The Association of Racial Residential Segregation and Survival After Out-of-Hospital Cardiac Arrest in the United States.

Background: Residential segregation has been identified as drivers of disparities in health outcomes, but further work is needed to understand this association with clinical outcomes for out-of-hospital cardiac arrest (OHCA). We utilized Cardiac Arrest Registry to Enhance Survival (CARES) dataset to examine if there are differences in survival to discharge and survival with good neurological outcome, as well as likelihood of bystander CPR, using validated measures of racial, ethnic, and economic segregation. Methods: We conducted a retrospective observational study using data from the Cardiac Arrest Registry to Enhance Survival (CARES) dataset to examine associations among adult OHCA patients. The primary predictor was the Index of Concentration at the Extremes (ICE), a validated measure that includes race, ethnicity, and income across three measures at the census tract level. The primary outcomes were survival to discharge and survival with good neurological status. A multivariable modified Poisson regression modeling approach with random effects at the EMS agency and hospital level was utilized. Results: We identified 626,264 OHCA patients during the study period. The mean age was 62 years old (SD 17.2 years), and 35.7% (n =223,839) of the patients were female. In multivariable models, we observed an increased likelihood of survival to discharge and survival with good neurological outcome for those patients residing in predominately White population census tracts and higher income census tracts as compared to lower income Black and Hispanic/Latinx population census tracts (RR 1.24, CI 1.20-1.28) and a 32% increased likelihood of receiving bystander CPR in higher income census tracts as compared to reference (RR 1.32, CI 1.30-1.34). Conclusions: In this study examining the association of measures of residential segregation and OHCA outcomes, there was an increased likelihood of survival to discharge, survival with good neurological status, and likelihood of receiving B-CPR for those patients residing in predominately White population and higher income census tracts when compared to predominately Black and/or Hispanic Latinx populations and lower income census tracts. This research suggests that areas impacted by residential and economic segregation are important targets for both public policy interventions as well as addressing disparities in care across the chain of survival for OHCA.

Helicopter emergency medical services (HEMS) response to out-of-hospital cardiac arrest (OHCA) in the United States.

Introduction: Helicopter emergency medical services (HEMS) are used in the United States and globally to respond to patients with critical illness and victims of traumatic injury. Relatively limited research has examined their role in responding to out-of-hospital cardiac arrests (OHCA) in the United States. In this study, we compared OHCA treated by HEMS units with cardiac arrests treated by ground ambulances. Methods: We queried a large national-level database of emergency medical services (EMS) activations in the United States (NEMSIS). Inclusion criteria were OHCA activations between January 1, 2022 and December 31, 2022 treated by either HEMS or ground ambulance. Key arrest data from both groups were then compared. Interfacility transfers and cardiac arrests after EMS arrival were excluded. Results: A total of 1,233 cardiac arrests treated by HEMS and 341,096 cardiac arrests treated by ground ambulances met inclusion criteria. Comparing the two groups, cardiac arrests with HEMS response were more likely to be male (66.7% vs. 62.8%, p < 0.01), White (50.2% vs. 45.7%, p < 0.01), under 18 years old (10.9% vs. 2.7%, p < 0.001), associated with traumatic injury (19.1% vs. 5.7%, p < 0.001), witnessed (72.7% vs. 37.3%, p < 0.001), and initially-shockable (24.7% vs. 11.1%, p < 0.001). Conclusion: Our comparison of cardiac arrests treated by HEMS with cardiac arrests treated by ground ambulance reveals significant differences between the two groups. Further research is needed to better characterize HEMS' ideal role in the response to OHCA as new prehospital resuscitative techniques for non-traumatic and traumatic cardiac arrest are developed.

Infant out-of-hospital cardiac arrest during nights and weekends.

