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Signa Vitae

Journal of Intensive Care and Emergency Medicine

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Targeting out-of-hospital cardiac arrest: the effect of heparin administered during cardiopulmonary resuscitation (T-ARREST)

Abstract

Introduction. Heparin administration during cardiopulmonary resuscitation (CPR) may prevent activation of coagulation after successful resuscitation for out-of-hospital cardiac arrest (OHCA). We hypothesize that such an approach is not associated with an increased rate of bleeding, but it has not been evaluated. We performed a pilot randomized clinical study assessing the safety of intra-arrest heparin administration in OHCA patients with suspected acute myocardial infarction (AMI) and its impact on their prognosis.
Materials and Methods.  OHCA patients were randomized during CPR to 10 000 units of intra-arrest intravenous heparin (Group H) or to treatment without heparin (Group C). The occurrence of major bleeding and the presence of a favourable neurological result 3 months after OHCA, were analyzed.
Results. Out of 88 randomized patients, AMI was subsequently confirmed in 63 of them (71.6 %). There were 30 patients in group H and 33 in group C. No major bleeding event was observed in either group. Return of spontaneous circulation (ROSC, Group H: 40.0%, Group C: 45.4%, p=0.662) and a good neurological result 3 months after OHCA (Group H: 6.7 %, Group C: 9.1 %, p=0.921) did not differ between groups.
Conclusions. Intravenous administration of 10 000 units of heparin during CPR for OHCA in patients with supposed AMI was safe. We did not find any improvement in prognosis for our sample of limited size. Though the procedure proved safe, we recommend postponing the administration of heparin until ROSC, assessment of  clinical state and  recording of a  twelve-lead ECG.

Key words: out-of-hospital cardiac arrest, heparin, major bleeding

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Assessing outcome of out-of-hospital cardiac arrest due to subarachnoid hemorrhage using brain CT during or immediately after resuscitation

Abstract

Objectives. The clinical course and outcome of out-of-hospital cardiopulmonary arrest (OHCPA) due to subarachnoid hemorrhage (SAH) is unclear. The objective of this study is to clarify them.
Study design. Single- center, observational study.
Setting. We usually perform a brain computed tomography (CT) in OHCPA patients who present without a clear etiology (42% of all OHCPA), such as trauma, to determine the cause of OHCPA and to guide treatment.
Patients. The study included OHCPA patients without a clear etiology, who were transferred to our center and who underwent a brain CT during resuscitation.
Methods of measurement. Patients’ records were reviewed; initial cardiac rhythm, existence of a witness and bystander cardiopulmonary resuscitation efforts (CPR) were compared with patients’ outcomes.
Results. Sixty-six patients were enrolled. 72.7% achieved return of spontaneous circulation (ROSC), 71.2% were admitted, 30.3% survived more than 7 days, and 9.1. survived-to-discharge. In 41 witnessed OHCPA, 87.8% obtained ROSC, 85.4% were admitted, and 14.6% survived-to-discharge. All survivors were witnessed. In 25 non-witnessed OHCPA, 48% obtained ROSC and were admitted, and no patients were discharged. Initial cardiac rhythm was ventricular fibrillation (VF), pulseless electrical activity (PEA) and asystole in 3.0%, 39.4%, and 47.0%. In 2 VF patients 50.0% survived-to- discharge, and there was no survivor with PEA or asystole.
Conclusion. This study shows a high rate of ROSC and admission in OHCPA patients with a SAH, and also reveals their very poor neurological outcome. We conclude that the detection of a SAH in OHCPA patients is important to determine the accurate frequency of SAH in this patient group and to guide appropriate treatment of all OHCPA patients.

Keywords: out-of-hospital cardiac arrest, brain CT, outcome, autopsy imaging, postmortem imaging

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Regional cardiac resuscitation systems of care

Abstract

Out-of-hospital cardiac arrest (OOHCA) is a common public health problem, with large and important regional variations in outcomes. Survival rates vary widely among patients treated with OOHCA by emergency medical services (EMS), or among patients transported to the hospital after return of spontaneous circulation. Most regions lack a well-coordinated approach to post-cardiac arrest care. Effective hospital-based interventions for OOHCA exist but are used infrequently. Increased volume of patients or procedures of individual providers and hospitals is associated with better outcomes for several other clinical disorders. Regional systems of cardiac resuscitation include a process for identification of patients with OOHCA, standard field and hospital care protocols for patients with OOHCA, monitoring of care processes and outcome, and periodic review and feedback of these quality improvement data to identify problems and implement solutions. Similar systems have improved provider experience and patient outcomes for those with ST-elevation myocardial infarction and life-threatening traumatic injury. Many more people could survive OOHCA if regional systems of cardiac resuscitation were implemented and maintained. The time has come to do so wherever feasible.

Key words: out-of-hospital cardiac arrest, emergency medical services, hospital-based interventions, regional systems of cardiopulmonary resuscitation (CPR), monitoring, outcome, transport time, improve of quality, survival

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Refibrillation during out-of-hospital arrest: A frequent event with clinical consequences

Abstract

The refibrillation was a frequent event in out-of-hospital cardiac arrest (OHCA). The number of recurrences of ventricular fibrillation (VF) is in inverse relationship with survival. In this article we discuss about causes and mechanism of refibrillation. The amiodarone and new technical solution (defibrillators that may allow continuous monitoring of the heart rhythm, while chest compressions continue and recommend defibrillation when refibrillation occurs) are promising new strategy to improve outcome of OHCA and recurrent VF.

Keywords: out-of-hospital cardiac arrest, ventricular fibrillation, defibrillation, refibrillation, amiodarone, continuous monitoring of the heart rhythm

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