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his is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed. This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Background: Studies examining gender-based differences in outcomes of patients experiencing out-of-hospital cardiac arrest have demonstrated that, despite a higher likelihood of return of spontaneous circulation, women do not have higher survival. Methods: Patients successfully resuscitated from out-of-hospital cardiac arrest enrolled in the CCC trial (Trial of Continuous or Interrupted Chest Compressions during CPR) were included. Hierarchical multivariable logistic regression models were constructed to evaluate the association between gender and survival after adjustment for age, gender, cardiac arrest rhythm, witnessed status, bystander cardiopulmonary resuscitation, episode location, epinephrine dose, emergency medical services response time, and duration of resuscitation. Do not resuscitate (DNR) and withdrawal of life-sustaining therapy (WLST) order status were used to assess whether differences in postresuscitation outcomes were modified by baseline prognosis. The analysis was replicated among ALPS trial (Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest) participants. Results: Among 4875 successfully resuscitated patients, 1825 (37.4%) were women and 3050 (62.6%) were men. Women were older (67.5 versus 65.3 years), received less bystander cardiopulmonary resuscitation (49.1% versus 54.9%), and had a lower proportion of cardiac arrests that were witnessed (55.1% versus 64.5%) or had shockable rhythm (24.3% versus 44.6%, P P =0.009) and had WLST (32.8% versus 29.8%, P =0.03). Discharge survival was significantly lower in women (22.5% versus 36.3%, P P =0.005). The association between gender and survival to discharge was modified by DNR and WLST order status such that women had significantly reduced survival to discharge among patients who were not designated DNR (31.3% versus 49.9%, P =0.005; adjusted odds ratio, 0.74 [95% CI, 0.60–0.91]) or did not have WLST (32.3% versus 50.7%, P =0.002; adjusted odds ratio, 0.73 [95% CI, 0.60–0.89]). In contrast, no gender difference in survival was noted among patients receiving a DNR order (6.7% versus 7.4%, P =0.90) or had WLST (2.8% versus 2.4%, P =0.93). Consistent patterns of association between gender and postresuscitation outcomes were observed in the secondary cohort. Conclusions: Among patients resuscitated after experiencing out-of-hospital cardiac arrest, discharge survival was significantly lower in women than in men, especially among patients considered to have a favorable prognosis.

BACKGROUND No Food and Drug Administration-approved medication improves outcomes following traumatic brain injury (TBI). A forthcoming clinical trial that evaluated the effects of two prehospital tranexamic acid (TXA) dosing strategies compared with placebo demonstrated no differences in thromboelastography (TEG) values. We proposed to explore the impact of TXA on markers of coagulation and fibrinolysis in patients with moderate to severe TBI. METHODS Data were extracted from a placebo-controlled clinical trial in which patients 15 years or older with TBI (Glasgow Coma Scale, 3-12) and systolic blood pressure of ≥90 mm Hg were randomized prehospital to receive placebo bolus/placebo infusion (placebo), 1 g of TXA bolus/1 g of TXA infusion (bolus maintenance), or 2 g of TXA bolus/placebo infusion (bolus only). Thromboelastography was performed, and coagulation measures including prothrombin time, activated partial thromboplastin time, international ratio, fibrinogen, D-dimer, plasmin-antiplasmin (PAP), thrombin antithrombin, tissue plasminogen activator, and plasminogen activator inhibitor 1 were quantified at admission and 6 hours later. RESULTS Of 966 patients receiving study drug, 700 had laboratory tests drawn at admission and 6 hours later. There were no statistically significant differences in TEG values, including LY30, between groups (p > 0.05). No differences between prothrombin time, activated partial thromboplastin time, international ratio, fibrinogen, thrombin antithrombin, tissue plasminogen activator, and plasminogen activator inhibitor 1 were demonstrated across treatment groups. Concentrations of D-dimer in TXA treatment groups were less than placebo at 6 hours (p < 0.001). Concentrations of PAP in TXA treatment groups were less than placebo on admission (p < 0.001) and 6 hours (p = 0.02). No differences in D-dimer and PAP were observed between bolus maintenance and bolus only. CONCLUSION While D-dimer and PAP levels reflect a lower degree of fibrinolysis following prehospital administration of TXA when compared with placebo in a large prehospital trial of patients with TBI, TEG obtained on admission and 6 hours later did not demonstrate any differences in fibrinolysis between the two TXA dosing regimens and placebo. LEVEL OF EVIDENCE Diagnostic test, level III.

Background: Antiarrhythmic drugs have not proven to significantly improve overall survival after out-of-hospital cardiac arrest from shock-refractory ventricular fibrillation/pulseless ventricular tachycardia. How this might be influenced by the route of drug administration is not known. Methods: In this prespecified analysis of a randomized, placebo-controlled clinical trial, we compared the differences in survival to hospital discharge in adults with shock-refractory ventricular fibrillation/pulseless ventricular tachycardia out-of-hospital cardiac arrest who were randomly assigned by emergency medical services personnel to an antiarrhythmic drug versus placebo in the ALPS trial (Resuscitation Outcomes Consortium Amiodarone, Lidocaine or Placebo Study), when stratified by the intravenous versus intraosseous route of administration. Results: Of 3019 randomly assigned patients with a known vascular access site, 2358 received ALPS drugs intravenously and 661 patients by the intraosseous route. Intraosseous and intravenous groups differed in sex, time-to-emergency medical services arrival, and some cardiopulmonary resuscitation characteristics, but were similar in others, including time-to-intravenous/intrasosseous drug receipt. Overall hospital discharge survival was 23%. In comparison with placebo, discharge survival was significantly higher in recipients of intravenous amiodarone (adjusted risk ratio, 1.26 [95% CI, 1.06–1.50]; adjusted absolute survival difference, 5.5% [95% CI, 1.5–9.5]) and intravenous lidocaine (adjusted risk ratio, 1.21 [95% CI, 1.02–1.45]; adjusted absolute survival difference, 4.7% [95% CI, 0.7–8.8]); but not in recipients of intraosseous amiodarone (adjusted risk ratio, 0.94 [95% CI, 0.66–1.32]) or intraosseous lidocaine (adjusted risk ratio, 1.03 [95% CI, 0.74–1.44]). Survival to hospital admission also increased significantly when drugs were given intravenously but not intraosseously, and favored improved neurological outcome at discharge. There were no outcome differences between intravenous and intraosseous placebo, indicating that the access route itself did not demarcate patients with poor prognosis. The study was underpowered to assess intravenous/intraosseous drug interactions, which were not statistically significant. Conclusions: We found no significant effect modification by drug administration route for amiodarone or lidocaine in comparison with placebo during out-of-hospital cardiac arrest. However, point estimates for the effects of both drugs in comparison with placebo were significantly greater for the intravenous than for the intraosseous route across virtually all outcomes and beneficial only for the intravenous route. Given that the study was underpowered to statistically assess interactions, these findings signal the potential importance of the drug administration route during resuscitation that merits further investigation.

Purpose of review The purpose of the review is to briefly describe the derivation, validation and implementation of the Termination of Resuscitation Rules for out-of-hospital adult cardiac arrest and to describe the controversies surrounding implementation that have been recently published. Recent findings New guidelines, new interventions that alter baseline survival, the use of eCPR and issues related to duration of CPR have minimal impact on the sustainability and application of the TOR rule.Some published articles related to using only one criterion in the rule may be cavalier and miss potential survivors.Decisions based on discretion may cause wide variation in termination rates and evidence-based decision rules are in the best interest of distributive justice for the patient and comfort for the provider. Summary The Universal Termination of Resuscitation Rule has a built-in sensibility to the introduction of new treatment guidelines, including emphasis on CPR metrics, changes in baseline survival rates, duration of resuscitation and new treatment options including eCPR and postarrest care. As well, the TOR rule continues to address inconsistencies in practice and improve provider comfort.

Introduction: Prognostication is a significant challenge early in the post-cardiac arrest period. Common prognostic factors for neurological survival are unreliable (high false positive rates) until 72 hours post-cardiac arrest. It is not known whether there are a combination of factors that can be utilized earlier in the post-cardiac arrest period to accurately predict patient outcome. Our objective was to predict neurological outcome utilizing a novel combination of patient factors early in the post-cardiac arrest period. Methods: We conducted a retrospective cohort study using data from our local registry. We included adult patients who obtained a return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA). We excluded patients who did not survive for at least 24 hours post-ROSC and those who had a do not resuscitate (DNR) order within 2 hours of ROSC. We performed an ordinal regression analysis using the proportional odds model to predict neurological outcome (modified rankin score (mRS)). We included a good neurological outcome (mRS 0-2), poor neurological outcome (mRS 3-5), and dead (mRS 6) as an ordinal outcome. We included a number of patient demographics, intra- and post-cardiac arrest factors as covariates in our model. The predictive performance of our model was analyzed using receiver operating characteristic (ROC) curves for discrimination and Brier statistic for calibration. Results: We included 3448 patients in our analysis. We found that an initial shockable rhythm (odds ratio (OR) 4.1; 95% confidence interval (CI) 3.6, 5.4), the absence of pupillary reflexes (OR 3.5; 95% CI 2.4,4.8) and maximum motor score on the Glasgow Coma Scale (GCS) (OR 1.5; 95% CI 1.4,1.6) had the greatest association with improved neurologic outcome. Longer duration of resuscitation was associate with worse outcomes (OR 0.84, 95% CI 0.82,0.87). The overall performance of our model was excellent with an area under the ROC curve of 0.89 and a Brier statistic of 0.13. Conclusion: Our model predicted good neurological outcome with a high rate of accuracy, however external validation of the model is required. This model may be useful to provide risk stratification of patients in clinical practice and future research on post-cardiac arrest care.

