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Aim: Mechanical chest compression devices in the 30:2 mode generally provide a pause of three seconds to give two insufflations without evidence supporting this pause duration. We aimed to explore the optimal pause duration by measuring the time needed for two insufflations, during advanced life support with manual compressions. Methods: Prospectively collected data in the AmsteRdam REsuscitation STudies (ARREST) registry were analysed, including thoracic impedance signal and waveform capnography from manual defibrillators of the Amsterdam ambulance service. Compression pauses were analysed for number of insufflations, time interval from start of the compression pause to the end of the second insufflation, chest compression pause duration and ventilation subintervals. Results: During 132 out-of-hospital cardiac arrests, 1619 manual chest compression pauses to ventilate were identified. In 1364 (84%) pauses, two insufflations were given. In 28% of these pauses, giving two insufflations took more than three seconds. The second insufflation is completed within 3.8 seconds in 90% and within 5 seconds in 97.5% of these pauses. An increasing likelihood of achieving two insufflations is seen with increasing compression pause duration up to five seconds. Conclusion: The optimal chest compression pause duration for mechanical chest compression devices in the 30:2 mode to provide two insufflations, appears to be five seconds, warranting further studies in the context of mechanical chest compression. A 5-second pause will allow providers to give two insufflations with a very high success rate. In addition, a 5-second pause can also be used for other interventions like rhythm checks and endotracheal intubation.

Study objective While often prioritized in the resuscitation of patients with out-of-hospital cardiac arrest, the optimal timing of advanced airway insertion is unknown. We evaluated the association between the timing of advanced airway (laryngeal tube and endotracheal intubation) insertion attempt and survival to hospital discharge in adult out-of-hospital cardiac arrest. Methods We performed a secondary analysis of the Pragmatic Airway Resuscitation Trial (PART), a clinical trial comparing the effects of laryngeal tube and endotracheal intubation on outcomes after adult out-of-hospital cardiac arrest. We stratified the cohort by randomized airway strategy (laryngeal tube or endotracheal intubation). Within each subset, we defined a time-dependent propensity score using patients, arrest, and emergency medical services systems characteristics. Using the propensity score, we matched each patient receiving an initial attempt of laryngeal tube or endotracheal intubation with a patient at risk of receiving laryngeal tube or endotracheal intubation attempt within the same minute. Results Of 2,146 eligible patients, 1,091 (50.8%) and 1,055 (49.2%) were assigned to initial laryngeal tube and endotracheal intubation strategies, respectively. In the propensity score-matched cohort, timing of laryngeal tube insertion attempt was not associated with survival to hospital discharge: 0 to lesser than 5 minutes (risk ratio [RR]=1.35, 95% confidence interval [CI] 0.53 to 3.44); 5 to lesser than10 minutes (RR=1.07, 95% CI 0.66 to 1.73); 10 to lesser than 15 minutes (RR=1.17, 95% CI 0.60 to 2.31); or 15 to lesser than 20 minutes (RR=2.09, 95% CI 0.35 to 12.47) after advanced life support arrival. Timing of endotracheal intubation attempt was also not associated with survival: 0 to lesser than 5 minutes (RR=0.50, 95% CI 0.05 to 4.87); 5 to lesser than10 minutes (RR=1.20, 95% CI 0.51 to 2.81); 10 to lesser than15 minutes (RR=1.03, 95% CI 0.49 to 2.14); 15 to lesser than 20 minutes (RR=0.85, 95% CI 0.30 to 2.42); or more than/equal to 20 minutes (RR=0.71, 95% CI 0.07 to 7.14). Conclusion In the PART, timing of advanced airway insertion attempt was not associated with survival to hospital discharge.

Publisher Copyright: © 2021 The Authors Objective: Airway management to ensure sufficient gas exchange is of major importance in emergency care. Prehospital endotracheal intubation (ETI) by paramedics is a widely debated method to ensure a patent airway. ETI is performed with procedural sedation in comatose patients because of the regulation. The use of medications increases the rate of successful airway management compared with nonmedication ETI and may also improve outcomes in patients with traumatic brain injury. In the absence of an operative emergency physician and with long distances, paramedic-induced airway management may increase the survival of patients in selected scenarios. A paramedic-staffed helicopter emergency medical system in Northern Finland operates in a rural area without an emergency physician and paralytic medications and treats critically ill patients using basic or advanced life support ground units. The aim of this study was to evaluate the success rates of ETI performed by a small, appropriately trained, and experienced group of 8 nurse paramedics in an out-of-hospital setting. Methods: The inclusion criterion for the study was an attempted intubation in patients with medical or traumatic indication for airway management by nurse paramedic. Results: Fifty-one patients were treated with ETI. The first-pass success rate was 72.5%, the second-pass success rate was 94.1%, and the overall success rate was 100% within 4 attempts. The median on-scene time was 54 minutes, and there were no signs of aspiration during laryngoscopy or after successful ETI. The primary mortality rate was 11.7%. Conclusion: The use of a rigid standard operating procedure for paramedic rapid sequence induction, paralytics, a video laryngoscope, and a gum elastic bougie might positively affect the ETI first-pass success rate. A follow-up study after these future modifications is needed. This small study suggests that intubation might be 1 option for airway management by an experienced nonanesthesiologist in Lapland.

Aims Out of hospital cardiac arrest (OHCA) is still a leading cause of mortality worldwide. In recent years, resuscitative endovascular balloon occlusion of the aorta (REBOA) has been progressively studied as an adjunct to standard advanced life support (ALS) in both traumatic and non-traumatic refractory OHCA. Since January 2019, the REBOA procedure has been applied to all the patients experiencing both traumatic and non-traumatic refractory OHCA (≥15 min of cardiopulmonary resuscitation) not eligible for ECPR for clinical or logistic reasons. We aimed at describing the feasibility and effects of REBOA performed both in the Emergency Department and in the pre-hospital environment served by the local HEMS for refractory OHCA. Methods Twenty consecutive patients experiencing refractory OHCA and in whom REBOA was attempted in 2019 and 2020 were included in the study, Utstein data and REBOA specific variables were recorded. Results Successful catheter placement was achieved in 18 out of 20 patients, 11 of these were non-traumatic OHCAs while 7 were traumatic OHCAs, the 2 failures were related to repeated arterial puncture failure. Median time between the EMS dispatch and REBOA catheter placing attempt was 46 min. An increase in etCO2 over 10 mmHg was observed after balloon inflation in 12 out of 18 patients (8/11 non-traumatic and 4/7 traumatic OHCAs), a sustained ROSC was observed in 5 patients (1 traumatic and 4 non-traumatic OHCA) that were subsequently admitted to the ICU. Four out of the 5 patients reached the criteria for brain death in the subsequent 24 h while one patient experienced another episode of refractory cardiac arrest in ICU and subsequently died. Conclusion Our data confirm the feasibility of REBOA technique as an adjunct to ALS in both the ED and prehospital phase and most of the treated patients experienced a transient ROSC after balloon inflation while 5 out of 18 experienced a sustained ROSC. However, while in the trauma setting increasing evidence suggests an improved survival when REBOA is applied to refractory OHCA, in non-traumatic OHCA this has yet to be demonstrated and large studies are needed.