BACKGROUND: A growing body of evidence suggests outcomes for cardiac arrest in adults are worse during nights and weekends when compared with daytime and weekdays. Similar research has not yet been carried out in the infant setting. METHODS: We examined the National Emergency Medical Services Information System (NEMSIS), a database containing millions of emergency medical services (EMS) runs in the United States. Inclusion criteria were infant out-of-hospital cardiac arrests (patients <1 years old) taking place prior to EMS arrival between January 2021 and December 2022 where EMS documented whether return of spontaneous circulation (ROSC) was achieved. Cardiac arrests were classified as occurring during either the day (defined as 0800-1959) or the night (defined as 2000-0759) and weekends (Saturday/Sunday) or weekdays (Monday-Friday). Rates of ROSC achievement were compared. RESULTS: A total of 8549 infant cardiac arrests met inclusion criteria: 5074 (59.4%) took place during daytime compared with 3475 (40.6%) during nighttime, and 5989 (70.1%) arrests occurred on weekdays compared with 2560 (29.9%) on weekends. Rates of ROSC achievement were significantly lower on weekends versus weekdays (16.8% vs. 14.1%; p = 0.00097). A difference in ROSC rates when comparing daytime and nighttime was seen, but this difference was not statistically significant (16.4% vs. 15.3%; p = 0.08076). CONCLUSION: ROSC achievement rates for infant out-of-hospital cardiac arrest are significantly lower on weekends when compared with weekdays. Further study and quality improvement work is needed to better understand this.

The Public Health and Economic Impact of Drug Overdose Out-of-Hospital Cardiac Arrest in the United States.

OBJECTIVE: To calculate disability-adjusted life years (DALY) and labor productivity loss due to drug overdose out-of-hospital cardiac arrest (DO-OHCA) and compare its contribution to the burden of disease and economic impact of all-cause nontraumatic out-of-hospital cardiac arrest (OHCA) in the US. METHODS: We performed a retrospective observational cohort analysis of all adult (age ≥18 years) nontraumatic emergency medical services-treated OHCA events, including those due to DO-OHCA, from the national Cardiac Arrest Registry to Enhance Survival (CARES) database from January 1, 2017 and December 31, 2020. The main outcome measures of interest were disability-adjusted life years, annual, and lifetime labor productivity loss over the 4-year study period. The findings for the study population were extrapolated to a national level using the CARES population catchment and U.S. population estimates by year. RESULTS: A total of 378,088 adult OHCA events, including 23,252 DO-OHCA (6.2%) met study inclusion criteria. The DO-OHCA DALY increased from 156,707 in 2017 to 265,692 in 2020. Per year, DO-OHCA contributed to 11.4%, 12.0%, 10.5%, and 11.4% of all OHCA DALY lost from 2017-2020, respectively. The mean annual and lifetime productivity losses for all OHCA were stable over time (annual: $47K in 2017 to $50K in 2020; lifetime: $647K in 2017 to $692K in 2020). The CARES population catchment increased by 39.8% over the study period (102.6 M in 2017 to 143.4 M in 2020). For DO-OHCA, the mean annual productivity loss was approximately 30% higher than non-DO-OHCA ($64K vs. $49K in 2020, respectively). The mean lifetime productivity loss for DO-OHCA was 2.5 times higher than non-DO-OHCA ($1.6 M vs. $630K in 2020, respectively). CONCLUSIONS: The DALY due to DO-OHCA has increased over time with expansion of the CARES dataset, but its relative contribution to total OHCA DALY (all non-traumatic etiologies) remained fairly stable. The DO-OHCAs represent approximately 6% of all adult non-traumatic EMS-treated OHCA events but has a disproportionately greater economic impact. Continued efforts to reduce DO-OHCA through public health initiatives are warranted to lessen the societal impact of OHCA in the U.S.

Shenfu injection as treatment for critical illness: a narrative review of clinical trials.