Background Mathematical optimization of automated external defibrillator (AED) placement may improve AED accessibility and out‐of‐hospital cardiac arrest (OHCA) outcomes compared with American Heart Association (AHA) and European Resuscitation Council (ERC) placement guidelines. We conducted an in silico trial (simulated prospective cohort study) comparing mathematically optimized placements with placements derived from current AHA and ERC guidelines, which recommend placement in locations where OHCAs are usually witnessed. Methods and Results We identified all public OHCAs of presumed cardiac cause from 2008 to 2016 in Copenhagen, Denmark. For the control, we computationally simulated placing 24/7‐accessible AEDs at every unique, public, witnessed OHCA location at monthly intervals over the study period. The intervention consisted of an equal number of simulated AEDs placements, deployed monthly, at mathematically optimized locations, using a model that analyzed historical OHCAs before that month. For each approach, we calculated the number of OHCAs in the study period that occurred within a 100‐m route distance based on Copenhagen’s road network of an available AED after it was placed (“OHCA coverage”). Estimated impact on bystander defibrillation and 30‐day survival was calculated by multivariate logistic regression. The control scenario involved 393 AEDs at historical, public, witnessed OHCA locations, covering 15.8% of the 653 public OHCAs from 2008 to 2016. The optimized locations provided significantly higher coverage (24.2%; P P P Conclusions Mathematical optimization can significantly improve OHCA coverage and estimated clinical outcomes compared with a guidelines‐based approach to AED placement.

Background: Out-of-hospital cardiac arrest (OHCA) commonly presents with nonshockable rhythms (asystole and pulseless electric activity). It is unknown whether antiarrhythmic drugs are safe and effective when nonshockable rhythms evolve to shockable rhythms (ventricular fibrillation/pulseless ventricular tachycardia [VF/VT]) during resuscitation. Methods: Adults with nontraumatic OHCA, vascular access, and VF/VT anytime after ≥1 shock(s) were prospectively randomized, double-blind, to receive amiodarone, lidocaine, or placebo by paramedics. Patients presenting with initial shock-refractory VF/VT were previously reported. The current study was a prespecified analysis in a separate cohort that initially presented with nonshockable OHCA and was randomized on subsequently developing shock-refractory VF/VT. The primary outcome was survival to hospital discharge. Secondary outcomes included discharge functional status and adverse drug-related effects. Results: Of 37 889 patients with OHCA, 3026 with initial VF/VT and 1063 with initial nonshockable-turned-shockable rhythms were treatment-eligible, were randomized, and received their assigned drug. Baseline characteristics among patients with nonshockable-turned-shockable rhythms were balanced across treatment arms, except that recipients of a placebo included fewer men and were less likely to receive bystander cardiopulmonary resuscitation. Active-drug recipients in this cohort required fewer shocks, supplemental doses of their assigned drug, and ancillary antiarrhythmic drugs than recipients of a placebo ( P P =0.24). No significant interaction between treatment assignment and discharge survival occurred with the initiating OHCA rhythm (asystole, pulseless electric activity, or VF/VT). Survival in each of these categories was consistently higher with active drugs, although the trends were not statistically significant. Adjusted absolute differences (95% confidence interval) in survival from nonshockable-turned-shockable arrhythmias with amiodarone versus placebo were 2.3% (−0.3, 4.8), P =0.08, and for lidocaine versus placebo 1.2% (−1.1, 3.6), P =0.30. More than 50% of these survivors were functionally independent or required minimal assistance. Drug-related adverse effects were infrequent. Conclusions: Outcome from nonshockable-turned-shockable OHCA is poor but not invariably fatal. Although not statistically significant, point estimates for survival were greater after amiodarone or lidocaine than placebo, without increased risk of adverse effects or disability and consistent with previously observed favorable trends from treatment of initial shock-refractory VF/VT with these drugs. Together the findings may signal a clinical benefit that invites further investigation. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01401647.

Context: Research in an emergency setting is challenging because the window of opportunity to treat may be short, and preclude time to obtain informed consent from the patient or their representative. Such research can be conducted under exception from informed consent (EFIC) if specific criteria are met. In the United States, this includes notification of an enrolled subject or their representative as soon as feasible after enrollment so that they have autonomy to opt out from ongoing study participation. To date, there is limited empiric information about time to notification (TTN). Objective: To describe variation in TTN among sites participating in randomized trials conducted under exception from informed consent for emergency research. Methods: Notification strategies were determined at each site prior to initiation of subject enrollment, and approved by a local institutional review board or equivalent. TTN was summarized overall, as well as stratified by site and clinical outcome among patients enrolled in multiple trials conducted by the Resuscitation Outcomes Consortium (ROC). Results: Included were 34,868 patients enrolled in four trials. Of these, 33,805 had with out-of-hospital cardiac arrest; and 1,063 had life-threatening traumatic injury. TTN varied (Table). Conclusions: There is large variation in TTN in trials conducted under EFIC for emergency research. Early notification is difficult; delayed notification may reduce the autonomy of patients or their representative.

Background: “Priority setting” is something that we do in research in order to get a range of opinions on what research questions are the most important or timely in a particular field. This is typically done with a group of expert health care providers and researchers and has not involved patients, family or the public. Methods: With funding from the Canadian Institutes of Health Research we partnered with the James Lind Alliance (JLA) in the UK to use their proven consensus methodology to build a Public Priority Setting Partnerships (PSP) on out-of-hospital Cardiac Arrest (OHCA). We developed and administered two rounds of online surveys with survivors, family members and health care professionals to create the initial priority lists. From there we held a full-day in-person workshop to come to consensus on the top 10 priorities from a short list of 25. The workshop also included survivors, family members and health care professionals. Results: The initial survey yielded more than 425 responses and 1500 “questions”/comments from survivors, family members, lay responders, physicians, nurses, rehabilitation specialists, paramedics, etc. The second survey asked participants to rank a narrowed list of 125 questions. The final top 25 questions were brought to the in-person consensus meeting and a top 10 were selected. The results will be revealed publicly for the first time at the ReSS meeting. Conclusions: The JLA methodology is world-renowned for its rigor and we now have an official PSP on OHCA. This type of inclusive research priority setting provides crucial information for the AHA and the international resuscitation research community about where to invest our limited research resources. The results will also drive our community to include questions that matter to SCA survivors and their families in all of our work.

Background: Despite significant advances in resuscitation efforts, there are some patients who remain in ventricular fibrillation (VF) after multiple defibrillation attempts during out-of-hospital cardiac arrest (OHCA). Double sequential external defibrillation (DSED) and vector change defibrillation (VC) have been proposed as alternate therapeutic strategies for OHCA patients in shock-refractory VF. Objective: To determine the feasibility, safety and sample size required for a larger, multicentered, 3-arm, cluster randomized controlled trial (RCT) with 2 crossovers comparing DSED or VC to standard defibrillation (control group) for OHCA patients presenting in shock-refractory VF. Methods: We conducted a pilot cluster randomized controlled trial with crossover including all consecutive treated adult OHCA patients who presented in VF and received a minimum of three successive shocks. In addition to standard cardiac arrest care, each EMS agency was randomly assigned to provide standard defibrillation (control), DSED, or VC, followed by crossover to an alternate defibrillation strategy after 6 months. Results: Prior to the launch of the trial, 2,500 paramedics received in-person training in the techniques of DSED and VC defibrillation using a combination of didactic, video and simulated scenarios. Between March 2018 and June 2019, 113 patients were enrolled in 4 Canadian EMS agencies, with zero missed cases. Monthly enrollment varied from 1 to 6 cases per agency. With respect to feasibility, 96% of cases were compliant with the study protocol, and only five (4.4%) cases received a defibrillation strategy that differed from the allocation schedule. There were no reported cases of defibrillator malfunction, no concerns expressed by paramedics, patients, families, or ED staff about the trial, and no reported cases of skin burns or difficulty with pad placement. Conclusions: Findings from our pilot implementation trial suggest the DOSE VF protocol is feasible and safe. The results of this internal pilot trial will allow us to calculate a sample size for a definitive multicenter cluster RCT with crossovers to determine if these alternate defibrillation strategies for OHCA shock refractory VF will impact patient-centered, clinical outcomes.