International audience; INTRODUCTION: Traumatic cardiac arrest (TCA) guidelines emphasize specific actions that aim to treat the potential reversible causes of the arrest. The aim of this study was to measure the impact of these recommendations on specific rescue measures carried out in the field, and their influence on short-term outcomes in the resuscitation of TCA patients. METHODS: We conducted a retrospective study of all TCA patients treated in two emergency medical units, which are part of the Northern Alps Emergency Network, from January 2004 to December 2017. We categorised cases into three periods: pre-guidelines (from January 2004 to December 2007), during guidelines (from January 2008 to December 2011), and post-guidelines (from January 2012 to December 2017). Local guidelines, a physician education programme, and specific training were set up during the post-guidelines period to increase adherence to recommendations. Utstein variables, and specific rescue measures were collected: advanced airway management, fluid administration, pelvic stabilisation or tourniquet application, bilateral thoracostomy, and thoracotomy procedures. The primary endpoint was survival rate at day 30 with good neurological status (cerebral performance category scores 1 and 2) in each period, considering the pre-guidelines period as the reference. RESULTS: There were 287 resuscitation attempts in the TCA cases included, and 279 specific interventions were identified with a significant increase in the number of fluid expansions (+16%), bilateral thoracostomies (+75%), and pelvic stabilisations (+25%) from the pre- to post-guidelines periods. However, no improvement in survival over time was found. CONCLUSION: Reversible measures were applied but to a varying degree, and may not adequately capture pre-hospital performance on overall TCA survival.

Background This review is the latest in a series of regular annual reviews undertaken by the editors and aims to highlight some of the key papers published in Resuscitation during 2020. The number of papers submitted to the Journal in 2020 increased by 25% on the previous year.MethodsHand-searching by the editors of all papers published in Resuscitation during 2020. Papers were selected based on then general interest and novelty and were categorised into general themes.ResultsA total of 103 papers were selected for brief mention in this review.ConclusionsResuscitation science continues to evolve rapidly and incorporate all links in the chain of survival.

The objective of this study was to design a risk model with variables determined before hospital arrival to predict the risk of serious adverse events in patients with acute poisoning.A preliminary prospective, multicentre cohort study of adults with prehospital diagnosis of acute intoxication was conducted. The study was carried out in the Public Health System of the Community of Castilla-Leon (Spain), including seven advanced life support units and five hospitals, between April 1, 2018, and June 30, 2019. People aged18 years with a main prehospital diagnosis of acute poisoning admitted to a referral hospital on advanced life support were included. The main outcome measure was prehospital and hospital serious adverse events in patients with acute poisoning.We included 221 patients, with a median age of 47 years (interquartile range: 33-61). The most frequent cause of poisoning was psychopharmaceuticals (111 cases, 49.8%): 38 (17.2%) patients had a serious adverse event, with a hospital mortality of 4.1% (nine cases) in the 30 days after the index event. The final model included age ≥65 years (odds ratio [OR]: 9.59, 95% confidence interval [CI]: 3.48-26.45; p 0.001), oxygen saturation/fraction of inspired oxygen index ≤300 (OR: 15.03, 95% CI: 5.74-39.33; p 0.001), and point-of-care lactate ≥4 mmol/L (OR: 7.68, 95% CI: 2.88-20.45; p 0.001). The poisoning Early Warning Score was constructed from these three variables, and 1 point was assigned to each variable. The area under the curve of the score was 0.896 (95% CI: 0.82-0.96; p 0.001).The poisoning Early Warning Score may help in decision-making and promote early identification of high-risk patients with acute poisoning in the prehospital context.

Informed by a series of systematic reviews, scoping reviews and evidence updates from the International Liaison Committee on Resuscitation, the 2021 European Resuscitation Council Guidelines present the most up to date evidence-based guidelines for the practice of resuscitation across Europe. The guidelines cover the epidemiology of cardiac arrest; the role that systems play in saving lives, adult basic life support, adult advanced life support, resuscitation in special circumstances, post resuscitation care, first aid, neonatal life support, paediatric life support, ethics and education.

AIM Advanced life support courses have a clear educational impact; however, it is important to determine whether participation of one or more members of the resuscitation team in an accredited advanced life support course improves in-hospital cardiac arrest patient survival outcomes. METHODS We searched EMBASE.com, Medline, Cochrane and CINAHL from inception to 1 November 2022. Included studies were randomised or non-randomised interventional studies assessing the impact of attendance at accredited life support courses on patient outcomes. Accredited life support courses were classified into 3 contexts: Advanced Life Support (ALS), Neonatal Resuscitation Training (NRT), and Helping Babies Breathe (HBB). Existing systematic reviews were identified for each of the contexts and an adolopment process was pursued. Appropriate risk of bias assessment tools were used across all outcomes. When meta-analysis was appropriate a random-effects model was used to produce a summary of effect sizes for each outcome. RESULTS Of 2714 citations screened, 19 studies (1 ALS; 7 NRT; 11 HBB) were eligible for inclusion. Three systematic reviews which satisfied AMSTAR-2 criteria for methodological quality, included 16 of the studies we identified in our search. Among adult patients all outcomes including return of spontaneous circulation, survival to discharge and survival to 30 days were consistently better with accredited ALS training. Among neonatal patients there were reductions in stillbirths and early neonatal mortality. CONCLUSION These results support the recommendation that accredited advanced life support courses, specifically Advanced Life Support, Neonatal Resuscitation Training, and Helping Babies Breathe improve patient outcomes.

Cardiac arrest in pregnancy is a rare entity. However, owing to its uncommon occurrence, there exist deficits in proper competences among practitioners regarding advanced life support procedure of performing cardiopulmonary resuscitation (CPR) and requirement for peri-mortem caesarean section. We report a case of a 40-year-old multigravida patient with diagnosed pre-eclampsia, whose pregnancy was detected in the third trimester. She was non-compliant with oral antihypertensives and suffered from a cardiac arrest and underwent a peri-mortem caesarean section alongside simultaneous fetal and maternal resuscitation.

Neck injuries are an important cause of combat mortality and morbidity. This study's objective was to examine the characteristics and causes of neck injuries among Israel Defense Forces (IDF) and emphasize the best treatment protocols for the advanced life support providers in the prehospital combat environment.The IDF Trauma Registry (IDF-TR) includes prehospital data regarding casualties treated by the IDF's medical forces. This study was a retrospective, observational study that included all casualties who were injured between January 2006 and December 2018.Between January 2016 and December 2018, 3294 casualties were recorded. During the study period, 1% (41/3,394) of all injury casualties in the registry were isolated neck injuries compared to 94% (3185/3,394) without neck injury. 42% (14/41) percent of the neck casualties were classified as urgent compared to 26% (830/3185, P = 0.09) in the no neck group. The most frequent type of injury mechanism in the neck casualties was penetrating injury (54% 22/41), mostly due to shrapnel (68% 15/22). 60% of neck injured personnel were injured during the 2nd Lebanon War and Operation Protective Edge in high-intensity conflicts. As for life-saving interventions, advanced airway interventions were performed in 12% of neck injured group (5/41) compared to 3% (104/3185, P = 0.02) in the no neck group. We revealed that cricothyroidotomy was performed in almost 10% (4/41) of neck injured casualties compared to only 1% (19/3185, P0.0001) in no neck casualties. As for damage control resuscitation, neck injury casualties received higher amounts of Fresh Dried Plasma 7% (3/41) Vs. 1% (32/3185, P = 0.02) and Tranexamic acid 15% (6/41) Vs. 4% (124/3185, P = 0.01) compared to non-neck casualties.Military neck injuries are a significant cause of substantial disability and result in incompatibility with combat duties in previously healthy soldiers. Prompt medical care, especially urgent hemodynamic and airway management, is paramount in these injuries. Routine use of designated neck protection might lower the number of neck injuries, mitigate their severity, and even decrease mortality.Level III (Retrospective study with up to two negative criteria).

Despite the increased survival opportunities for extremely preterm infants, their long-term cognitive outcomes remain poor, with increased incidence of cognitive impairments in childhood and reduced opportunities to attend higher education in young adulthood compared to their term-born peers. Given that a considerable fraction of preterm infants develop cognitive impairments even without apparent sentinel events at birth and cerebral lesions on MRI assessed at term equivalent age, future strategies to improve the outcome may need to address cerebral dysfunction, which cannot be explained by the classical understanding of the injury cascade triggered by hypoxia-ischaemia around birth. Developmental care has been proposed to minimize neurodevelopmental impairments related to preterm birth. However, considerable modes of cares, environmental settings and procedures provided by the developmental care of current style appear to offer little benefit to the sound development of infants. Although it is obvious that advanced life support and neuroprotective treatments fall far short in compensating for the burden of preterm birth, researchers need to make further effort to fill the knowledge gap in the cerebral function of foetuses and newborn infants before establishing evidence-based developmental care. Clinicians need to develop an ability to translate the findings from basic and translational studies incorporating their potential biases and limitations. Care for newborn infants needs to be reassessed, including but not limited to developmental care, in the context that any sensory input and motor reaction of preterm infants may ultimately affect their cognitive functioning.