Background and Objective: Shenfu injection (SFI) is a traditional herbal medicine derived from components of ginseng and aconite and is commonly used in China to treat a variety of conditions. Shenfu has been suggested to have beneficial effects in various critical illnesses, including heart failure, cardiac arrest, and septic shock. In recent years, there have been a number of studies reporting that SFI improves patient outcomes when used concurrently with other treatments, but its use has not been adopted outside of China. This narrative review explored the results of clinical trials that have tested SFI's efficacy in various critical illnesses. Methods: PubMed was searched for clinical trials, systematic reviews and meta-analyses published between 1990 and July 2022 relating to clinical trials using SFI in various critical illnesses. Systematic reviews and meta-analyses were included to enable inclusion of data from trials originally not published in English. The selected articles were then summarized in the following disease categories: heart failure, cardiac arrest, sepsis, and severe pulmonary disease. Key Content and Findings: Clinical trials testing SFI in heart failure, cardiac arrest, sepsis, and pulmonary disease were reviewed. The design, methodology, and key findings of each trial or meta-analysis are summarized and discussed. Key limitations were also highlighted and discussed. Overall, several clinical trials suggest SFI may hold therapeutic potential for the treatment of critical illness, however, additional research is likely still needed. Conclusions: Based on the current body of literature, further research-especially multi-center randomized, double-blind trials with detailed reporting of all methods and results according to international guidelines-is needed to evaluate whether SFI is a useful addition to existing treatments for these conditions.

False Electrical Capture in Prehospital Transcutaneous Pacing by Paramedics: A Case Series.

INTRODUCTION: The use of transcutaneous pacing (TCP) for unstable bradycardia has a class 2B recommendation from the American Heart Association. Prior studies have not adequately described the frequency or possible causes of treatment failure. EMS clinicians and leaders have reported false electrical capture as a potential cause. In this study, we aimed to describe the frequency of true electrical capture, documented verification of mechanical capture, and its association with systolic blood pressure (SBP) and survival. METHODS: This was a retrospective study of patients treated by an urban, hospital-based EMS network comprising two EMS agencies between March 2021 and March 2023. Inclusion criteria were adults with a heart rate of <60 bpm and attempted TCP. Variables included: initial electrocardiogram rhythm, SBP, current applied, neurological status at discharge, and diagnosis. The primary outcome was true electrical capture, defined as the presence of a visible wide QRS and T wave. This enabled calculation of false electrical capture. Additional outcomes included change in SBP and neurological status at discharge. RESULTS: 19 of the 23 (82.6%) patients who underwent TCP had false electrical capture despite all 23 having documented mechanical capture by palpated pulse. For patients with true electrical capture, the median change in SBP was +40 mmHg (IQR = 24.25, range= -12 to +49 mmHg). For patients with false electrical capture, the median change in SBP was -1 mmHg (IQR = 58.50, range= -90 to +23 mmHg). Median current for patients with true electrical capture was 95 mA (IQR = 13.75, range = 85-110) versus 70 mA (IQR = 30, range = 55-160) in those with false electrical capture. 16 (69.6%) had outcome data available. Patients with true electrical capture and outcome data (n = 2) survived to admission but only one survived to discharge with good functional capacity. Of 14 with false electrical capture and outcome data, 10 (71.4%) survived to admission; none survived to discharge with functional capacity. CONCLUSIONS: These findings suggest a high proportion of patients undergoing TCP are at risk of false electrical capture despite a recorded palpable pulse. While our analysis is limited to a single EMS network, these data raise concerns regarding the incidence of prehospital false electrical capture. Further research is warranted to calculate the incidence of false electrical capture and evaluate mitigation strategies.

Cardiac Arrest Following Drug Overdose in the United States: An Analysis of the Cardiac Arrest Registry to Enhance Survival.