Itroduction: Previous research has quantified the impact of EMS response time on the probability of survival from OHCA, but the impact on different subpopulations is currently unknown. Aim: To investigate how response time affects OHCA survival for different patient subpopulations. Methods: We conducted a logistic regression analysis on non-EMS witnessed OHCAs of presumed cardiac etiology from the Toronto Regional RescuNet between January 1, 2007 and December 31, 2016. We predicted survival using age, sex, public location, presenting rhythm, bystander witnessed, bystander resuscitation, and response time, defined as the time interval from 911 call to EMS arrival at the patient. We conducted subgroup analyses to quantify the effect of response time on survival for eight different subpopulations: public, private, bystander resuscitation, no bystander resuscitation, patients ≥65, patients Results: We identified 22,988 OHCAs. Overall, a one-minute delay in EMS response time was associated with a 13.2% reduction in the odds of survival. The reduction varied by subpopulation, ranging from a 7.2% reduction in survival odds for unwitnessed arrests to a 16.4% reduction in survival odds for arrests with bystander resuscitation. Response time had the largest impact on survival for the subpopulation of OHCAs that were both witnessed and received bystander resuscitation (17.4% reduction in survival odds). Conclusion: The effect of a one-minute delay in EMS response on the odds of survival from OHCA can be as low as a 7.2% reduction and as high as a 17.4% reduction. This variability contrasts with the currently accepted 10% rule that is assumed across the entire population.

Background: Bystander cardiopulmonary resuscitation (BCPR) improves survival from out-of-hospital cardiac arrest (OHCA), yet BCPR rates remain low. It is unknown whether BCPR delivery disparities exist based on victim gender. We measured BCPR rates by gender in private and public environments, hypothesizing that females would be less likely than males to receive BCPR in public settings, with an associated difference in survival to hospital discharge. Methods and Results: We analyzed data from adult, nontraumatic OHCA events within the Resuscitation Outcomes Consortium registry (2011–2015). Using logistic regression, we modeled the likelihood of receiving BCPR by gender, including patient-level variables, stratified by location. A cohort of 19 331 OHCAs was assessed. Mean age was 64±17 years, and 63% (12 225/19 331) were male. Overall, 37% of OHCA victims received bystander CPR. In public locations, 39% (272/694) of females and 45% (1170/2600) of males received BCPR ( P P =NS). Among public OHCAs, males had significantly increased odds of receiving BCPR compared with females (odds ratio, 1.27; 95% CI, 1.05–1.53; P =0.01); this was not the case in the private setting (odds ratio, 0.93; 95% CI, 0.87–1.01; P =NS). Controlling for site, age, and race, BCPR was significantly associated with survival to hospital discharge (odds ratio, 1.69; 95% CI, 1.54–1.85; P P Conclusions: Males had an increased likelihood of receiving BCPR compared with females in public. BCPR improved survival to discharge, with greater survival among males compared with females.

The American Heart Association (AHA) commends the recently released Institute of Medicine (IOM) report, Strategies to Improve Cardiac Arrest Survival: A Time to Act (2015). The AHA recognizes the unique opportunity created by the report to meaningfully advance the objectives of improving outcomes for sudden cardiac arrest. For decades, the AHA has focused on the goal of reducing morbidity and mortality from cardiovascular disease though robust support of basic, translational, clinical, and population research. The AHA also has developed a rigorous process using the best available evidence to develop scientific, advisory, and guideline documents. These core activities of development and dissemination of scientific evidence have served as the foundation for a broad range of advocacy initiatives and programs that serve as a foundation for advancing the AHA and IOM goal of improving cardiac arrest outcomes. In response to the call to action in the IOM report, the AHA is announcing 4 new commitments to increase cardiac arrest survival: (1) The AHA will provide up to $5 million in funding over 5 years to incentivize resuscitation data interoperability; (2) the AHA will actively pursue philanthropic support for local and regional implementation opportunities to increase cardiac arrest survival by improving out-of-hospital and in-hospital systems of care; (3) the AHA will actively pursue philanthropic support to launch an AHA resuscitation research network; and (4) the AHA will cosponsor a National Cardiac Arrest Summit to facilitate the creation of a national cardiac arrest collaborative that will unify the field and identify common goals to improve survival. In addition to the AHA’s historic and ongoing commitment to improving cardiac arrest care and outcomes, these new initiatives are responsive to each of the IOM recommendations and demonstrate the AHA’s leadership in the field. However, successful implementation of the IOM recommendations will require a timely response by all stakeholders identified in the report and a coordinated approach to achieve our common goal of improved cardiac arrest outcomes.

BACKGROUND: Injury surveillance is critical in identifying the need for targeted prevention initiatives. Understanding the geographic distribution of injuries facilitates matching prevention programs with the population most likely to benefit. At the population level, however, the geographic site of injury is rarely known, leading to the use of location of residence as a surrogate. To determine the accuracy of this approach, we evaluated the relationship between the site of injury and of residence over a large geographic area. METHODS: Data were derived from a population-based, prehospital registry of persons meeting triage criteria for major trauma. Patients dying at the scene or transported to the hospital were included. Distance between locations of residence and of injury was calculated using geographic information system network analysis. RESULTS: Among 3,280 patients (2005-2010), 88% were injured within 10 miles of home (median, 0.2 miles). There were significant differences in distance between residence and location of injury based on mechanism of injury, age, and hospital disposition. The large majority of injuries involving children, the elderly, pedestrians, cyclists, falls, and assaults occurred less than 10 miles from the patient's residence. Only 77% of motor vehicle collision occurred within 10 miles of the patient's residence. CONCLUSION: Although the majority of patients are injured less than 10 miles from their residence, the probability of injury occurring "close to home" depends on patient and injury characteristics. LEVEL OF EVIDENCE: Epidemiologic study, level III. Language: en

Background— Out-of-hospital cardiac arrest (OHCA) is associated with a poor prognosis and poses a significant burden to the healthcare system, but few studies have evaluated whether OHCA incidence and survival have changed over time. Methods and Results— A population-based cohort study was conducted, including 34 291 OHCA patients >20 years of age who were transported alive to the emergency department of an acute-care hospital from April 1, 2002, to March 31, 2012, in Ontario, Canada. Patients with life-threatening trauma and those who died before hospital arrival were excluded. The overall age- and sex-standardized incidence of OHCA patients who were transported alive was 36 cases per 100 000 persons and did not significantly change over the study period. Cardiac risk factor prevalence increased significantly, whereas the rate of most cardiovascular conditions decreased significantly. The 30-day survival improved from 9.4% in 2002 to 13.6% in 2011; 1-year survival improved from 7.7% to 11.8% ( P Conclusions— OHCA patients who were transported alive are increasingly likely to have cardiovascular risk factors but less likely to have previous cardiovascular conditions. The overall incidence of OHCA patients transported to hospital alive did not change over the past decade. Short- and longer-term survival after OHCA has substantially improved, with younger patients experiencing the greatest improvement.

The goal of this statement is to develop consensus recommendations aimed at measuring and optimizing outcomes after in-hospital cardiac arrest (IHCA). For the purposes of this statement, IHCA is defined as a cardiac arrest that occurs in a hospital (whether the patient is admitted or not) and for which resuscitation is attempted with chest compressions, defibrillation, or both. Members of the writing group were selected for their expertise in cardiac resuscitation and post–cardiac arrest care. Monthly telephone conferences and “webinars” over a 10-month period were used to define the scope of the statement and to assign writing teams for each section. The first draft of each section was discussed and sent to the chair to be compiled into a single document. Revised versions were then sent to all writing group members until consensus was achieved. The final draft underwent 3 sets of independent peer review before publication. The American Heart Association (AHA) is committed to the highest ethical standards. The AHA believes that having experts who have a relationship with industry or other relevant relationships on writing groups can strengthen the writing group effort when these relationships are transparent and managed. The AHA conflict of interest policy requires each member to declare relevant and current conflicts of interest. The chair may not have any relationship with industry relevant to the topic. The majority of writing group members (defined as>50% +1) must be free of relevant relationships with industry. Every writing group member agrees to maintain his or her current status with respect to relationships with industry throughout the development of the manuscript to publication. In addition, each member formally declares his or her conflict of interest or relationship with industry at the time of publication. All members of this writing group were compliant with this policy (“Writing Group Disclosures”). IHCA …

Background— Guidelines for cardiopulmonary resuscitation recommend a chest compression rate of at least 100 compressions per minute. Animal and human studies have reported that blood flow is greatest with chest compression rates near 120/min, but few have reported rates used during out-of-hospital (OOH) cardiopulmonary resuscitation or the relationship between rate and outcome. The purpose of this study was to describe chest compression rates used by emergency medical services providers to resuscitate patients with OOH cardiac arrest and to determine the relationship between chest compression rate and outcome. Methods and Results— Included were patients aged ≥20 years with OOH cardiac arrest treated by emergency medical services providers participating in the Resuscitation Outcomes Consortium. Data were abstracted from monitor-defibrillator recordings during cardiopulmonary resuscitation. Multiple logistic regression analysis assessed the association between chest compression rate and outcome. From December 2005 to May 2007, 3098 patients with OOH cardiac arrest were included in this study. Mean age was 67±16 years, and 8.6% survived to hospital discharge. Mean compression rate was 112±19/min. A curvilinear association between chest compression rate and return of spontaneous circulation was found in cubic spline models after multivariable adjustment ( P =0.012). Return of spontaneous circulation rates peaked at a compression rate of ≈125/min and then declined. Chest compression rate was not significantly associated with survival to hospital discharge in multivariable categorical or cubic spline models. Conclusions— Chest compression rate was associated with return of spontaneous circulation but not with survival to hospital discharge in OOH cardiac arrest.