Background We conducted a rapid review of current international and Australian advanced life support (ALS) guidelines for cardiac arrest associated with anaphylaxis to (1) assess the variation and (2) determine if a systematic review update of ALS guideline recommendations is warranted. Method A search and comparison of key recommendations was conducted for major international and Australian clinical guidelines, including member societies and councils of the World Allergy Organisation and the International Liaison Committee on Resuscitation (ILCOR). Systematic database searches (Medline, Cochrane Database of Systematic Reviews, PROSPERO international register of systematic reviews and ClinicalTrials.gov databases) was conducted to identify existing and in-progress research published on the topic of anaphylaxis and cardiac arrest. Results Eight international guidelines were identified from Australia/New Zealand, Europe, United States and Canada, and 5 national guidelines were identified for Australia. There was general consensus across all guidelines for the use of adrenaline, oxygen, patient positioning and glucagon. There was variation across international and Australian guidelines for adrenaline dosing and frequency, antihistamines and corticosteroid recommendations. Most recommendations were based on low-level evidence, and the review of published systematic reviews and clinical trials identified new evidence in the last decade. Conclusions We found significant variation between current ALS guideline recommendations for treating anaphylaxis. While there is no new evidence to suggest a systematic review of guideline recommendations is needed, there may be an opportunity to produce more consistent international guideline recommendations and educational materials.

Introduction Good quality basic life support (BLS) is associated with improved outcome from cardiac arrest. Chest compression fraction (CCF) is a BLS quality indicator, which may be influenced by the type of airway used. We aimed to assess CCF according to the airway strategy in the PARAMEDIC2 study: no advanced airway, supraglottic airway (SGA), tracheal intubation, or a combination of the two. Our hypothesis was that tracheal intubation was associated with a decrease in the CCF compared with alternative airway management strategies. Methods PARAMEDIC2 was a multicentre double-blinded placebo-controlled trial of adrenaline vs placebo in out-of-hospital cardiac arrest. Data showing compression rate and ratio from patients recruited by London Ambulance Service (LAS) as part of this study was collated and analysed according to the advanced airway used during the resuscitation attempt. Results CPR process data were available from 286/ 2058 (13.9%) of the total patients recruited by LAS. The mean compression rate for the first 5 min of data recording was the same in all groups (P = 0.272) and ranged from 104.2 (95% CI of mean: 100.5, 107.8) min−1 to 108.0 (95% CI of mean: 105.1, 108.3) min−1. The mean compression fraction was also similar across all groups (P = 0.159) and ranged between 74.7% and 78.4%. There was no difference in the compression rates and fractions across the airway management groups, regardless of the duration of CPR. Conclusion There was no significant difference in the compression fraction associated with the airway management strategy.

Introduction Acute myocardial infarction (AMI) is a time sensitive emergency. In resource limited settings, prompt identification and management of patients experiencing AMI in the pre-hospital setting may minimise the negative consequences associated with overburdened emergency medical and hospital services. Expedited care thus, in part, relies on the dispatch of appropriate pre-hospital medical providers by emergency medical dispatchers. Identification of these patients in call centres is challenging due to a highly diverse South African society, with multiple languages, cultures, and levels of education. The aim of this study was therefore, to describe the terms used by members of the South African public when calling for an ambulance for patients suffering an AMI. Methods In this qualitative study, we performed content analysis to identify keywords and phrases that callers used to describe patients who were experiencing an advanced life support (ALS) paramedic-diagnosed AMI. Using the unique case reference number of randomly selected AMI cases, original voice recordings between the caller and emergency medical dispatcher at the time of the emergency were extracted and transcribed verbatim. Descriptors of AMI were identified, coded and categorised using content analysis, and quantified. Results Of the 50 randomly selected calls analysed, 5 were not conducted in English. The descriptors used by callers were found to fall into three categories; Pain: Thorax, No pain: Thorax and Ill- health. The code that occurred most often was no pain, heart related (n = 16; 23.2%), followed by the code describing pain in the chest (n = 15; 21.7%). Conclusion South African callers use a consistent set of descriptors when requesting an ambulance for a patient experiencing an AMI. The most common of these are non-pain descriptors related to the heart. These descriptors may ultimately be used in developing validated algorithms to assist dispatch decisions. In this way, we hope to expedite the correct level of care to these time- critical patients and prevent the unnecessary dispatch of limitedly available ALS paramedics to inappropriate cases.

Aim of the study For out-of-hospital-cardiac-arrest (OHCA) due to ventricular fibrillation (VF) guidelines recommend early defibrillation followed by chest compressions for two minutes before analyzing shock success. If rhythm analysis reveals VF again, it is obscure whether VF persisted or reoccurred within the two-minutes-cycle of chest compressions after successful defibrillation. We investigated the time of VF-recurrence in OHCA. Methods We examined all cases of OHCA presenting with initial VF rhythm at arrival of ALS-ambulance (Marburg-Biedenkopf-County, 246.648 inhabitants) from January 2014 to March 2018. Three independent investigators analyzed corpuls3® ECG-recordings. We included ECG-data from CPR-beginning until four minutes after the third shock. VF termination was defined as the absence of a VF-waveform within 5 s of shock delivery. VF recurrence was defined as the presence of a VF-waveform in the interval 5 s post shock delivery. Results We included 185 shocks in 82 patients. 74.1% (n = 137) of all shocks terminated VF, but VF recurred in 81% (n = 111). The median (IQR) time of VF-recurrences was 27 s (13.5 s/80.5 s) after shock. 51.4% (n = 57) of VF-recurrence occurred 5–30 s after shock, 13.5% (n = 15) VF-recurrence occurred 31−60 s after shock, 21.6% (n = 24) of VF-recurrence occurred 61–120 s after shock, 13.5% (n = 15) of VF-recurrence occurred 121–240 s after shock. Conclusions Although VF was terminated by defibrillation in 74.1%, VF recurred in 81% subsequent to the chest compression interval. Thus, VF reappears frequently and early. It is unclear to which extend chest compressions influence VF-relapse. Further studies need to re-evaluate the algorithm, timing of antiarrhythmic therapy or novel defibrillation strategies to minimize refibrillation during shockable OHCA.

This2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendationsfor 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.

INTRODUCTION: The role of advanced life support (ALS) versus basic life support (BLS) in blunt trauma is controversial. Previous studies have shown no mortality benefit with ALS for penetrating trauma but the blunt population has mostly remained unaddressed. METHODS: A retrospective cohort study was conducted at a Level 1 trauma center comparing outcomes in blunt trauma patients managed by ALS versus BLS from July 1, 2014 to December 31, 2014. Both Injury Severity Score (ISS) and select Abbreviated Injury Score (AIS) were used to determine differences in mortality, length of stay (LOS) and complications based on mode of transportation, prehospital time, and number of prehospital interventions. RESULTS: 698 total patients were identified. Mortality and complications were grossly higher in ALS patients (p = 0.01 and < 0.001, respectively). When accounting for ISS and AIS there was no difference in mortality (p=

Technical skills (TS) and non-technical skills (NTS) are the primary elements ensuring patient safety during advanced life support (ALS) and effective crisis resource management (CRM). Both skills are needed to perform high-quality ALS, though they are traditionally practiced separately. The evidence of the association between NTS and TS in high-quality ALS performance is insufficient. Hence, we aimed to evaluate the association between the skills in real-life in-hospital ALS situations.We video recorded real-life in-hospital ALS situations, analyzed TS and NTS demonstrated in them with an instrument measuring TS and NTS, and tested the linear association between NTS and TS using a linear mixed model.Among 50 real-life in-hospital ALS situations that we recorded, 20 had adequate data for analysis. NTS and TS total scores were associated with one another (slope 0.48, P 0.001). All NTS subcategories were associated with the TS total score (slopes ranging from 0.29 to 0.39, P 0.001). The NTS total score and TS subcategories (chest compression quality, ventilation quality, rhythm control and defibrillation quality) were associated with one another (slopes ranging from 0.37 to 0.56, P 0.01).The resuscitation teams who demonstrated good NTS also performed the technical aspects of ALS better. The results suggest that NTS and TS have an association with one another in real-life in-hospital ALS situations. NTS performance had the most evident association with chest compression quality and rhythm control and defibrillation quality; these are considered the most crucial elements affecting outcomes of ALS. The findings of the study present novel information of what and why to emphasize in ALS training.ClinicalTrials.gov, NCT03017144.