BACKGROUND: Given increases in drug overdose-associated mortality, there is interest in better understanding of drug overdose out-of-hospital cardiac arrest (OHCA). A comparison between overdose-attributable OHCA and nonoverdose-attributable OHCA will inform public health measures. METHODS AND RESULTS: We analyzed data from 2017 to 2021 in the Cardiac Arrest Registry to Enhance Survival (CARES), comparing overdose-attributable OHCA (OD-OHCA) with OHCA from other nontraumatic causes (non-OD-OHCA). Arrests involving patients <18 years, health care facility residents, patients with cancer diagnoses, and patients with select missing data were excluded. Our main outcome of interest was survival with good neurological outcome, defined as Cerebral Performance Category score 1 or 2. From a data set with 537 100 entries, 29 500 OD-OHCA cases and 338 073 non-OD-OHCA cases met inclusion criteria. OD-OHCA cases involved younger patients with fewer comorbidities, were less likely to be witnessed, and less likely to present with a shockable rhythm. Unadjusted survival to hospital discharge with Cerebral Performance Category score =1 or 2 was significantly higher in the OD-OHCA cohort (OD: 15.2% versus non-OD: 6.9%). Adjusted results showed comparable survival with Cerebral Performance Category score =1 or 2 when the first monitored arrest rhythm was shockable (OD: 28.9% versus non-OD: 23.5%, P=0.087) but significantly higher survival rates with Cerebral Performance Category score =1 or 2 for OD-OHCA when the first monitored arrest rhythm was nonshockable (OD: 9.6% versus non-OD: 3.1%, P<0.001). CONCLUSIONS: Among patients presenting with nonshockable rhythms, OD-OHCA is associated with significantly better outcomes. Further research should explore cardiac arrest causes, and public health efforts should attempt to reduce the burden from drug overdoses.

Soybean polyenylphosphatidylcholine (PPC) is beneficial in liver and extrahepatic tissue injury: An update in experimental research.

Polyenylphosphatidylcholine (PPC) is a purified polyunsaturated phosphatidylcholine extract of soybeans. This article updates PPC's beneficial effects on various forms of liver cell injury and other tissues in experimental research. PPC downregulates hepatocyte CYP2E1 expression and associated hepatotoxicity, as well as attenuates oxidative stress, apoptosis, lipoprotein oxidation and steatosis in alcoholic and nonalcoholic liver injury. PPC inhibits pro-inflammatory cytokine production, while stimulating anti-inflammatory cytokine secretion in ethanol or lipopolysaccharide-stimulated Kupffer cells/macrophages. It promotes M2-type macrophage polarization and metabolic reprogramming of glucose and lipid metabolism. PPC mitigates steatosis in NAFLD through inhibiting polarization of pro-inflammatory M1-type Kupffer cells, alleviating metabolic inflammation, remodeling hepatic lipid metabolism, correcting imbalances between lipogenesis and lipolysis and enhancing lipoprotein secretion from hepatocytes. PPC is antifibrotic by preventing progression of alcoholic hepatic fibrosis in baboons and also prevents CCl4-induced fibrosis in rats. PPC supplementation replenishes the phosphatidylcholine content of damaged cell membranes, resulting in increased membrane fluidity and functioning. Phosphatidylcholine repletion prevents increased membrane curvature of the endoplasmic reticulum and Golgi and decreases sterol regulatory element binding protein-1-mediated lipogenesis, reducing steatosis. PPC remodels gut microbiota and affects hepatic lipid metabolism via the gut-hepatic-axis and also alleviates brain inflammatory responses and cognitive impairment via the gut-brain-axis. Additionally, PPC protects extrahepatic tissues from injury caused by various toxic compounds by reducing oxidative stress, inflammation, and membrane damage. It also stimulates liver regeneration, enhances sensitivity of cancer cells to radiotherapy/chemotherapy, and inhibits experimental hepatocarcinogenesis. PPC's beneficial effects justify it as a supportive treatment of liver disease.

Frequency of Mass Casualty Incidents (MCIs) Responded to by Helicopter Emergency Medical Services (HEMS).