In 2003, the International Liaison Committee on Resuscitation published a consensus document on education in resuscitation that strongly recommended that “…instruction in CPR [cardiopulmonary resuscitation] be incorporated as a standard part of the school curriculum.”1 The next year the American Heart Association (AHA) recommended that schools “…establish a goal to train every teacher in CPR and first aid and train all students in CPR” as part of their preparation for a response to medical emergencies on campus.2 Since that time, there has been an increased interest in legislation that would mandate that school curricula include training in CPR or CPR and automated external defibrillation. Laws or curriculum content standards in 36 states (as of the 2009–2010 school year) now encourage the inclusion of CPR training programs in school curricula. The language in those laws and standards varies greatly, ranging from a suggestion that students “recognize” the steps of CPR to a requirement for certification in CPR. Not surprisingly, then, implementation is not uniform among states, even those whose laws or standards encourage CPR training in schools in the strongest language. This statement recommends that training in CPR and familiarization with automated external defibrillators (AEDs) should be required elements of secondary school curricula and provides the rationale for implementation of CPR training, as well as guidance in overcoming barriers to implementation. Sudden cardiac arrest is a leading cause of death in the United States and Canada. It is estimated that each year emergency medical services (EMS) personnel assess 294 851 (quasi-confidence intervals, 236 063 to 325 007) out-of-hospital cardiac arrests (OHCAs) in the United States. Survival, which is defined as being discharged alive from the hospital, varies widely by region (3.0% to 16.3%; median, 8.4%), but the overall average rate of survival to discharge from the hospital is estimated …

Out-of-hospital trauma triage is the process of using field-based information to determine which patients require immediate transport to a trauma center. Although simple in concept, the practice of out-of-hospital triage is quite complex. Identification of high-risk injured patients in the field is based on limited information obtained during a relatively short period of time in an often chaotic setting, all of which contribute to an imperfect process. The original out-of-hospital trauma triage criteria were generated by national consensus conferences and published by the American College of Surgeons Committee on Trauma (ACSCOT) in 1976.1 The first “step” of these criteria includes physiologic measures, which are intended to identify the highest risk trauma patients. Target ranges for the three core physiologic measures (i.e., Glasgow Coma Scale [GCS] score, systolic blood pressure [SBP], and respiratory rate) have changed very little during the last 20 years.1,2 Although there have been numerous studies evaluating the out-of-hospital trauma triage guidelines,3-16 few studies have rigorously evaluated potential revisions of the ACSCOT step 1 physiologic criteria. The current step 1 physiologic criteria are believed to identify the highest risk trauma patients,4,5,7,8,12,13 although questions persist regarding the utility of certain components of the criteria (e.g., respiratory rate), the ranges used, and whether additional physiologic measures would further improve predictive value. Previous studies assessing these measures have primarily focused on patients transported directly to major trauma centers, which can introduce selection bias and inflate the apparent predictive value of the criteria. The potential value of additional physiologic measures (e.g., shock index [pulse/SBP], pulse rate, and pulse oximetry) remains unclear, as does the relative utility of combining physiologic measures. Further, although out-of-hospital intubation has been suggested to be predictive of mortality and poor neurologic outcome,17 intubation is not explicitly included in the ACSCOT guidelines. Other authors have questioned field intubation as an indicator of resource need.18 Improving field triage guidelines may allow for more accurate selection of patients in need of immediate trauma center resources, identification of those most likely to benefit from early aggressive resuscitative care, and assist in selecting appropriate patients for field-based interventional therapies. Among injured adults evaluated by emergency medical service (EMS) providers in 11 North American sites, we sought to (1) provide an unbiased estimate of the incidence of mortality and prolonged hospital stay among patients meeting ACSCOT step 1 field physiologic criteria and (2) assess whether more restrictive criteria (with or without demographic and mechanism information) would improve the specificity of this step without missing an excessive number of high-risk patients.

Objective: To identify the barriers to implementation of mild therapeutic hypothermia for adult survivors of cardiac arrest. Despite scientific evidence to support therapeutic hypothermia for resuscitated cardiac arrest patients, it is inconsistently and at times inadequately used. Design: Qualitative study, using semistructured interviews. Setting: A stratified random sample of 14 sites from an estab- lished network of 43 hospitals, including both community and tertiary care centers in Southern Ontario, Canada. Participants: Twenty-one intensive care unit and emergency department physicians and nurses. Interventions: None. Measurements and Main Results: Purposive sampling was used to interview individuals who were most likely to be involved in the implementation and evaluation of the hypothermia protocol. All interviews were conducted by telephone by a clinician and a qualitative researcher. Interviews were recorded electronically and transcribed unless the participant declined to have the inter- view recorded. Untranscribed interviews were recorded as field notes and as direct quotations. New interviews were conducted until thematic saturation occurred. The analysis was completed through three phases of coding. Respondents identified lack of familiarity and availability of concrete therapeutic hypothermia protocols and process issues as the most frequent barriers. Process concerns included availability of equipment, equipment costs, and high workload demands for emergency nurses. Other barriers identified were variable nursing awareness, variable staff uptake, lack of agreement with supporting evidence, lack of interdisciplinary collaboration between the intensive care unit and emergency department, lack of interprofessional education be- tween nurses and physicians, and challenges inherent in applying an intervention infrequently. Conclusions: This study demonstrated that the systematic adoption of a new intervention, therapeutic hypothermia, is met with interdependent generic, local, and individual barriers. A working awareness of the types of barriers that exist at multiple sites will assist in targeting specific knowledge translation strat- egies to improve adherence to evidence-based practice. (Crit Care Med 2010; 38:504-509)

Background and Purpose— Intravenous tissue plasminogen activator for ischemic stroke is approved for eligible patients who can be treated within a 3-hour window, but treatment rates remain disappointingly low, often Methods— We compared consecutive patients with stroke arriving to our stroke center during the first 4 months of this new triage protocol (February 14 to June 14, 2005) versus the same 4-month period in 2004. Results— The protocol resulted in an immediate doubling in the number of patients with acute stroke arriving to our regional stroke center within 2.5 hours of symptom onset. We observed a 4-fold increase in patients who were eligible for and treated with tissue plasminogen activator. The tissue plasminogen activator treatment rate for ischemic stroke patients increased from 9.5% to 23.4% ( P =0.01), and one in 2 patients with ischemic stroke arriving within 2.5 hours received thrombolysis during this period (one in 5 of patients with ischemic stroke overall). The median onset-to-needle time for tissue plasminogen activator-treated patients was significantly reduced. Many implementation challenges were identified and addressed. Conclusions— This prehospital triage was immediately successful in improving tissue plasminogen activator access for patients with ischemic stroke, enabling our center to achieve one of the highest tissue plasminogen activator treatment rates in North America and underscoring the need for coordinated systems of acute stroke care. Sustainability of such an initiative will be dependent on interdisciplinary teamwork, ongoing paramedic training, adequate hospital staffing, bed availability, and repatriation agreements with community hospitals.

Intracranial hemorrhage (ICH) is common in traumatic brain injury (TBI) and a major determinant of death and disability. ICH commonly increases in size and coagulopathy has been implicated in such progression. We investigated the association between coagulopathy diagnosed by routine laboratory tests and ICH progression.Subgroup post hoc analysis from a randomized controlled trial including adult patients with blunt severe TBI (Glasgow Coma Scale scoreor=8) and repeat computerized tomography scans in 48 hours. Coagulopathy was defined as international normalized ratioor=1.3, activated partial thromboplastin timeor=35, or platelet count (PLT)or=100 x 10/L any time in the first 24 hours. Progression was any size increase or new ICH. TBI-associated coagulopathy was investigated measuring soluble tissue factor (TF) and d-dimer.The ICH progressed in 37 of 72 patients (51%), in 80% if any abnormal laboratory test (coagulopathic patients) versus 36% in noncoagulopathic (p = 0.0004). Abnormal international normalized ratio (odds ratio [OR] = 4.09; 95% confidence interval [CI] = 1.29-12.95; p = 0.017), PLT (OR = 12.59; 95% CI = 1.52-108.57; p = 0.019), head Abbreviated Injury Scale (AIS) (OR = 1.82; 95% CI = 1.15-2.88; p = 0.011) were significantly associated with progression (univariate analysis). In a multiple logistic regression, only head AIS (OR = 1.81; 95% CI 1.10-2.98; p = 0.0198) and PLT (OR = 11.8; 95% CI = 1.38-101.23; p = 0.024) correlated with progression. All patients with abnormal partial thromboplastin time experienced progression. ICH progression carried a 5-fold higher odds of death; 32% with progression died versus 8.6% without. Age, head AIS, Injury Severity Score, and d-dimer were also associated with mortality. Tissue factor was not associated with progression or mortality.This study demonstrates an association between coagulopathy, diagnosed by routine laboratorial tests in the first 24 hours, with ICH progression; and ICH progression with mortality in patients with severe TBI. The causal relationship between coagulopathy and ICH progression will require further studies.