International audience; Aims: There are large differences between emergency medical systems, which may account for variability in outcomes. We seek to compare prehospital organizations, response modes, patient characteristics and outcomes after out-of-hospital cardiac arrest, between France and Canada, and discuss the need for the first European-North American prehospital research network on out-of-hospital cardiac arrest.Methods: Preliminary comparative description of data drawn from two nation-wide, population-based, Utstein-style prospectively implemented registries for out-of-hospital cardiac arrest in France and Canada (France: RéAC, Canada: CanROC), covering approximately 80 million people, and soon to be participating in an international research network in 2020.Results: Since creation, 103,722 cases were included in France and approximately 99,317 in Canada. Data used in this work were drawn from 2011 to 2016, and comprised around 33,688 adult, non-traumatic, treated cases in Canada, and 55,358 in France, leading to estimated incidence rates of 75.3/100,000 inhabitants in France and 83/100,000 in Canada. In both countries, out-of-hospital cardiac arrest predominantly occurred in male patients, in their late sixties, at home, of presumed cardiac aetiology. Bystander cardiopulmonary resuscitation was provided in half of the cases. First assessed cardiac rhythm was shockable in 16% (France) vs. 22% (Canada). Professional resuscitation was attempted in 82% (France) and 60% (Canada). Prehospital organizations and response modes differed in the constitution of responding teams (France: physician-led advanced life support, Canada: trained paramedics), in response time intervals (call to first professional responders' arrival at scene 6.5 min (interquartile range IQR [5.2-8.3]) (Canada) vs. 10 min [7-15] (France)), in on-scene interventions, type of referral at hospital (France: systematic bypass of emergency department, tertiary hospital first, Canada: occasional bypass, mainly closest hospital first), and in outcomes (overall survival at hospital discharge in France: 5% vs. Canada: 11%).Conclusion: Despite similarities in some out-of-hospital cardiac arrest Utstein variables, several differences exist between French and Canadian prehospital systems, and ultimately, between outcomes. The creation of the ReACanROC research network will facilitate the conduction of further analyses to better understand predictors of this variability.

What can anterior neck and airway ultrasound add to the established methods in emergency airway management, including capnography? The aim of this narrative review is to review relevant methods. We describe three major categories of anterior neck and airway ultrasound exam methods in order to distinguish its applicability within a defined clinical context. We particularly describe two types of focused anterior neck ultrasound exam styles depending on the clinical scenario, post-intubation (type #1 style) and during intubation (type #2 style). Regarding both exam styles, the key message is to identify or rule out a double tract immediately, indicating an esophageal misplacement. For this finding no ventilation trial is mandatory. In case of clinical emergency scenarios, this is the major advantage in comparison to capnometry. Exam type #1 style is a very brief sonoscopy-like exam and can be performed within 10 s in an ALS-conformed way. As these stethoscope-like examinations can be integrated into the advanced life support algorithm, it is suggested that anterior neck and airway ultrasound should be part of the collection of methods of “Resuscitation Ultrasound” and training. To make it available to a wider audience, the exam techniques are visualized in video clips and available at www.yumpu.com/en/SonoABCD . Considering the evidence and limitations of anterior neck and airway ultrasound procedures in emergencies, training within scenarios or a defined clinical context is recommended. These point-of-care ultrasound methods should be readily accessible for emergency and critical care practitioners.

Background Cardiac arrests are associated with poor outcomes. The International Liaison Committee on Resuscitation (ILCOR) evaluates resuscitation science and produced, until 2015, five-yearly consensus on science and treatment recommendations (CoSTRs), informing global resuscitation guidelines. We aimed to identify similarities/differences in resuscitation guidelines from ILCOR members, noting concurrence over time, and CoSTRs influence on these guidelines. Methods We considered the component elements of paediatric and adult, basic and advanced resuscitation guidelines, published in 2010 and 2015, along with matching ILCOR CoSTRs to examine their influence. We contacted the responsible councils when guidelines were unavailable online. Results Complete resuscitation guidelines were found for six of the seven ILCOR council members. The Resuscitation Council of Asia only had adult basic life support (BLS) guidelines in English. Three members used the AHA guidelines. Therefore, five rather than seven sets of resuscitation guidelines were compared to the CoSTRs. Concurrence between CoSTRs recommendations and ILCOR council member's resuscitation guidelines has improved over time. Minor variations were identified in both basic and advanced life support, with most variance in paediatric guidelines, but these narrowed over time. Conclusion The improved concurrence across the resuscitation guidelines with the CoSTRs suggests that ILCOR members accept and hence incorporate CoSTRs recommendations to inform their own resuscitation guidelines. This is one step towards the development of international universal guidelines for adult and paediatric resuscitation.

Aim We aimed to investigate whether the ability of the volumetric capnography-derived parameter, the volume of CO2 eliminated per minute and per kg body weight (V’CO2 kg−1), in monitoring the quality of CPR and predicting the return of spontaneous circulation (ROSC) remains undisturbed by hyperventilation. Methods This randomised crossover study included 12 male domestic pigs. After 4 min of untreated ventricular fibrillation, mechanical CPR was administered. Following 5-min washout periods, each animal underwent two sessions of experiments; four 5-min ventilation trials followed by advanced life support, consecutively in the two sessions. Results Different ventilation types had no significant impact on V’CO2 kg−1 or haemodynamics. However, PETCO2 was significantly affected by the ventilation type and coronary perfusion pressure (P Conclusions V’CO2 kg−1 performs better than PETCO2 in monitoring the quality of CPR during hyperventilation. In predicting ROSC during variations in a ventilation state, V’CO2 kg−1 has good predictive ability.

Background Adrenaline is an important component in the resuscitation of individuals experiencing out-of-hospital cardiac arrest (OHCA). The 2018 Advanced Cardiac Life Support (ACLS) algorithm gives the option of either intravenous (IV) or intraosseous (IO) routes for adrenaline administration during cardiac arrest. However, the optimal route during prehospital resuscitation remains controversial. This study aims to investigate whether IV and IO routes lead to different outcomes in OHCA patients who received prehospital adrenaline. Methods This retrospective analysis included adult patients with OHCA of presumed cardiac origin who had Emergency Medical Services (EMS) CPR, received adrenaline, and were enrolled in the Resuscitation Outcomes Consortium (ROC) Cardiac Epistry version 3 database between 2011 and 2015. We divided the study population into IV and IO groups based on the administration route. Logistic regression analysis was performed to evaluate the association between adrenaline delivery routes and prehospital return of spontaneous circulation (ROSC), survival to hospital discharge, and favorable neurological outcome. Results Of the 35,733 patients included, 27,758 (77.7%) had adrenaline administered via IV access and 7975 (22.3%) via IO access. With the IO group as a reference in the logistic regression model, the adjusted odds ratios of the IV group for prehospital ROSC, survival and favorable neurological outcome were 1.367 (95%CI, 1.276–1.464), 1.468 (95%CI, 1.264–1.705) and 1.849 (95%CI, 1.526–2.240), respectively. Similar results were found in the propensity score matched population and subgroup analysis. Conclusion Compared with the IO approach, the IV approach appears to be the optimal route for adrenaline administration in advanced life support for OHCA during prehospital resuscitation.

The Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) Bioethics Working Group has developed recommendations on the Limitation of Advanced Life Support Treatment (LLST) decisions, with the aim of reducing variability in clinical practice and of improving end of life care in critically ill patients. The conceptual framework of LLST and futility are explained. Recommendations referred to new forms of LLST encompassing also the adequacy of other treatments and diagnostic methods are developed. In addition, planning of the possible clinical courses following the decision of LLST is commented. The importance of advanced care planning in decision-making is emphasized, and intensive care oriented towards organ donation at end of life in the critically ill patient is described. The integration of palliative care in the critical patient treatment is promoted in end of life stages in the Intensive Care Unit.

Background Advanced life support (ALS) short training courses are in demand across Africa, though overwhelmingly designed and priced for non-African contexts. The continental expansion of emergency care is driving wider penetration of these courses, but their relevance and accessibility is not known. We surveyed clinicians within emergency settings to describe ALS courses' prevalence and perceived value in Africa. Methods We conducted a cross-sectional quantitative analysis of 235 clinicians' responses to the African Federation for Emergency Medicine's online needs assessment for an open-access ALS course in Africa. Participants responded to multiple-choice and open answer questions assessing demographics, ALS course certification and availability, perceptions of ALS courses, and barriers and facilitators to undertaking such courses. Results 235 clinicians working in 23 African nations responded. Most clinicians reported ALS course completion within the past three years (73%) and in-country access to ALS courses (76%). Most believed the content adequately met their region's needs (60%). Price and course availability were the most common barriers to taking an ALS course. The most common courses were cardiac and paediatric-focused, and the most common reasons to take a course included general career development, personal interest, and departmental requirements. Conclusion One-quarter of emergency care clinicians lack access to ALS courses in twenty-three African nations. Most clinicians believe that ALS courses have value in their clinical settings and meet the needs of their region. Our findings illustrate the need for an affordable, widely available ALS course tailored to lower-resource African settings that could reach rural and peri-urban clinicians.

Aim The European Resuscitation Council guidelines recommend a slow rate of rewarming of 0.25 °C/h–0.5 °C/h for out-of-hospital cardiac arrest (OHCA) patients receiving therapeutic hypothermia (TH). Conversely, a very slow rewarming of 1 °C/day is generally applied in Japan. The rewarming duration ranged from less than 24 h up to more than 50 h. No randomized control trials have examined the optimal rewarming speed for TH in OHCA patients. Therefore, we examined the association between the rewarming duration and neurological outcomes in OHCA patients who received TH. Methods This study was a secondary analysis of the Japanese Population-based Utstein-style study with defibrillation and basic/advanced Life Support Education and implementation-Hypothermia (J-PULSE-HYPO) study registry, a multicenter prospective cohort study. Patients suffering from OHCA who received TH (target temperature, 34 °C) after the return of spontaneous circulation from 2005 to 2011 in 14 hospitals throughout Japan were enrolled. The rewarming duration was defined as the time from the beginning of rewarming at a target temperature of 34 °C until reaching 36 °C. The primary outcome was an unfavorable neurological outcome at hospital discharge, i.e., a cerebral performance category of 3–5. Results The J-PULSE-HYPO study enrolled 452 OHCA patients. Of these, 328 were analyzed; 79.9% survived to hospital discharge, of which 56.4% had a favorable neurological outcome. Multivariable logistic regression analysis revealed that the rewarming duration was independently associated with unfavorable neurological outcomes [odds ratio (per 5 h), 0.89; 95% confidence interval, 0.79–0.99; p = 0.032]. Conclusion A longer rewarming duration was significantly associated with and was an independent predictor of favorable neurological outcomes in OHCA patients who received TH.

Objective: To describe the characteristics of paediatric patients with suspected poisoning treated by advanced life support (ALS) units, and to evaluate quality indicators (QI) for the prehospital emergency care of these patients. Method: A one-year observational study of patients under 18 years of age exposed to poisoning and treated by an ALS unit of the Medical Emergency System in Catalonia. Severe clinical criteria were defined, with 8 QI being evaluated for prehospital emergency care of poisoned paediatric patients. Results: The study included a total of 254 patients, with a median age of 14 years old (p25-75 = 7–16), with intentional poisoning in 50.8% of cases. The most frequently involved toxic agent was carbon monoxide (CO) (33.8%). Poisoning was found in 48.8% of those patients, being serious in 16.5%. Intentionally (OR 5.1; 95% CI: 1.9–13.8) and knowledge of the time of exposure (OD 3.1; 95% CI: 1.3–7.3) were independent risk factors associated with the appearance of severe clinical symptoms. Five QI did not reach the quality standard and included, availability of specific clinical guidelines, activated charcoal administration in selected patients, oxygen therapy administration at maximum possible concentration in carbon monoxide poisoning, electrocardiographic assessment in patients exposed to cardiotoxic substances, and recording of the minimum data set. Conclusions: Paediatric patients attended by ALS units showed specific characteristics, highlighting the involvement of CO and adolescents with voluntary poisoning. The QI assessment was useful to detect weak points in the quality of care of these patients and to develop strategies for improvement. Resumen: Objetivo: Describir las características de los pacientes pediátricos con sospecha de intoxicación atendidos por unidades de soporte vital avanzado (SVA) y evaluar los indicadores de calidad (IC) para la atención urgente prehospitalaria de estos pacientes. Método: Estudio observacional de los pacientes menores de 18 años con exposición a tóxicos, que fueron atendidos por una unidad de SVA del Sistema de Emergencias Médicas en Cataluña, durante un año. Se definieron criterios de clínica grave. Se evaluaron 8 IC para la atención urgente prehospitalaria de los pacientes pediátricos intoxicados. Resultados: Se incluyó a 254 pacientes. La edad mediana fue de 14 años (p25-75 = 7-16), con exposición intencionada en el 50,8% de los casos. El tóxico más frecuentemente implicado fue el monóxido de carbono (CO) (33,8%). Presentó clínica de toxicidad el 48,8%, siendo grave en el 16,5%. La intencionalidad (OR 5,1; intervalo de confianza del 95%: 1,9-13,8) y el desconocimiento del tiempo transcurrido desde el contacto (OR 3,1; intervalo de confianza del 95%: 1,3-7,3) fueron factores de riesgo independientes asociados a clínica grave. Cinco IC no alcanzaron el estándar de calidad: disponibilidad de guías de actuación específicas, administración de carbón activado en pacientes seleccionados, aplicación de oxigenoterapia a la máxima concentración posible en intoxicación por CO, valoración electrocardiográfica en pacientes expuestos a sustancias cardiotóxicas y registro del conjunto mínimo de datos. Conclusiones: Los pacientes pediátricos expuestos a tóxicos y atendidos por unidades SVA presentan características propias. Destacan la implicación del CO y de los adolescentes con intoxicaciones voluntarias. La evaluación de los IC ha sido útil para detectar puntos débiles en la calidad asistencial de estos pacientes y desarrollar estrategias de mejora.

