were different in all cases. SUMMARY: Higher values of ETCO2 during resuscitation from cardiac arrest are generally associated with a greater likelihood of ROSC. However, timing of measurements and cut-off values used show significant variability across different studies, making it hard to draw any conclusions about the utility of any particular reading for prognostication. Future studies might aim to develop an accepted standard for the timing and cut-off value of ETCO2 used, to enable comparison of the parameter across different studies.

Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations.

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.

Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.

Prognostication with point-of-care echocardiography during cardiac arrest: A systematic review.

AIM: To conduct a prognostic factor systematic review on point-of-care echocardiography during cardiac arrest to predict clinical outcomes in adults with non-traumatic cardiac arrest in any setting. METHODS: We conducted this review per PRISMA guidelines and registered with PROSPERO (ID pending). We searched Medline, EMBASE, Web of Science, CINAHL, and the Cochrane Library on September 6, 2019. Two investigators screened titles and abstracts, extracted data, and assessed risks of bias using the Quality in Prognosis Studies (QUIPS) template. We estimated prognostic test performance (sensitivity and specificity) and measures of association (odds ratio). Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology evaluated the certainty of evidence. RESULTS: In total, 15 studies were included. We found wide variation across studies in the definition of 'cardiac motion' and timing of sonographic assessment. Most studies were hindered by high risks of bias from prognostic factor measurement, outcome measurement, and lack of adjustment for other prognostic factors. Ultimately, heterogeneity and risk of bias precluded meta-analyses. We tabulated ranges of prognostic test performance and measures of association for 5 different combinations of definitions of 'cardiac motion' and sonographic timing, as well as other miscellaneous sonographic findings. Overall certainty of this evidence is very low. CONCLUSIONS: The evidence for using point-of-care echocardiography as a prognostic tool for clinical outcomes during cardiac arrest is of very low certainty and is hampered by multiple risks of bias. No sonographic finding had sufficient and/or consistent sensitivity for any clinical outcome to be used as sole criterion to terminate resuscitation.

Oxygenation and ventilation targets after cardiac arrest: A systematic review and meta-analysis.

AIM: To perform a systematic review and meta-analysis of the literature on oxygenation and ventilation targets after successful resuscitation from cardiac arrest in order to inform an update of international guidelines. METHODS: The review was performed according to PRISMA and registered on PROSPERO (ID: X). Medline, EMBASE, and the Cochrane Library were searched on August 22, 2019. The population included both adult and pediatric patients with cardiac arrest. Two investigators reviewed abstracts, extracted data, and assessed the risk of bias. Meta-analyses were performed for studies without excessive bias. Certainty of evidence was evaluated using GRADE. RESULTS: We included 7 trials and 36 observational studies comparing oxygenation or ventilation targets. Most of the trials and observational studies included adults with out-of-hospital cardiac arrest. There were 6 observational studies in children. Bias for trials ranged from low to high risk, with group imbalances and blinding being primary concerns. Bias for observational studies was rated as serious or critical risk with confounding and exposure classification being primary sources of bias. Meta-analyses including two trials comparing low vs high oxygen therapy and two trials comparing hypercapnia vs no hypercapnia were inconclusive. Point estimates of individual studies generally favored normoxemia and normocapnia over hyper- or hypoxemia and hyper- or hypocapnia. CONCLUSIONS: We identified a large number of studies related to oxygenation and ventilation targets in cardiac arrest. The majority of studies did not reach statistical significance and were limited by excessive risk of bias. Point estimates of individual studies generally favored normoxemia and normocapnia.

Advanced airway management during adult cardiac arrest: A systematic review.

AIM: To systematically review the literature on advanced airway management during adult cardiac arrest in order to inform the International Liaison Committee of Resuscitation (ILCOR) consensus on science and treatment recommendations. METHODS: The review was performed according to PRISMA guidelines and registered on PROSPERO (CRD42018115556). We searched Medline, Embase, and Evidence-Based Medicine Reviews for controlled trials and observational studies published before October 30, 2018. The population included adult patients with cardiac arrest. Two investigators reviewed studies for relevance, extracted data, and assessed the risk of bias of individual studies. RESULTS: We included 78 observational studies and 11 controlled trials. Most of the observational studies and all of the controlled trials only included patients with out-of-hospital cardiac arrest. The risk of bias for individual observational studies was overall assessed as critical or serious, with confounding and selection bias being the primary sources of bias. Three of the controlled trials, all published in 2018, were powered for clinical outcomes with two comparing a supraglottic airway to tracheal intubation and one comparing bag-mask ventilation to tracheal intubation. All three trials had some concerns regarding risk of bias primarily due to lack of blinding and variable adherence to the protocol. Clinical and methodological heterogeneity across studies, for both the observational studies and the controlled trials, precluded any meaningful meta-analyses. CONCLUSIONS: We identified a large number of studies related to advanced airway management in adult cardiac arrest. Three recently published, large randomized trials in out-of-hospital cardiac arrest will help to inform future guidelines. Trials of advanced airway management during in-hospital cardiac arrest are lacking.

2018 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary.

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the second annual summary of International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations that includes the most recent cardiopulmonary resuscitation science reviewed by the International Liaison Committee on Resuscitation. This summary addresses the role of antiarrhythmic drugs in adults and children and includes the Advanced Life Support Task Force and Pediatric Task Force consensus statements, which summarize the most recent published evidence and an assessment of the quality of the evidence based on Grading of Recommendations, Assessment, Development, and Evaluation criteria. The statements include consensus treatment recommendations approved by members of the relevant task forces. Insights into the deliberations of each task force are provided in the Values and Preferences and Task Force Insights sections. Finally, the task force members have listed the top knowledge gaps for further research.