The contributors to this statement were selected to ensure expertise in all the disciplines relevant to post–cardiac arrest care. In an attempt to make this document universally applicable and generalizable, the authorship comprised clinicians and scientists who represent many specialties in many regions of the world. Several major professional groups whose practice is relevant to post–cardiac arrest care were asked and agreed to provide representative contributors. Planning and invitations took place initially by e-mail, followed a series of telephone conferences and face-to-face meetings of the cochairs and writing group members. International writing teams were formed to generate the content of each section, which corresponded to the major subheadings of the final document. Two team leaders from different countries led each writing team. Individual contributors were assigned by the writing group cochairs to work on 1 or more writing teams, which generally reflected their areas of expertise. Relevant articles were identified with PubMed, EMBASE, and an American Heart Association EndNote master resuscitation reference library, supplemented by hand searches of key papers. Drafts of each section were written and agreed on by the writing team authors and then sent to the cochairs for editing and amalgamation into a single document. The first draft of the complete document was circulated among writing team leaders for initial comment and editing. A revised version of the document was circulated among all contributors, and consensus was achieved before submission of the final version for independent peer review and approval for publication. This scientific statement outlines current understanding and identifies knowledge gaps in the pathophysiology, treatment, and prognosis of patients who regain spontaneous circulation after cardiac arrest. The purpose is to provide a resource for optimization of post–cardiac arrest care and to pinpoint the need for research focused on gaps in knowledge that would potentially improve outcomes …

Introduction: Targeted temperature management (TTM) reduces neurologic injury from out-of-hospital cardiac arrest (OHCA). As the risk of neurologic injury increases with prolonged cardiac arrests, the benefit of TTM may depend upon cardiac arrest duration. We hypothesized that there is a time-dependent effect of TTM on neurologic outcomes from OHCA. Methods: Retrospective, observational study of the Toronto RescuNET Epistry-Cardiac Arrest database from 2007 to 2014. We included adult (>18) OHCA of presumed cardiac etiology that remained comatose (GCS Results: There were 1496 patients who met our inclusion criteria, of whom 981 (66%) received TTM. Of the patients who received TTM, 59% had a good neurologic outcome compared to 39% of patients who did not receive TTM (p< 0.001). After adjusting for the Utstein variables, use of TTM was associated with improved neurologic outcome (OR 1.60, 95% CI 1.10-2.32; p = 0.01) but not with survival to discharge (OR 1.23, 95% CI 0.90-1.67; p = 0.19). The impact of TTM on neurologic outcome was dependent on the duration of cardiac arrest (p Conclusion: The use of TTM was associated with improved neurologic outcome at hospital discharge. Patients with prolonged durations of cardiac arrest benefited more from TTM.

Background: Mathematical optimization can be used to plan future AED placement to maximize out-of-hospital cardiac arrest (OHCA) coverage. Many public access AEDs are placed in locations without 24/7 access. AED coverage can be overestimated unless temporal availability is considered. Objective: To develop a new spatiotemporal AED location optimization model that accounts for both spatial and temporal information. Methods: We identified all atraumatic public-location OHCAs occurring in Toronto, Canada from Jan. 2006 – Aug. 2014. We gathered location and operating hours data for 4898 buildings that were used as potential sites for AED placement. We extended a previously published spatial optimization model, which identifies locations to place AEDs that maximize the number of historical OHCAs occurring within 100 m of an AED. The new spatiotemporal model finds AED locations that maximize the number of OHCAs occurring within 100 m of an available AED, considering when the OHCAs occurred (“actual coverage”). We then compared the spatial and spatiotemporal models on actual coverage of out-of-sample OHCAs using 10-fold cross validation. Statistical analysis was performed using McNemar’s test. Results: We identified 2440 atraumatic public-location OHCAs. AED locations chosen by the spatiotemporal model outperformed those chosen by the spatial model by 26.1% in actual coverage (p Conclusion: Spatiotemporal optimization can maximize actual OHCA coverage by accounting for AED availability when identifying future AED locations. The largest gains occurred during the evening and night, which is when the largest coverage losses were experienced by Toronto’s existing AEDs.

Introduction: Research and quality assessment of cardiopulmonary resuscitation (CPR) quality has traditionally been limited to the first five minutes of resuscitation due to significant costs in both time and personnel from manual data abstraction. Manual CPR quality data abstraction of entire episodes of resuscitation may be too resource-intensive for many emergency medical service (EMS) agencies and hospitals. Moreover, the first five minutes of CPR are also different in many aspects compared to later time periods during cardiac arrest resuscitation, which represents significant knowledge gaps since the majority of resuscitations go beyond five minutes. Methods: We developed a software program to facilitate and help automate data abstraction from electronic defibrillator files for entire resuscitation episodes. Internal validation of the software program was performed on 50 randomly selected out-of-hospital cardiac arrest cases with resuscitation durations up to 60 minutes. CPR quality data variables were abstracted as minute averages, which included ventilation rate, CPR compression rate, depth, fraction, and end-tidal CO2. CPR quality data variables were manually abstracted independently by two trained data abstractors and automatically by the software program. Error rates and the time needed for data abstraction were measured. Results: A total of 9826 data points were abstracted. Manual data abstraction resulted in a total of six errors (0.06%) compared to zero errors by the software program. The mean time ± SD needed for data abstraction was 20.3 ± 2.7 minutes manually and 5.3 ± 1.4 minutes using the software program (p=0.003). Conclusion: Our data abstraction software was 100% accurate in abstracting CPR quality data for complete cardiac arrest resuscitation episodes. It significantly reduced the time and resources required to abstract CPR quality data, and will allow EMS agencies and hospitals to evaluate their CPR quality in a cost-effective manner. The development of this software will enable future studies to efficiently evaluate CPR quality during entire resuscitation episodes, including its impact on patient outcomes during prolonged cardiac arrests.

Background: Out-of-hospital cardiac arrests (OHCAs) occur at all times of the day and night. Immediate access to an AED increases survival. However, most public-location AEDs are placed in buildings without 24 hour access. Objective: To measure fixed-location public AED coverage of OHCAs by time of day and day of week in a Canadian urban setting. Methods: We identified all atraumatic public OHCAs occurring in Toronto, Canada from Jan. 2006 – Aug. 2014. We obtained a list of registered AEDs from Toronto Emergency Medical Services as of March 2015 and determined the hours that each AED was available based on operating hours of the building housing the AED. We counted the number of OHCAs that occurred within 100 m of an AED (“assumed 24/7 coverage”) and the number that occurred both within 100 m of an AED and when the AED was available (“actual coverage”). Statistical analysis was performed using a χ 2 test. Results: We identified 2440 atraumatic public OHCAs and 737 registered AED locations. A total of 451 OHCAs were covered under assumed 24/7 coverage. In terms of actual coverage, 354 OHCAs were covered, representing a coverage loss of 25.5%. The figure shows coverage decreased by 8.6% during the day (8am-3:59pm), 28.6% in the evening (4pm-11:59pm), and 48.4% at night (12am-7:59am); the differences were statistically significant (p Conclusion: One out of every four OHCAs in proximity of an AED occurs when that AED is inaccessible due to lack of 24/7 access. When deciding on candidate locations for placement of AEDs, temporal access should be considered to maximize the number of lives saved.

Introduction: Evidence for the effectiveness of coronary angiography after out-of-hospital cardiac arrest (OHCA) is conflicting. Our objective was to evaluate the association between receiving coronary angiography within 72 hours of hospital arrival and survival with favorable neurologic outcome. Methods: This was a population-based retrospective cohort study of consecutive cases of adult OHCA transported to and treated at 28 hospitals in Southern Ontario between March 1, 2010 and December 31, 2014. We included patients with atraumatic OHCA, who achieved return of spontaneous circulation, and were alive 6 hours after hospital arrival. Multi-level logistic regression was used to measure the association between early coronary angiography and neurologically intact survival (Modified Rankin Score 0-2), while controlling for potential confounders and clustered data. We controlled for age, sex, initial cardiac rhythm, witness status, bystander resuscitation, EMS response time, prehospital return of spontaneous circulation, location of arrest, daytime presentation, neurologic status at hospital arrival, STEMI status, cardiac history, initiation of therapeutic hypothermia, hospital size and type, and hospital annual cardiac arrest volume. Results: During the period of study, 2678 consecutive OHCA patients met the inclusion criteria. The mean age was 66(±16), 31.7% were female, 54.1% had a bystander witnessed arrest, 35.2% received bystander CPR, 45.9% had a shockable initial rhythm, 30.1% had ST elevation on the first post arrest ECG, and 32.4% received coronary angiography. Receiving coronary angiography was strongly associated with neurologically intact survival (OR 2.30, CI95 1.69-3.15) and survival (OR 2.08, CI95 1.53-2.82). A similar association was observed in the subgroup of patients without STEMI (OR 3.24, CI95 2.16-4.87 and OR 2.66, CI95 1.78-3.99, respectively). Conclusions: Neurologically intact survival among post cardiac arrest patients may be improved with coronary angiography, particularly for patients without STEMI. This observation should be confirmed with future randomized controlled studies.