Background The Basic life support (BLS) and Advanced life support (ALS) are known prediction rules for termination of resuscitation (TOR) in out-of-hospital cardiac arrest (OHCA). Recently, a new rule was developed by Jabre et al. We aimed to independently validate and compare the predictive accuracy of these rules. Methods OHCA cases in Iceland from 2008 to 2017 from a population-based, prospectively registered database. Primary outcome was survival to discharge among patients that met all conditions of abovementioned rules: BLS (not witnessed by EMS personnel, no defibrillation nor ROSC before transport), ALS (BLS criteria plus not witnessed nor CPR by bystander) and Jabre (not witnessed by EMS personnel, initial rhythm non-shockable, no sustainable ROSC before third dose of adrenaline). Results Overall, 568 OHCA patients were included in validation of TOR rules. Mean age 67, males 74%, witnessed by EMS 11%, by bystander 66% that attempted CPR in 50%, transported to hospital 60%, overall survival 20%. All rules had high specificity for mortality, 99.6–100% (95%CI 95–100). The Jabre and BLS rules had similar sensitivity 47% (43–52) vs. 44% (40–49), respectively, the sensitivity of ALS was lower, 8% (5–11). Combined use of positive BLS and Jabre rules performed the best, identifying 88/226 (39%) of futile cases transported to hospital, specificity 100% (97–100) and sensitivity 59% (55–64). Conclusions The accuracy of the BLS and Jabre TOR rules to predict mortality after OHCA is very good and their combined use may be superior to the use of either one.

Background There is little evidence about pre-hospital advanced life support including epinephrine administration for pediatric out-of-hospital cardiac arrests (OHCAs). Objectives This study aimed to assess the effect of pre-hospital epinephrine administration by emergency-medical-service (EMS) personnel for pediatric OHCA. Methods This nationwide population-based observational study in Japan enrolled pediatric patients age 8 to 17 years with OHCA between January 2007 and December 2016. Patients were sequentially matched with or without epinephrine during cardiac arrest using a risk-set matching based on time-dependent propensity score (probability of receiving epinephrine) calculated at each minute after initiation of cardiopulmonary resuscitation by EMS personnel. The primary endpoint was 1-month survival. Secondary endpoints were 1-month survival with favorable neurological outcome, defined as the cerebral performance category scale of 1 or 2, and pre-hospital return of spontaneous circulation (ROSC). Results During the study period, a total of 1,214,658 OHCA patients were registered, and 3,961 pediatric OHCAs were eligible for analyses. Of these, 306 (7.7%) patients received epinephrine and 3,655 (92.3%) did not receive epinephrine. After time-dependent propensity score-sequential matching, 608 patients were included in the matched cohort. In the matched cohort, there were no significant differences between the epinephrine and no epinephrine groups in 1-month survival (epinephrine: 10.2% [31 of 304] vs. no epinephrine: 7.9% [24 of 304]; risk ratio [RR]: 1.13 [95% confidence interval (CI): 0.67 to 1.93]) and favorable neurological outcome (epinephrine: 3.6% [11 of 304] vs. no epinephrine: 2.6% [8 of 304]; RR: 1.56 [95% CI: 0.61 to 3.96]), whereas the epinephrine group had a higher likelihood of achieving pre-hospital ROSC (epinephrine: 11.2% [34 of 304] vs. no epinephrine: 3.3% [10 of 304]; RR: 3.17 [95% CI: 1.54 to 6.54]). Conclusions In this study, pre-hospital epinephrine administration was associated with ROSC, whereas there were no significant differences in 1-month survival and favorable neurological outcome between those with and without epinephrine.

Background: Inconsistent use of seat belts in an ambulance may increase the risk of injury for emergency medical services (EMS) professionals and their patients. Our objectives were to: (1) describe the prevalence of seat belt usage based on patient acuity and seat location, and (2) assess the association between EMS-related characteristics and consistent use of a seat belt. Methods: We administered a cross-sectional electronic questionnaire to a random sample of 20,000 nationally-certified EMS professionals, measuring seat belt use in each seating location of an ambulance during transport of stable, critical, or no patients. We included practicing, non-military, emergency medical technicians or higher who reported working in ambulances. We used multivariable logistic regression models to estimate the odds of consistent (≥50% of the time) use of seat belts for the rear-facing jump seat and right-sided crew bench during transport of stable and critical patients. Results: A total of 1431 respondents were included in the analysis. Patient compartment seat belt use varied with the highest use in forward-facing seats when no patient was being transported (59.8%) and lowest use in the left-side “CPR” seat with a critical patient (9.4%). Only 40.2% of respondents reported an agency policy regarding seat belt use while riding in the patient compartment. In all multivariable logistic regression models, advanced life support level certification and fewer years of experience were associated with decreased odds of consistent seat belt use. An agency seat belt policy was strongly associated with increased odds of seat belt use in the patient compartment. Conclusions: Seat belt use was low and varied by seating location and patient acuity in the patient compartment of an ambulance. Practical Applications: EMS organizations should consider primary prevention approaches of provider education, improved ambulance designs, enactment and enforcement of policies to improve seat belt compliance and provider safety.

AIM: To examine the relationship between survival and diastolic blood pressure (DBP) throughout resuscitation from paediatric asphyxial cardiac arrest. METHODS: Retrospective, secondary analysis of 200 swine resuscitations. Swine underwent asphyxial cardiac arrest and were resuscitated with predefined periods of basic and advanced life support (BLS and ALS, respectively). DBP was recorded every 30 s. Survival was defined as 20-min sustained return of spontaneous circulation (ROSC). RESULTS: During BLS, DBP peaked between 1–3 min and was greater in survivors (20.0 [11.3, 33.3] mmHg) than in non-survivors (5.0 [1.0, 10.0] mmHg; p

Aim Whether time of day influences survival after out-of-hospital cardiac arrest (OHCA) remains controversial. We compared outcomes after OHCA between day and night and explored whether characteristics of pre-hospital advanced life support (ALS)-quality varied by time of day. Methods We conducted a prospective cohort study of individuals that suffered a non-traumatic OHCA in the city of Vienna between August 2013 and August 2015 and who received resuscitative efforts by EMS. We compared clinical outcomes between day and night, defined as 7:00 pm–7:00 am based on EMS shift time including rates of sustained return of spontaneous circulation (ROSC), 30-day survival and favourable neurologic outcome (cerebral performance category 1 or 2). ALS quality measures included time to first medical contact, time to first shock, total dose of epinephrine, and multiple ALS performance measures. Results We included 1811 patients (37% female) with a mean age of 67 ± 16 years in our analyses. Rates of ROSC and 30-day survival with favourable neurological outcome did not differ between day or night (30% vs 28%, p = 0.33; 12% vs. 11%, p = 0.51, respectively). These results remained unchanged after multivariate adjustment for ROSC (RR, 1.1; 95% CI, 1.0–1.3, p = 0.19) and 30-day survival with favourable neurological outcome (RR, 1.2; 95% CI, 1.0–1.5, p = 0.10). The quality of ALS did not differ between day and night. Conclusions In contrast to previous studies, there was no significant difference in sustained ROSC rates and 30-day survival with favourable neurological outcome after OHCA between day and night in the city of Vienna. This is likely due to nearly identical high bystander CPR rates and identical ALS performance provided by EMS personnel irrespective of time of the day.

Generally considered a sign of life, PEA is the most common arrhythmia encountered following pre-hospital traumatic cardiac arrest. Some recommend cardiac ultrasound (CUS) to determine cardiac wall motion (CWM) prior to terminating resuscitation efforts. This purpose of this study was to evaluate the outcomes of patients with traumatic cardiac arrest presenting with PEA, with and without CWM.Trauma patients who underwent pre-hospital CPR were identified from the registries of two level-1 trauma centers. Pre-hospital management by emergency medical transport services was guided by advanced life support protocols. The on-duty trauma surgeon directed the resuscitations and performed or supervised CUS and determined CWM.Among 277 patients who underwent pre-hospital CPR, 110 patients had PEA on arrival to ED. 69 (62.7%) were injured by blunt mechanisms. Median CPR duration was 20.0 and 8.0 min for pre-hospital and ED, respectively. Sixty-three patients (22.7%) underwent resuscitative thoracotomy. One hundred seventy-two patients (62.1%) received CUS and of these 32 (18.6%) had CWM. CWM was significantly associated with survival to hospital admission (21.9% vs. 1.4%; P 0.001); however, no patient with CUS survived to hospital discharge. Overall, only one patient with PEA on arrival survived to discharge.Following pre-hospital traumatic cardiac arrest, PEA on arrival portends death. Although CWM is associated with survival to admission, it is not associated with meaningful survival. Heroic resuscitative measures may be unwarranted for PEA following pre-hospital traumatic arrest, regardless of CWM.