OBJECTIVE: Mass casualty incidents (MCIs) challenge out-of-hospital and in-hospital personnel as well as impose significant pressure on available resources. Helicopter emergency medical services (HEMS) crews may be involved in the response to an MCI. Thus, there is epidemiological interest to understand the frequency of MCIs responded to by HEMS. METHODS: We used a nationally representative database of emergency medical services activations in the United States (National Emergency Medical Services Information System). We queried 911-initiated (scene) activations during the years 2021 and 2022 within the database and paid special attention to activations defined by crews as MCIs. From this, we were able to calculate the frequency at which HEMS crews responded to MCIs relative to the total number of HEMS scene activations. RESULTS: Of a total of 177,509 HEMS scene activations, less than 1% involved MCIs (0.27%, 486/177,509). Nationally, HEMS crews responded to roughly 2.74 MCIs per 1,000 activations. Variation in MCI frequency was noted across the day of the week, the month of the year, and the time of the day. CONCLUSION: HEMS crews do respond to MCIs although infrequently. Certain time periods are associated with a greater frequency of MCIs. These data will hopefully be able to inform preparedness and training.

Kidney-specific biomarkers for predicting acute kidney injury following cardiac arrest.

AIM: To evaluate the performance of kidney-specific biomarkers (neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), and cystatin-C) in early detection of acute kidney injury (AKI) following cardiac arrest (CA) when compared to serum creatinine. METHODS: Adult CA patients who had kidney-specific biomarkers of AKI collected within 12 h of return of spontaneous circulation (ROSC) were included. The association between renal biomarker levels post-ROSC and the development of KDIGO stage III AKI within 7 days of enrollment were assessed as well as their predictive value of future AKI development, neurological outcomes, and survival to discharge. RESULTS: Of 153 patients, 54 (35%) developed stage III AKI within 7 days, and 98 (64%) died prior to hospital discharge. Patients who developed stage III AKI, compared to those who did not, had higher median levels of creatinine, NGAL, and cystatin-C (p < 0.001 for all). There was no statistically significant difference in KIM-1 between groups. No biomarker outperformed creatinine in the ability to predict stage III AKI, neurological outcomes, or survival outcomes (p > 0.05 for all). However, NGAL, cystatin-C, and creatinine all performed better than KIM-1 in their ability to predict AKI development (p < 0.01 for all). CONCLUSION: In post-CA patients, creatinine, NGAL, and cystatin-C (but not KIM-1) measured shortly after ROSC were higher in patients who subsequently developed AKI. No biomarker was statistically superior to creatinine on its own for predicting the development of post-arrest AKI.

Human Trafficking and Emergency Medical Services (EMS).

Human trafficking is associated with wide-ranging mental and physical morbidity, as well as mortality, in the United States and globally. Emergency Medical Services (EMS) providers are often first responders to victims of human trafficking. Given their proximity to patients' social and environmental circumstances, these clinicians need to be familiar with the signs and symptoms of human trafficking, as well understand how to best provide care for suspected or confirmed trafficked patients. Evidence from multiple studies indicates that providers who have received formal training may be better able to recognize the signs and symptoms of human trafficking, and thus, can provide better care to potential victims of human trafficking. This review will summarize the relevance of human trafficking to prehospital emergency care, touch on best practices for the care of patients with suspected or confirmed ties to human trafficking, and outline future directions for education and research.

Fatal Air Medical Accidents in the United States (2000-2020).