Background: Published survival rates after out-of-hospital cardiac arrests (OHCA) are lower than in-hospital cardiac arrest (IHCA). Current estimates for the incidence and rate of survival for maternal cardiac arrest are published only for IHCA. There are no studies that report the incidence and outcomes of maternal OHCA. Current cardiopulmonary resuscitation guidelines contain specific maternal recommendations, although compliance with recommended benchmarks has not been reported. The objective of this study was to report maternal OHCA incidence, outcomes, and compliance with resuscitation and maternal specific guidelines. Methods: This was a population-based cohort study of consecutive maternal OHCA between May 2010 and April 2014. The denominator was estimated from the total regional population of all women of childbearing age obtained from census and age-specific pregnancy rates provided by regional health authorities. Resuscitation performance was measured against the 2010 AHA Guidelines. Results: A total of 6 maternal OHCA occurred amongst 1,085 OHCA occurring in females of child bearing age (15-49) over 4yrs; Incidence-1.85:100,000 (95% CI 1.76 to 1.95) vs. 19.4 per 100,000 (95% CI, 19.37 to 19.43). Maternal and neonatal survival to discharge was 16.7% and 33.3%, respectively. Compliance with CPR quality metrics averaged 83% with a range from 75% to 100%. Compliance with maternal-specific resuscitation guidelines averaged 46.9%, with a range from 0% to 100%. The only performance metrics with 100% compliance was intravenous line insertion above the diaphragm and prehospital activation of the maternal cardiac arrest team. Uterine displacement compliance was low at 0%. Conclusion: The incidence of maternal OHCA was 1.85:100,000, which is lower than the published estimate for maternal IHCA. Survival after OHCA for mother and for child was higher than OHCA occurring in non-pregnant adult females of child bearing age; however, the number of survivors was small (

This Part describes the process of creating the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC), informed by the 2015 International Consensus on CPR and ECC Science With Treatment Recommendations (CoSTR) publication.1,2 The process for the 2015 International Liaison Committee on Resuscitation (ILCOR) systematic review is quite different when compared with the process used in 2010.1–3 For the 2015 systematic review process, ILCOR used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) (www.gradeworkinggroup.org) approach to systematic reviews and guideline development. For the development of this 2015 Guidelines Update, the AHA used the ILCOR reviews as well as the AHA definition of Classes of Recommendation (COR) and Levels of Evidence (LOE) (Table 1). This Part summarizes the application of the ILCOR GRADE process to inform the creation of 2015 Guidelines Update, and the process of assigning the AHA COR and LOE. View this table: Table 1. Applying Class of Recommendations and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* ### Grading of Recommendations Assessment, Development, and Evaluation The 2015 CoSTR summarizes the published scientific evidence that was identified to answer specific resuscitation questions. ILCOR uses the GRADE system to summarize evidence and determine confidence in estimates of effect as well as to formulate treatment recommendations. GRADE is a consensus-crafted tool in wide use by many professional societies and reference organizations, including the American College of Physicians, the American Thoracic Society, and the Cochrane Collaboration, as well as the Centers for Disease Control and the World Health Organization. The choice of the GRADE approach was based on its increasingly ubiquitous use, practicality, and unique features. To our knowledge, the ILCOR evidence review process represents the largest application of the GRADE system in a healthcare-related review. GRADE is a system to review evidence to determine …

Publication of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) marks 49 years since the first CPR guidelines were published in 1966 by an Ad Hoc Committee on Cardiopulmonary Resuscitation established by the National Academy of Sciences of the National Research Council.1 Since that time, periodic revisions to the Guidelines have been published by the AHA in 1974,2 1980,3 1986,4 1992,5 2000,6 2005,7 2010,8 and now 2015. The 2010 AHA Guidelines for CPR and ECC provided a comprehensive review of evidence-based recommendations for resuscitation, ECC, and first aid. The 2015 AHA Guidelines Update for CPR and ECC focuses on topics with significant new science or ongoing controversy, and so serves as an update to the 2010 AHA Guidelines for CPR and ECC rather than a complete revision of the Guidelines. The purpose of this Executive Summary is to provide an overview of the new or revised recommendations contained in the 2015 Guidelines Update. This document does not contain extensive reference citations; the reader is referred to Parts 3 through 9 for more detailed review of the scientific evidence and the recommendations on which they are based. There have been several changes to the organization of the 2015 Guidelines Update compared with 2010. “Part 4: Systems of Care and Continuous Quality Improvement” is an important new Part that focuses on the integrated structures and processes that are necessary to create systems of care for both in-hospital and out-of-hospital resuscitation capable of measuring and improving quality and patient outcomes. This Part replaces the “CPR Overview” Part of the 2010 Guidelines. Another new Part of the 2015 Guidelines Update is “Part 14: Education,” which focuses on evidence-based recommendations to facilitate widespread, consistent, efficient and effective implementation …

Background: Out-of-Hospital-Cardiac Arrest (OHCA) in young individuals is a tragic and unexpected event, often occurring in seemingly healthy individuals. We examined the etiologies and medications in a large urban cohort of young sudden death patients in order to ascertain the accuracy of this assumption. Methods: A prospective population-based registry of all OHCAs in the Toronto area was used to identify cases from 2009-2012. Eligible cases were defined as OHCA patients aged 2-45 who had “no obvious cause” as defined by Emergency Medical Services (EMS) and hospital records, who died, and had a coroner record available. All cases were subsequently classified as primary cardiac or non-cardiac etiology by 3 reviewers (KA, AP, PD) using all available sources of information, including EMS reports, in-hospital data coroner investigative statements, autopsy, toxicology and police reports. Disagreement was resolved by consensus. Cardiac etiology was classified as one of: structural heart disease (HD), ischemic HD, primary arrhythmic, other or undetermined. A positive drug screen was defined as any psychoactive drug, ethanol, or drug of abuse detected at therapeutic, significant or toxic concentrations post-mortem. Cases were further subdivided by age (2-34 vs. 35-45) and gender. Results: A total of 470 patients were identified as having adjudicated primary cardiac etiologies. Causes of death and drug information are detailed in Table 1. Both men and women had a relatively high rate of psychoactive drug use (antipsychotics, antidepressants, and opioids). Overall, women had higher rates of medications compared to men. Conclusions: Younger, seemingly healthy OHCA patients die more often from structural heart disease than from primary arrhythmia disorders. The high rates of psychoactive drug use, as well as high rates of positive toxicology screens in this cohort suggests that prior illness and drugs may play an important role in the cause of sudden death.

Introduction: The frequency of lethal overdose due to prescription and non-prescription drugs is increasing in North America. The contribution of drug overdose (OD) to regional variation in the incidence and outcome out-of-hospital cardiac arrest (OHCA) is unclear. Objective: To estimate overall and regional variation in incidence and outcomes of emergency medical services (EMS)-treated OD-OHCA cases across North America. Methods: The Resuscitation Outcomes Consortium (ROC) is a clinical research network with 10 regional clinical centers in United States (US) and Canada that uses uniform methods for surveillance of all EMS-treated OHCA in participating regions. Cases of OHCA from 2006 to 2010 were reviewed for evidence of association with or without OD. Incidence of OD-OHCA was calculated as the number of OD-OHCA in a region per 100,000 cumulative person-years, using 2000 US Census and 2006 Statistics Canada population counts. Patient and EMS characteristics as well as outcome were described. Multiple logistic regression was used to describe the association between OD status on return of spontaneous circulation (ROSC) and survival to hospital discharge, while adjusting for case characteristics and consortium center. Results: Included were 56,272 cases of OHCA. Regional incidence of OD-OHCA varied between 0.5 and 2.7 per 100,000 person years (p Conclusions: OD-OHCA are a small proportion of all OHCA, although incidence varied up to 5-fold across regions. OD-OHCA were more likely to survive than non-OD-OHCA.