Prehospital Emergency Medical Services must attend to patients with complex physiopathological situations with little data and in the shortest possible time. The objective of this work was to study lactic acid values and their usefulness in the prehospital setting to help in clinical decision-making.We conducted a longitudinal prospective, observational study on patients over 18 years of age who, after being evaluated by the Advanced Life Support Unit, were taken to the hospital between April and June 2018. We analyzed demographic variables, prehospital lactic acid values and early mortality (30 days). The area under the curve of the receiver operating characteristic was calculated for the prehospital value of lactic acid.A total of 279 patients were included in our study. The median age was 68 years (interquartile range: 54-80 years). Overall 30-day mortality was 9% (25 patients). The area under the curve for lactic acid to predict overall mortality at 30 days of care was 0.82 (95% CI: 0.76-0.89). The lactate value with the best sensitivity and specificity overall was 4.25 mmol/L with a sensitivity of 84% (95% CI: 65.3-93.6) and specificity of 70% (95% CI: 65.0-76.1).The level of lactic acid can be a complementary tool in the field of prehospital emergencies that will guide us early in the detection of critical patients.

Background: Waveform capnography has proven to be of great value in the provision of safe patient care especially in the intubated patient. Although seldom available, or used in African contexts, capnography has become standard practice in well-resourced out-of-hospital services for confirmation of intubation, and optimization of resuscitation and ventilation. To date there has been little research into the knowledge of out-of-hospital staff, both local and internationally, utilising capnography. This study describes the knowledge of paramedics who use waveform capnography in the out-of-hospital environment. Methods: A cohort of advanced life support qualified paramedics in a private ambulance service in South Africa undertook a web-based survey around their background, training and use of capnography. Participants’ knowledge was assessed by exploring their interpretation of waveform capnography and establishing attitudes pertaining to training and constraints of availability of capnography. Results: Seventy eight paramedics responded, and most (91%) indicated they were likely to use capnography when the tool was available. The majority of training in capnography had been during their primary qualification (85%). Most participants indicated that they would like further training (91%). Use of capnography for confirmation of endotracheal tube placement and quality of compressions during cardiopulmonary resuscitation was well understood (correct in 94% and 84% respectively), while more complicated knowledge such as waveform changes during ventilation (66%) and the effect of hypovolaemia (48%) on capnography were lacking. Conclusion: Paramedics report using waveform capnography extensively when it is available in the South African out-of-hospital environment. Although the knowledge around capnography and its usage was found to be good in most areas, more complicated scenarios exposed flaws in the knowledge of many paramedics and suggest the need for improved and ongoing training, as well as incorporation into curricula as the field develops across the continent. Keywords: Waveform capnography, Paramedics, Emergency medical services, South Africa

Prognostic tools for decision-making whether to continue advanced life support or limit life sustaining interventions in In-Hospital Cardiac Arrest (IHCA), remain scarce and inconclusive. In this regard it seems intuitive that the presence of aortic stenosis (AS) impacts on both central and peripheral perfusion during resuscitative attempts and might worsen outcome. Therefore, we aimed to investigate the prognostic value of AS on outcome after IHCA.Out of 11,641 patients presenting with acute coronary syndrome, a total of 151 patients were identified that received a standardized echocardiographic diagnostic immediately prior to an IHCA. Binary logistic regression analysis was used to elucidate the prognostic impact of AS on outcome.Within the entire study population, a total of 51 individuals with AS (mild: n = 19 [12.5%]; moderate: n = 11 [7.2%]; severe: n = 21 [13.8%]) were identified. We observed that 81% of patients with severe AS did not survive until hospital discharge. Additionally, the presence of AS showed a strong and independent inverse association with return of spontaneous circulation (adjusted odds ratio [OR] of 0.10 [95%CI:0.03-0.36], p 0.001), survival (adj. OR of 0.14 [95%CI: 0.04-0.48]; p = 0.002) and favourable neurological outcome (OR of 0.16 [95%CI: 0.06-0.49]; p = 0.001). The observed prognostic impact remained stable irrespective of AS severity.AS proved to be a strong and independent predictor for mortality and poor outcome after IHCA. Therefore, the presence of AS mirrors an easily available predictive tool for risk stratification and decision-making.

Background Epinephrine is recommended for the treatment of non-shockable out of hospital cardiac arrest (OHCA) to obtain return of spontaneous circulation (ROSC). Epinephrine efficiency and safety remain under debate. Objective We propose to describe the association between the cumulative dose of epinephrine and the failure of ROSC during the first 30 min of advanced life support (ALS). Methodology A retrospective observational cohort study using the Paris SAMU 75 registry including all non-traumatic OHCA. All OHCA receiving epinephrine during the first 30 min of ALS were enrolled. Cumulative epinephrine dose given during ALS to ROSC was retrieved from medical reports. Results Among 1532 patients with OHCA, 776 (51%) had initial non-shockable rhythm. Fifty-four patients were excluded for missing data. The mean value of cumulative dose of epinephrine was 10 ± 4 mg in patients who failed to achieve ROSC (ROSC−) and 4 ± 3 mg (p = 0.04) for those who achieved ROSC. ROC curve analysis indicated a cut-off point of 7 mg total cumulative epinephrine associated with ROSC− (AUC = 0.89 [0.86–0.92]). Using propensity score analysis including age, sex and no-flow duration, association with ROSC− only remained significant for epinephrine > 7 mg (p ≤10–3, OR [CI95] = 1.53 [1.42–1.65]). Conclusion An association between total cumulative epinephrine dose administered during OHCA resuscitation and ROSC− was reported with a threshold of 7 mg, best identifying patients with refractory OHCA. We suggest using this threshold in this context to guide the termination of ALS and early decide on the implementation of extracorporeal life support or organ harvesting in the first 30 min of ALS.

Background: Medical emergency teams were introduced in Australia in 1996 however, evidence indicated deteriorating patients continued to be under-reported to them. Socio-cultural, behavioural and workforce barriers to medical emergency team calls have been identified but their impact, where these teams have operated for many years, has not been investigated. Aim: To explore metropolitan and regional nurses' and midwives' experiences prior to, during and after medical emergency team calls in settings where these teams have operated for at least five years. Methods: Quantitative and qualitative data were collected from nurses and midwives from eight metropolitan and regional Australian hospitals. Participants were invited to respond to a 29-item survey instrument specifically designed for this study. Descriptive statistics were undertaken; augmented by respondents' comments. Results: The 121 responses (73 metropolitan; 48 regional) were analysed. Previously identified barriers such as unsupportive health professionals, acuity of other patients, ward busyness and individual workload were not perceived as detractors from call activation. Workload, however, impacted on care of other patients with support wanted during medical emergency team calls (especially by regional staff co-opted into the teams). Debriefing following difficult medical emergency team calls was also sought. Discussion: Differences between metropolitan and regional settings related primarily to staffing issues. Medical emergency teams in metropolitan settings largely consisted of critical care staff, whereas regional teams were limited to available staff. Conclusion: Overall, barriers to medical emergency team calls appeared markedly decreased compared to results in earlier studies. However, further research on events during and after medical emergency team calls and regular advanced life support training of regional staff was recommended. Refereed/Peer-reviewed

Background Most patients transferred from a non–percutaneous coronary intervention (PCI) facility for primary PCI do not meet target reperfusion times. Direct transportation of patients with ST-elevation myocardial infarction (STEMI) from the scene by advanced life support (ALS) paramedics has been shown to improve reperfusion times and outcomes. Objective The aim of this study was to determine whether it is safe to bypass the closest hospital and transport by basic life support (BLS) provider to a PCI facility. Methods This was a health records review of consecutive patients transported to a regional PCI center under an STEMI bypass protocol. Under the PCI bypass protocol, patients were eligible if they presented with symptoms of chest pain, a 12-lead electrocardiogram meeting STEMI criteria, and if transported to the regional PCI center within 60 min. The occurrence of predefined adverse events during transport was determined, which included bradycardia 140 beats/min, hypotension, cardiac arrest, and death. Results There were 46 cases of STEMI bypass between February 2005 and February 2013. Mean transport time was 29.9 min (range 20−62 min). Mean contact-to-balloon time was 95.2 min (range 68–159 min). Twenty-five adverse events occurred in 20 patients during transport. In 16 of the 20 patients, the adverse events were transiently abnormal vital sign requiring no intervention. In 3 of the patients, the adverse event was clinically significant and it is believed that the patient would have benefitted from advanced cardiac life support care not within the scope of practice of the BLS providers. Conclusions In our region, STEMI patients can be diagnosed accurately and transported safely on bypass to a PCI center for primary PCI while respecting target reperfusion times.