INTRODUCTION: Currently, many airplanes and helicopters are used as air ambulances to transport high-acuity patients. Unfortunately, civilian air medical transport in the United States has experienced a significant number of serious and fatal accidents. At the moment, additional research is needed to identify what factors affect air medical safety. METHODS: Accident reports from the National Transportation Safety Board (NTSB) were queried. Accident reports were analyzed if the accident occurred from 2000 through 2020, involved a helicopter or airplane on an air medical flight (as identified by the NTSB), and had at least one fatality. The date of the accident, the model of aircraft involved, and NTSB-determined probable causes of the accident were examined. RESULTS: Eighty-seven (87) accidents and 239 fatalities took place from January 2000 through December 2020. Nearly three-fourths (72.4%) of fatalities occurred on helicopters, while just 27.6% occurred on airplanes. Interpreting the NTSB findings, various human factors probably contributed to 87.4% of fatalities. These include pilot disorientation, pilot errors, maintenance errors, impairment, fatigue, or weather misestimation. Nighttime-related factors probably contributed to 38.9% of fatalities, followed by weather-related factors (35.6%), and various mechanical failures (17.2%). CONCLUSION: These data show that the probable causes of fatal air medical accidents are primarily human factors and are, therefore, likely preventable. Developing a safety-first culture with a focus on human factors training has been shown to improve outcomes across a wide range of medical specialties (eg, anesthesia, surgery, and resuscitation). While there have been fewer fatal accidents in recent years, a continued emphasis on various training modalities seems warranted.

Full Moons and Helicopter Emergency Medical Services (HEMS) Activations in The United States.

A long-standing misconception in emergency medicine is that full moons are associated with increased patient volume. Although there has been ample work debunking this belief, virtually no scholarship has tackled this question from the perspective of helicopter emergency medical services (HEMS). We examined a national-level database populated by EMS agencies throughout the United States (NEMSIS) and compared three-day periods containing every full moon in 2019 with control three-day periods one week immediately before and one week immediately after a given full moon. The daily average number of HEMS activations was then compared. A significant increase was defined as full moon periods having at least 20% more HEMS activations than the control periods before and after the full moon. In 2019, full moons had a daily average of 496 HEMS activations, and non-full moon periods had a daily average of 510 HEMS activations. Furthermore, no months saw full moons having a significant increase in HEMS activations. Our data provides important support for the idea that full moons do not translate into increased HEMS activations.

A comparison between sudden cardiac arrest on military bases and non-military settings.

INTRODUCTION: Out-of-hospital cardiac arrests contribute to significant morbidity and mortality in both non-military/civilian and military populations. Early CPR and AED use have been linked with improved outcomes. There is public health interest in identifying communities with high rates of both with the hopes of creating generalizable tactics for improving cardiac arrest survival. METHODS: We examined a national registry of EMS activations in the United States (NEMSIS). Inclusion criteria were witnessed cardiac arrests from January 2020 to September 2022 where EMS providers documented the location of the arrest, whether CPR was provided prior to their arrival (yes/no), and whether an AED was applied prior to their arrival (yes/no). Cardiac arrests were then classified as occurring on a military base or in a non-military setting. RESULTS: A total of 60 witnessed cardiac arrests on military bases and 202,605 witnessed cardiac arrests in non-military settings met inclusion criteria. Importantly, the prevalence of CPR and AED use prior to EMS arrival was significantly higher on military bases compared to non-military settings. CONCLUSIONS: Reasons for the trends we observed may be a greater availability of CPR-trained individuals and AEDs on military bases, as well as a widespread willingness to provide aid to victims of cardiac arrest. Further research should examine cardiac arrests on military bases.

Mechanical Cardiopulmonary Resuscitation's Role in Helicopter Air Ambulances: A Narrative Review.

Helicopter emergency medical services (HEMS) frequently respond to out-of-hospital cardiac arrest (OHCA) situations. Some have speculated mechanical cardiopulmonary resuscitation (mCPR) may be able to rectify the inadequacy of human performance of cardiopulmonary resuscitation (CPR) during transport. A number of studies have examined the performance of mCPR devices in the air medical setting specifically. Many aspects of the HEMS environment seem uniquely conducive to mCPR, and a growing body of research seems to suggest mCPR holds promise for the treatment of cardiac arrest by HEMS clinicians. Simulation studies show that mCPR leads to improved CPR performance compared with manual CPR in HEMS. Case reports and the experience of several HEMS programs suggest that mCPR can be effectively integrated into HEMS care. However, further research regarding the effectiveness of mCPR in the HEMS environment and in general cardiac arrest care is needed.