BACKGROUND: Pre-shock pause duration of < 20 seconds is associated with improved survival after cardiac arrest. Manual mode defibrillation has been associated with the shortest duration of pre-shock pause but is largely practiced by paramedics (EMT-P) whereas defibrillator only providers (EMT-D) routinely use the defibrillator in automatic mode. OBJECTIVE: We sought to explore the relationship between manual mode defibrillation, pre-shock pause duration and shock appropriateness when defibrillation is provided by EMT-P vs. EMT-D level of providers. METHODS: We performed a retrospective review of all treated non-traumatic adult OHCA presenting in a shockable rhythm over a one year period beginning January 1, 2012. Our primary outcome measure was the proportion of manual mode shocks delivered by EMT-D’s with pre- shock pause duration of < 20 secs when compared to EMT-P’s. Our secondary outcome measures were the duration of pre-, post- and peri-shock pause and the proportion of appropriate shocks (defined as correct identification and shock delivery to patients in a shockable rhythm) delivered by either level of provider. This study had a power of 90% to detect an absolute difference of 15% between provider levels in proportion of shocks delivered with pre-shock pause duration RESULTS: Among 2019 treated OHCA, 335(20%) presented in a shockable rhythm. Manual defibrillation was performed in 155 (46%) of these cases (196 shocks by EMT-P, 143 shocks by EMT-D). There were no differences in the proportion of shocks delivered with pre-shock pause duration CONCLUSIONS: Manual mode defibrillation by EMT-D’s produced similar measures of pre-shock pause when compared to EMT-P’s without increasing the rate of inappropriate shocks. More widespread use of EMT-D manual mode defibrillation may have the potential to decrease shock pause duration and improve survival.

Background: Death due to out-of-hospital cardiac arrest (OHCA) is most commonly attributed to “no obvious cause” after review of the prehospital and in-hospital documentation. To establish cause of death in younger patients, autopsy and toxicology data are important, especially in younger patients. We examined the probable cause of death in a large urban cohort of younger OHCA patients. Methods: A prospective population-based registry of all OHCAs attended by Emergency Medical Services (EMS) in the Toronto area was used to identify cases from 2009-2012. Identified OHCAs were cases aged 2-45 who died and assigned ‘no obvious cause’ based on abstracted data from ambulance call reports and in-hospital chart review, including narrative review and contributing factors compliant with the Resuscitation Outcomes Consortium Epistry Manual of Operations. Cases with inadequate information (coroners and/or EMS), or with expected death (e.g. DNR or long term care) or homicide were then excluded. The remaining cases were adjudicated by 3 reviewers using additional data from coroner investigative statements, autopsy, toxicology and police reports, and classified as primary cardiac or another non-cardiac etiology. Results: A total of 2048 OHCA cases with no obvious cause were identified; of these, 547 were excluded. Of the remaining 1501 cases with complete information, 48.2% were treated by EMS. Of the treated cases, 41.3 % (299/724) of those assigned to ‘no obvious cause’ had an adjudicated cardiac etiology. Of the untreated group, 21.2% (165/777) had an adjudicated cardiac etiology. The majority consisted of drug overdoses (214/425; 50.3%) and other non-cardiac causes (49.7%) including trauma (Figure 1). Conclusions: In younger OHCA patients who die, the category "OHCA of no obvious cause”, on detailed review, is most often due to a non-cardiac cause. This observation may contribute to a better understanding of the etiology of sudden cardiac death in younger patients.

This consensus statement was commissioned in 2012 by the Board of Directors of the Society for Obstetric Anesthesia and Perinatology to improve maternal resuscitation by providing health care providers critical information (including point-of-care checklists) and operational strategies relevant to maternal cardiac arrest. The recommendations in this statement were designed to address the challenges of an actual event by emphasizing health care provider education, behavioral/communication strategies, latent systems errors, and periodic testing of performance. This statement also expands on, interprets, and discusses controversial aspects of material covered in the American Heart Association 2010 guidelines.

This section of the 2010 AHA Guidelines for CPR and ECC addresses cardiac arrest in situations that require special treatments or procedures beyond those provided during basic life support (BLS) and advanced cardiovascular life support (ACLS). We have included 15 specific cardiac arrest situations. The first several sections discuss cardiac arrest associated with internal physiological or metabolic conditions, such as asthma (12.1), anaphylaxis (12.2), pregnancy (12.3), morbid obesity (12.4), pulmonary embolism (PE) (12.5), and electrolyte imbalance (12.6). The next several sections relate to resuscitation and treatment of cardiac arrest associated with external or environmentally related circumstances, such as ingestion of toxic substances (12.7), trauma (12.8), accidental hypothermia (12.9), avalanche (12.10), drowning (12.11), and electric shock/lightning strikes (12.12). The last 3 sections review management of cardiac arrest that may occur during special situations affecting the heart, including percutaneous coronary intervention (PCI) (12.13), cardiac tamponade (12.14), and cardiac surgery (12.15). Asthma is responsible for more than 2 million visits to the emergency department (ED) in the United States each year, with 1 in 4 patients requiring admission to a hospital.1 Annually there are 5,000 to 6,000 asthma-related deaths in the United States, many occurring in the prehospital setting.2 Severe asthma accounts for approximately 2% to 20% of admissions to intensive care units, with up to one third of these patients requiring intubation and mechanical ventilation.3 This section focuses on the evaluation and treatment of patients with near-fatal asthma. Several consensus groups have developed excellent guidelines for the management of asthma that are available on the World Wide Web: ### Pathophysiology The pathophysiology of asthma consists of 3 key abnormalities: Complications of severe asthma, such as tension pneumothorax, lobar atelectasis, pneumonia, and pulmonary edema, can contribute to fatalities. Severe asthma exacerbations are commonly associated with …

The goals of resuscitation are to preserve life, restore health, relieve suffering, limit disability, and respect the individual's decisions, rights, and privacy. Decisions about cardiopulmonary resuscitation (CPR) efforts are often made in seconds by rescuers who may not know the victim of cardiac arrest or whether an advance directive exists. As a result, administration of CPR may be contrary to the individual's desires or best interests.1,–,3 However, practice is evolving as more emergency physicians reportedly honor legal advance directives in decisions about resuscitation.4,–,7 This section provides guidelines for healthcare providers who are faced with the difficult decision to provide or withhold emergency cardiovascular care. Healthcare professionals should consider ethical, legal, and cultural factors8,9 when caring for those in need of CPR. Although healthcare providers must play a role in resuscitation decision making, they should be guided by science, the individual patient or surrogate preferences, local policy, and legal requirements. ### Principle of Respect for Autonomy10 The principle of respect for autonomy is an important social value in medical ethics and law. The principle is based on society's respect for a competent individual's ability to make decisions about his or her own healthcare. Adults are presumed to have decision-making capability unless they are incapacitated or declared incompetent by a court of law. Truly informed decisions require that individuals receive and understand accurate information about their condition and prognosis, as well as the nature, risks, benefits, and alternatives of any proposed interventions. The individual must deliberate and choose among alternatives by linking the decision to his or her framework of values. Truly informed decisions require a strong healthcare provider–patient relationship/communication and a 3-step process: (1) the patient receives and understands accurate information about his or her condition, prognosis, the nature of any proposed interventions, alternatives, …

The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically unstable or symptomatic due to the arrhythmia. Drugs or, when appropriate, pacing may be used to control unstable or symptomatic bradycardia. Cardioversion or drugs or both may be used to control unstable or symptomatic tachycardia. ACLS providers should closely monitor stable patients pending expert consultation and should be prepared to aggressively treat those with evidence of decompensation.

To preserve the public trust and integrity of the International Liaison Committee on Resuscitation (ILCOR) evidence evaluation process, in 2004 ILCOR established a conflict of interest (COI) policy1,E1 to manage any real or potential conflicts of interest in an open and effective manner. Readers of the electronic version of this supplement can access the online documents by clicking on the E# callout, which will take them to the hyperlink in the Online Documents Cited list at the end of this editorial. Readers of the print version can access the documents at the URLs listed or by clicking the links found at http://www.C2005.org. This editorial explains the ILCOR and American Heart Association (AHA) COI policies and their application throughout the 2005 evidence evaluation process. ILCOR and the AHA also welcome readers’ questions and feedback on this process. The value of the ILCOR evidence evaluation process depends on rigorous expert review of published science. Therefore, it is essential that any potential professional conflict of interest be fully disclosed and managed effectively during the planning and conduct of the evidence evaluation process, especially when issues arise. Because many of the world’s most qualified scientific experts may have professional relationships that could pose a real or perceived conflict of interest, it is not always possible to avoid all involvement by such persons. It is necessary, however, to limit and manage their involvement in areas of potential conflict, especially to minimize their influence over consensus statements or recommendations in such areas. ILCOR COI procedures applied to all ILCOR delegates, 2005 Consensus Conference participants, observers, worksheet experts, worksheet authors, editors of the ILCOR 2005 CPR Consensus document (published in this supplement), and all others working on ILCOR projects. As host of the 2005 Consensus Conference, the AHA also required every participant to complete an AHA …

Introduction: The overall incidence of ventricular tachycardia/ventricular fibrillation (VT/VF) as the first recorded electrical rhythm in out of hospital cardiac arrest (OOHCA) has declined from ~70% to ~25% over the last 30 years. This change has been attributed to primary and secondary prevention of cardiovascular disease and VT/VF. We evaluated whether the incidence of VT/VF as first recorded rhythm differed by location among bystander AED applied patients and EMS witnessed cardiac arrests. Methods: Prospective cohort study of non-traumatic cardiac arrest from December 2005 to April 2007 in the Resuscitation Outcomes Consortium database from 10 US and Canadian sites. The incidence of an initial shockable rhythm on AED or documented VT/VF was compared among bystander applied AED patients and EMS witnessed arrests in public versus private settings. Results: The first rhythm was known in 13,235 of 14,059 (94%) adult EMS-treated cardiac arrests. Of the 13,235 with known rhythms, 3436 (26%) had VT/VF. Among 1115 EMS-witnessed arrests, 61/161 (38%) had VT/VF in public settings and 224/954 (23%) in private settings. Similarly, for bystander AED applied in the private setting 39/114 (34%) were shocked. But, in contrast, 125/159 (79%) (P Conclusions: The incidence of VT/VF is far greater in the public setting particularly for bystander witnessed AED applied arrests. Patients in the private home setting, even for EMS observed arrests, are far less likely to benefit from AED application than bystander witnessed patients in the public setting. CPR strategies may need to be tailored by arrest location.