Objectives The objective of this study was to evaluate the impact of the prior participation of one or more members of the adult resuscitation team in an accredited advanced life support course on patient outcomes (return of spontaneous circulation, survival to discharge, survival to 30 days, and survival to 1 year). Methods A systematic search of Medline, CINAHL, Embase, ERIC, and Cochrane databases was conducted through 6 March 2018. We included randomised and observational studies in any language. Reviewers independently extracted data on study design and outcomes. The GRADE approach was used to evaluate the overall quality of evidence for each outcome. Results Nine hundred and ninety-two articles were identified of which eight observational studies were included. No randomised controlled trials were identified. Meta-analysis showed an association between participation of healthcare personnel in an advanced life support course and return of spontaneous circulation [odds ratio (OR) 1.64; 95% CI 1.12–2.41, risk difference (RD) 0.10 (95% CI 0.03–0.17)]. Life support training showed a significant absolute effect on patient survival to discharge [RD 0.10, 95% CI 0.01–0.18], but non-significant relative effect [OR 2.12; 95% CI 0.98–4.57]. Data from one study showed an association with survival to 30 days [OR 7.15; 95% CI 1.61–31.69, RD 0.18 (95% CI 0.08–0.27)]. Conclusion The inference of this review is that the advanced life support courses have a positive impact upon return of spontaneous circulation and survival to hospital discharge. The data also implies a positive impact upon survival to 30 days of adult cardiac arrest patients.

Data on which to base guidelines on the management of in-flight medical emergencies are severely limited by the lack of uniform national and international reporting. In-flight cardiac arrest is rare during commercial passenger flights, but where the initial rhythm is shockable, survival rate to hospital is around 23%. With minor adjustments (for lack of space, noisy environment, limited medical facilities, etc.), standard CPR and use of an AED are appropriate. The ability to perform advanced life support procedures is very limited. Diversion of an aircraft is costly, and may incur risks to safety as well as inconvenience to passengers. It is mainly justified if a victim regains a circulation or remains in a shockable rhythm. Voluntary attendance by healthcare professionals at in-flight cardiac arrests is common, but may have little effect on survival of the patient. The legal position of healthcare professionals who volunteer to assist at an in-flight emergency is complicated, but successful prosecution or litigation is very rare. Future national and international discussion and research in the field is needed. In the meantime, deliberately didactic and pragmatic advice on the management of in-flight cardiac arrest is offered. It is hoped that this will stimulate discussion.

Background Prior observational studies suggest no additional benefit from advanced life support (ALS) when compared with providing basic life support (BLS) for patients with out-of-hospital cardiac arrest (OHCA). We compared the association of ALS care with OHCA outcomes using prospective clinical data from the Resuscitation Outcomes Consortium (ROC). Methods Included were consecutive adults OHCA treated by participating emergency medical services (EMS) agencies between June 1, 2011, and June 30, 2015. We defined BLS as receipt of cardiopulmonary resuscitation (CPR) and/or automated defibrillation and ALS as receipt of an advanced airway, manual defibrillation, or intravenous drug therapy. We compared outcomes among patients receiving: 1) BLS-only; 2) BLS + late ALS; 3) BLS + early ALS; and 4) ALS-first care. Using multivariable logistic regression, we evaluated the associations between level of care and return of spontaneous circulation (ROSC), survival to hospital discharge, and survival with good functional status, adjusting for age, sex, witnessed arrest, bystander CPR, shockable initial rhythm, public location, EMS response time, CPR quality, and ROC site. Results Among 35,065 patients with OHCA, characteristics were median age 68 years (IQR 56–80), male 63.9%, witnessed arrest 43.8%, bystander CPR 50.6%, and shockable initial rhythm 24.2%. Care delivered was: 4.0% BLS-only, 31.5% BLS + late ALS, 17.2% BLS + early ALS, and 47.3% ALS-first. ALS care with or without initial BLS care was independently associated with increased adjusted ROSC and survival to hospital discharge unless delivered greater than 6 min after BLS arrival (BLS + late ALS). Regardless of when it was delivered, ALS care was not associated with significantly greater functional outcome. Conclusion ALS care was associated with survival to hospital discharge when provided initially or within six minutes of BLS arrival. ALS care, with or without initial BLS care, was associated with increased ROSC, however it was not associated with functional outcome.

Introduction: Child abuse is a common condition in the emergency centres of South Africa. It is critical for both prehospital emergency care practitioners and emergency centre-based emergency medicine registrars to be competent in screening, diagnosing, treating, and documenting child abuse. Our goal was to assess the knowledge of child abuse management in a sample of prehospital emergency care practitioners and emergency medicine registrars in Cape Town, South Africa. Methods: A mixed-methods approach of quantitative and qualitative data was used to survey a sample of 120 participants (30 emergency medicine registrars and 90 prehospital emergency care practitioners: 30 Basic Life Support, 30 Intermediate Life Support, and 30 Advanced Life Support). An expert panel created the survey to ensure content validity and survey questions were designed to assess the perceived and actual knowledge of participants. We hypothesised that there would be significantly higher levels of perceived and actual knowledge in emergency medicine registrars compared to emergency care practitioners. An open-ended question on how participants felt dealing with child abuse was qualitatively analysed using thematic analysis. Results: There were significant differences in the levels of perceived knowledge (58% of emergency medicine registrars agreed that they felt adequately trained overall, versus 39% of emergency care practitioners; −19% difference, 95% CI −26% to −12%) and actual knowledge (83% of emergency medicine registrars with correct answers, versus 62% of emergency care practitioners; −21% difference, 95% CI −26% to −16%) among participants. Themes that emerged from qualitative analysis included personal distress, retaliation, frustration, medical system frustration, and personal competence concerns. Discussion: Significant perceived and actual knowledge deficits of child abuse management exist among both emergency care practitioners and emergency medicine registrars in this setting. Future interventions should address the need for guidelines and increased training opportunities to ensure the health and safety of abused children. Keywords: Paediatrics, Child abuse, Assessment, South Africa

Background Pulseless electrical activity (PEA) is a frequent initial rhythm in cardiac arrest, and ECG characteristics have been linked to prognosis. The aim of this study was to examine the development of ECG characteristics during advanced life support (ALS) and cardiopulmonary resuscitation (CPR) in cardiac arrest with initial PEA, and to assess any association with survival. Methods Patients with in-hospital cardiac arrest with initial PEA at St. Olav Hospital (Trondheim, Norway) over a three-year period were included. A total of 2187 combined observations of QRS complex rate (heart rate) and QRS complex width for the duration of ALS were determined from defibrillator recordings from 74 episodes of cardiac arrest. Results Increasing heart rate and decreasing QRS complex width during ALS was significantly more prevalent in patients who obtained return of spontaneous circulation compared to patients who were declared dead. Conclusion Changes in ECG characteristics during ALS in cardiac arrest presenting as PEA are related to prognosis. An increase in heart rate was observed in the last 3–6 min before ROSC was obtained.