2018 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary.

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the second annual summary of International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations that includes the most recent cardiopulmonary resuscitation science reviewed by the International Liaison Committee on Resuscitation. This summary addresses the role of antiarrhythmic drugs in adults and children and includes the Advanced Life Support Task Force and Pediatric Task Force consensus statements, which summarize the most recent published evidence and an assessment of the quality of the evidence based on Grading of Recommendations, Assessment, Development, and Evaluation criteria. The statements include consensus treatment recommendations approved by members of the relevant task forces. Insights into the deliberations of each task force are provided in the Values and Preferences and Task Force Insights sections. Finally, the task force members have listed the top knowledge gaps for further research.

Successful resuscitation from bupivacaine-induced cardiovascular collapse with intravenous lipid emulsion following femoral nerve block in an emergency department.

We report a case of a 69-year-old woman with femoral neck fracture undergoing bupivacaine femoral nerve block for preoperative analgesia in an ED. Seizure and cardiovascular collapse developed immediately after instillation of local anaesthetic. Resuscitation including 20% lipid emulsion was successful in achieving normalization of haemodynamic parameters and ECG QRS duration. No adverse sequelae of lipid administration were observed. We recommend the immediate availability of lipid emulsion in emergency room settings where local anaesthetics are used.

Prevalence of use, epidemiology and toxicity of 'herbal party pills' among those presenting to the emergency department.

The aim of the present study was to establish the prevalence of use, epidemiology and toxicity of 'herbal party pills' in ED presenters. This was an analytical cross-sectional survey of patients and relatives presenting to a large tertiary ED. Consenting participants completed a specifically designed questionnaire. A total of 1043 people completed the questionnaire (participation rate of 97.2%). One hundred and twenty-five (11.9%) had taken herbal party pills and subgroup analysis showed that use was most prevalent in those aged 14-25 years (30%). The majority had taken pills between two and five times (56%). Eighty-three (66.4%) had been drinking alcohol when they first took party pills. Only 80 (64%) had read the product directions, and 48 (38.4%) had, at some stage, taken more pills than recommended. One hundred and six (84.8%) had felt effects from party pills, but only 63 (59% of those feeling effects or 50.4% of total) described these as 'good'. Six (5.7% of those with effects or 4.8% of total) had sought medical attention for effects. Seventy-four (59.2%) would take herbal party pills again. In conclusion, the use of herbal party pills is common in presenters to the ED, particularly in those aged 14-25 years. These people are at risk for toxicity from the pills because there is a tendency for them not to read the instructions before ingestion, to take more pills than recommended and to coingest alcohol. Emergency physicians need to be aware of the use and potential adverse effects of herbal party pills to enable them to recognize signs of toxicity in ED presenters and thus provide appropriate supportive care.

Complementary and alternative medicines (including traditional Maori treatments) used by presenters to an emergency department in New Zealand: a survey of prevalence and toxicity.

AIM: To establish the prevalence of use of complementary and alternative medicines (CAM), including traditional Maori therapies, their perceived benefit, and frequency of adverse effects among presenters to an emergency department (ED) in New Zealand. METHOD: An analytical cross-sectional survey of a convenience sample of patients and relatives presenting to a large tertiary ED (Waikato Hospital, Hamilton) was undertaken. Consenting participants completed a specifically designed questionnaire. RESULTS: 1043 people completed the questionnaire (participation rate 97.2%). 1 in 3 (397 or 38.1%) people had used CAM, including 29 who had used a traditional Maori therapy. CAM use was significantly more likely in females (p<0.0001), those aged 20-60 yrs (p<0.001), and in those of European ethnicity (p=0.01). Only 148 (37.3%) people had told their medical practitioner that they were using CAM, and 103 (25.9%) had used conventional medicines concurrently. Most people (266, 67%) believed that CAM had been beneficial. Adverse effects were reported by 16 people (4% of users). CONCLUSIONS: Many ED presenters in New Zealand use CAM. These may be associated with adverse effects, toxicity, and interactions with conventional medicines, although the incidence of these appears to be low. Doctors in New Zealand should routinely specifically enquire about the use of CAM during patient assessment.

Intralipid prolongs survival in a rat model of verapamil toxicity.

OBJECTIVES: Verapamil is a lipid-soluble calcium channel blocker with significant mortality in overdose. Previous investigators have demonstrated the benefit of lipid emulsion therapy in ameliorating toxicity from lipid-soluble agents. The authors investigated the effect of Intralipid treatment in a rat model of verapamil toxicity. METHODS: Thirty sedated Wistar rats were infused with verapamil at 37.5 mg/kg/h. Five minutes after the start of infusion, animals were treated with a bolus of either 12.4 mL/kg 20% Intralipid or 12.4 mL/kg 0.9% saline. Verapamil infusion was continued until the animals were killed. Respiratory rate, heart rate, and electrocardiography were sampled every 2.5 minutes throughout. RESULTS: Survival was prolonged in the Intralipid-treated group (44 +/- 21 vs. 24 +/- 9 minutes; p = 0.003). The median lethal dose was increased in the Intralipid group (25.7 mg/kg [95% confidence interval {CI} = 24.7 to 26.7] vs. 13.6 mg/kg [95% CI = 12.2 to 15.0]). A less marked decrease in heart rate was observed during verapamil infusion in the Intralipid-treated group (6.8 beats/min [95% CI = 8.3 to 5.2] for Intralipid vs. 10.7 beats/min [95% CI = 12.6 to 8.9] for saline; p = 0.001). CONCLUSIONS: Intralipid treatment prolongs survival and doubles median lethal dose in a rat model of verapamil toxicity. The mechanism of action remains to be elucidated.