Introduction: Current CPR compression depth guidelines were empirically derived. We sought to study patterns of CPR compression depth and their associations with patient outcomes in out-of-hospital cardiac arrest (OOHCA). Methods: We studied OOHCA patients from the Resuscitation Outcomes Consortium Epistry - Cardiac Arrest for whom electronic CPR data were available from proprietary accelerometer technology attached to the prehospital defibrillators. We calculated anterior chest wall depression in millimeters and the period of active CPR (chest compression fraction [CCF]) for each minute of CPR. We controlled for covariates including compression rate and calculated adjusted odds ratios (OR) for any return of circulation (ROSC) and 24 hour survival. We calculated unadjusted OR for hospital discharge. Results: We included 615 adult patients from 6 U.S. and Canadian cities with these characteristics: mean age 68.9; male 62 %; witnessed 43%; bystander CPR 31%; initial rhythms - VF/VT 25%, PEA 17%, asystole 43%, unspecified non-shockable 15%; mean compression rate 103/min; mean compression depth 51mm 11%; median CCF 0.66; outcomes - ROSC 57%, 24 hour survival 18%, discharge 5%. We found an inverse association between depth and compression rate (P ), no association between depth and CCF (P=0.30), and a positive association between CCF and rate (P Conclusions: We found half of patients received suboptimal compression depth, an inverse association between compression depth and rate, and no clear association between survival and increased compression depth. Further study is required to determine the optimum chest compression depth and its interaction with rate and CCF in order to maximize outcomes. Compression Rate versus Compression Depth

Patients who present with ST-elevation myocardial infarction to hospitals without percutaneous coronary intervention (PCI) often cannot undergo primary PCI in a timely manner and therefore receive fibrinolysis. The role and optimal timing of routine PCI after fibrinolysis, using contemporary stents and pharmacotherapy, has not been studied in a large adequately powered randomized trial. To compare a pharmacoinvasive strategy of transfer for routine PCI within 6 hrs after fibrinolysis with standard treatment after fibrinolysis (including predefined criteria for rescue PCI). Pts presenting to non-PCI centres with STEMI within 12 hrs of symptom onset and with high-risk features were randomized to a pharmacoinvasive strategy (transfer for PCI within 6 hrs of fibrinolysis) or to standard treatment after fibrinolysis (which included rescue PCI as required for ongoing chest pain and < 50% resolution of ST-elevation at 60 –90 minutes). For standard treatment pts who did not require rescue PCI, cardiac catheterization was encouraged beyond 24 hrs. All pts received ASA and antithrombin therapy (unfractionated heparin or enoxaparin for age

Background The Utstein elements provide measures for comparing out-of-hospital cardiac arrest (OHCA) care and outcomes within and across communities. Whether these measures sufficiently predict survival and explain variation in outcome is not well studied. Hypotheses Utstein data elements predict survival to hospital discharge but explain only a portion of survival variation. Methods Design Prospective, population-based cohort using uniform data definitions. Setting Ten North American sites participating in the Resuscitation Outcomes Consortium, a prehospital emergency care network. Population Persons ≥ 20 years with OHCA from 12/1/2005 – 11/30/2006 (n=9582). Analyses We used logistic regression to assess association between Utstein elements and survival and to determine whether they accounted for site survival differences. We evaluated measures of residual variance to assess what proportion of outcome variation the Utstein elements predicted. Results Survival was 7.0% overall. Utstein elements were associated with survival (Table ). Relationships were similar when restricted to those with ventricular fibrillation. In analyses assessing variance of residuals, Utstein elements collectively accounted for 15% of variation in survival. Site was also associated with survival, ranging from 3.7% to 15.6%. In multivariable analyses, site association was not attenuated by adjusting for Utstein elements. Conclusion Although Utstein elements predict survival, they account for a modest portion of variation overall and do not explain survival differences across sites. Additional factors should be investigated to understand and potentially improve OHCA outcome.

Introduction: The American College of Surgeons (ACS) recommends immediate transport to a trauma center for all injured persons with field physiologic derangement (ACS Step 1 trauma triage criteria). However, it remains unclear whether these criteria could be refined to identify high-risk trauma patients with improved predictive value. Hypothesis: We assessed the hypothesis that an easily applied, prehospital, clinical decision rule could be developed to better identify high-risk injured persons meeting ACS Step 1 criteria. Methods: We conducted a prehospital prospective cohort study of injured adults > 15 years where field resuscitation was attempted and ACS physiologic criteria were present: SBP <90, RR 29 breaths/minute, GCS <12, or field intubation. Population-based data were collected from December 1, 2005 through November 30, 2006 by 268 EMS agencies transporting to 287 acute care hospitals (trauma and non-trauma centers) in 11 sites across the U.S. and Canada. Ten prehospital variables were assessed: SBP, RR, GCS, pulse, pulse oximetry, shock index (pulse/SBP), mechanism of injury, penetrating injury, age, and gender. High risk injured persons included: death (before or after admission) or hospital LOS >2 days. 60% of the sample was randomly selected for rule derivation and analyzed using classification and regression tree analysis. The remaining 40% were used for rule validation. The final rule was based on a targeted sensitivity of >90%. Results: Of 4,983 eligible patients, 4,326 injured persons had complete outcome information and were included in the analysis. The sample included 2,495 (58%) persons with death or LOS >2 days, as well as 1,061 (25%) patients that did not require admission. The final rule included the following variables (in order): field intubation, GCS < 8, shock index > 1.4, mechanism of injury, and age >=70 years. Rule validation demonstrated the following accuracy measures: sensitivity 94.9% (95% CI 93.5–96.3%), specificity 14.1% (95% CI 11.6 –16.6%). Conclusions: While we were able to generate a highly sensitive decision rule, the rule appears too complex for field application and is non-specific. Further refining ACS physiologic triage criteria to increase predictive value remains an ongoing challenge.

There is ongoing controversy about the relative effectiveness of air medical versus ground transportation for severely injured patients. In some systems, air medical crews may provide a higher level of care but may require longer transport times. We sought to evaluate the impact of mode of transport on outcome based on analysis of data from two randomized trials of prehospital hypertonic resuscitation.Injured patients were enrolled based on prehospital evidence of hypovolemic shock (systolic blood pressure ≤70 mm Hg or systolic blood pressure = 71-90 mm Hg with heart rate ≥108 bpm) or severe traumatic brain injury (TBI; Glasgow Coma Scale score ≤8). Patient demographics, injury severity, and physiology were compared based on mode of transport. Multivariate logistic regression was used to determine the impact of mode of transport on 24-hour and 28-day survival for all patients and 6-month extended Glasgow Outcome Scale for patients with TBI, adjusting for differences in injury severity.Included were 2,049 patients, of which 703 (34%) were transported by air. Patients transported by air were more severely injured (mean Injury Severity Score, 30.3 vs. 22.8; p0.001), more likely to be in the TBI cohort (70% vs. 55.4%; p0.001), and more likely blunt mechanism (94.0% vs. 78.1%; p0.001). Patients transported by air had higher rates of prehospital intubation (81% vs. 36%; p0.001), received more intravenous fluids (mean 1.3 L vs. 0.8 L; p0.001), and had longer prehospital times (mean 76.1 minutes vs. 43.5 minutes; p0.001). Adjusted analysis revealed no significant impact of mode of transport on survival or 6-month neurologic outcome (air transport-28-day survival: odds ratio, 1.11; 95% confidence interval, 0.82-1.51; 6-month extended Glasgow Outcome Scale score ≤4: odds ratio, 0.94; 95% confidence interval, 0.68-1.31).There was no difference in the adjusted clinical outcome according to mode of transport. However, air medical transported more severely injured patients with more advanced life support procedures and longer prehospital time.III.