Return of Spontaneous Circulation

ImportanceElectrocardiography (ECG) is an important tool to triage patients with out-of-hospital cardiac arrest (OHCA) after return of spontaneous circulation (ROSC). An immediate coronary angiography after ROSC is recommended only in patients with an ECG that is diagnostic of ST-segment elevation myocardial infarction (STEMI). To date, the benefit of this approach has not been demonstrated in patients with a post-ROSC ECG that is not diagnostic of STEMI.ObjectiveTo assess whether the time from ROSC to ECG acquisition is associated with the diagnostic accuracy of ECG for STEMI.Design, setting, and participantsThis retrospective, multicenter cohort study (the Post-ROSC Electrocardiogram After Cardiac Arrest study) analyzed consecutive patients older than 18 years who were resuscitated from OHCA between January 1, 2015, and December 31, 2018, and were admitted to 1 of the 3 participating centers in Europe (Pavia, Italy; Lugano, Switzerland; and Vienna, Austria).ExposureOnly patients who underwent coronary angiography during hospitalization and who acquired a post-ROSC ECG before the angiography were enrolled. Patients with a nonmedical cause of OHCAs were excluded.Main outcomes and measuresThe primary end point was false-positive ECG findings, defined as the percentage of patients with post-ROSC ECG findings that met STEMI criteria but who did not show obstructive coronary artery disease on angiography that was worthy of percutaneous coronary angioplasty.ResultsOf 586 consecutive patients who were admitted to the 3 participating centers, 370 were included in the analysis (287 men [77.6%]; median age, 62 years [interquartile range, 53-70 years]); 121 (32.7%) were enrolled in the participating center in Pavia, Italy; 38 (10.3%) in Lugano, Switzerland; and 211 (57.0%) in Vienna, Austria. The percentage of false-positive ECG findings in the first tertile of ROSC to ECG time (≤7 minutes) was significantly higher than that in the second (8-33 minutes) and third (>33 minutes) tertiles: 18.5% in the first tertile vs 7.2% in the second (odds ratio [OR], 0.34; 95% CI, 0.13-0.87; P = .02) and 5.8% in the third (OR, 0.27; 95% CI, 0.15-0.47; P 33 minutes: OR, 0.26; 95% CI, 0.14-0.47; P 33 minutes: OR, 0.27; 95% CI, 0.15-0.46; P 33 minutes: OR, 0.28; 95% CI, 0.15-0.52; P 33 minutes: OR, 0.27; 95% CI, 0.15-0.48; P 33 minutes: OR, 0.29; 95% CI, 0.15-0.55; P 33 minutes: OR, 0.27; 95% CI, 0.16-0.48; P 33 minutes: OR, 0.26; 95% CI, 0.15-0.46; P 33 minutes: OR, 0.27; 95% CI, 0.16-0.48; P Conclusions and relevanceThis study suggests that early ECG acquisition after ROSC in patients with OHCA is associated with a higher percentage of false-positive ECG findings for STEMI. It may be reasonable to delay post-ROSC ECG by at least 8 minutes after ROSC or repeat the acquisition if the first ECG is diagnostic of STEMI and is acquired early after ROSC.

ImportancePrehospital advanced airway management with either initial endotracheal intubation (ETI) or initial supraglottic airway (SGA) insertion in patients with out-of-hospital cardiac arrest (OHCA) remains controversial.ObjectiveTo compare the effectiveness of ETI and SGA in patients with nontraumatic OHCA.Design, setting, and participantsThe Supraglottic Airway Device vs Endotracheal intubation (SAVE) trial was a multicenter cluster randomized clinical trial conducted in Taipei City, Taiwan. Individuals aged 20 years or older who experienced nontraumatic OHCA requiring advanced airway management and were treated by participating emergency medical service agencies were enrolled from November 11, 2016, to December 31, 2019. The final day of follow-up was February 19, 2020.InterventionsFour advanced life support ambulance teams were divided into 2 randomization clusters, with each cluster assigned to either ETI or SGA in a biweekly period.Main outcomes and measuresThe primary outcome of the SAVE trial was sustained return of spontaneous circulation (ROSC) (≥2 hours) after resuscitation. Secondary outcomes included prehospital ROSC, survival to hospital discharge, and favorable neurologic outcome, defined as a cerebral performance category score less than or equal to 2. Prespecified subgroups and the association between time to advanced airways were explored. Per protocol and intention-to-treat analysis were performed.ResultsA total of 936 patients (517 in the ETI group and 419 in the SGA group) were included in the primary analysis (median age, 77 [IQR, 62-85] years; 569 men [60.8%]). The first-attempt airway success rates were 77% with ETI (n = 413) and 83% with SGA (n = 360). Sustained ROSC was 26.9% (n = 139) in the ETI group vs 25.8% (n = 108) in the SGA group. The odds ratio of sustained ROSC was 1.02 (95% CI, 0.98-1.06) in the ETI group vs SGA group. The odds ratio of ETA vs SGA was 1.04 (95% CI, 1.02-1.07) for prehospital ROSC, 1.00 (95% CI, 0.94-1.06) for survival to hospital discharge, and 0.99 (95% CI, 0.94-1.03) for cerebral performance category scores less than or equal to 2.Conclusions and relevanceIn this randomized clinical trial, among patients with OHCA, initial airway management with ETI did not result in a favorable outcome of sustained ROSC compared with SGA device insertion.Trial registrationClinicalTrials.gov Identifier: NCT02967952.

BackgroundOut-of-hospital cardiac arrest (OHCA) is a common reason for calls for intervention by emergency medical teams (EMTs) in Poland. Regardless of the mechanism, OHCA is a state in which the chance of survival is dependent on rapid action from bystanders and responding health professionals in emergency medical services (EMS). We aimed to identify factors associated with return of spontaneous circulation (ROSC).MethodsThe medical records of 2137 EMS responses to OHCA in the city of Wroclaw, Poland between July 2017 and June 2018 were analyzed.ResultsThe OHCA incidence rate for the year studied was 102 cases per 100,000 inhabitants. EMS were called to 2317 OHCA events of which 1167 (50.4%) did not have resuscitation attempted on EMS arrival. The difference between the number of successful and failed cardiopulmonary resuscitations (CPRs) was statistically significant (p ConclusionsThe factors associated with ROSC were occurrence in a public place, CPR initiation by witnesses, and presence of a shockable rhythm. Gender, age, and the type of EMT did not influence ROSC. Low bystander CPR rates reinforce the need for further efforts to train the public in CPR.

ObjectiveTo describe the clinical presentation of presumptive acute post-hypoxic myoclonus in a cat and a dog after cardiopulmonary arrest (CPA). In people, acute post-hypoxic myoclonus is a transient focal, multifocal, or generalized rhythmic myoclonus that results from global hypoxic-ischemic brain injury and may be cortical or subcortical in origin, specifically brainstem-generated. Post-hypoxic myoclonus typically presents within 48 h of CPA while the patient is still comatose. Although this neurologic sign has historically been associated with a poorer prognosis, recent studies suggest that evaluation of its clinical characterization in conjunction with electroencephalographic features should be considered.Case series summaryWe describe the cases of one cat and one dog that suffered CPA, underwent CPR, and experienced return of spontaneous circulation. Both cases developed presumed acute post-hypoxic myoclonus within 24 h of resuscitation, did not respond to antiseizure and sedative drugs, and were subsequently euthanized.New or unique information providedAcute post-hypoxic myoclonus can occur in cats and dogs after CPA and successful resuscitation.