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Martin Harpsø,1,2 Asger Granfeldt,3 Bo Løfgren,1,4,5 Charles D Deakin6 1Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark; 2Department of Internal Medicine, Regional Hospital of Horsens, Horsens, Denmark; 3Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark; 4Department of Internal Medicine, Regional Hospital of Randers, Randers, Denmark; 5Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; 6Respiratory Biomedical Research Unit, University Hospital Southampton, UK Purpose: Oxygen supplementation has previously been considered beneficial when managing critically ill patients in order to avoid hypoxia. However, in recent years, studies have shown that hyperoxia may be harmful in critical care patients. The aim of the study was to investigate whether hyperoxia within the first 24 hours of admission following major trauma is associated with 30-day in-hospital mortality. Patients and methods: We conducted a retrospective database study of trauma patients admitted to the general intensive care unit at University Hospital Southampton from October 2008 to October 2014. Hyperoxia was defined as one arterial blood gas with a pO2 ≥40.0 kPa during the first 24 hours of admission. Cox proportional hazards regression was used to compare 30-day in-hospital mortality between the two groups. HRs for death were calculated with 95% CIs and presented as both unadjusted and adjusted for age, sex, Acute Physiology and Chronic Health Evaluation II (APACHE II) score and number of arterial blood gases. Results: In total, 1,462 patients had trauma as the cause for admission. Of these, 343 patients met the study inclusion criteria, of which 265 were defined as normoxic and the remaining 78 patients as hyperoxic. The cumulative in-hospital risk of death within 30 days was 7.8% (95% CI: 4.9%–12.5%) for the normoxia group and 9.7% (95% CI: 4.4 %–20.4%) for the hyperoxia group. The crude HR for 30-day in-hospital mortality was 1.15 (95% CI: 0.45–2.90) for hyperoxia compared to normoxia. Adjusting for APACHE II, age, sex and number of arterial blood gases yielded an adjusted HR of 30-day in-hospital mortality of 0.65 (95% CI: 0.24–1.73) for the hyperoxia group compared to the normoxia group. Conclusion: In our convenience sample of 343 patients, hyperoxia within the first 24 hours following admission to intensive care with major trauma had no impact on 30-day in-hospital mortality. Keywords: oxygen, APACHE, arterial blood gas, in-hospital mortality

The pain of venous cannulation and arterial puncture can be greatly lessened by local anaesthesia. We sought information about the use of local anaesthesia for these procedures by doctors working in medicine, surgery and anaesthetics. A questionnaire was hand-delivered to 178 doctors in eight hospitals, all of whom responded. For insertion of large-bore cannulae, local anaesthesia was used by all the anaesthetists but less than half the medical and surgical doctors. For arterial blood sampling it was used by 60% of anaesthetists and 2% of ward doctors. Previous recommendations to use local anaesthesia seem to have been ignored, and in many instances these procedures are more painful than necessary. [ABSTRACT FROM AUTHOR]

Objective: This review summarises the current evidence base for combinations of neuroprotective CPR adjuncts (active compression-decompression chest compressions, impedance threshold devices, and head-up positioning) during out-of-hospital cardiac arrest., Methods: A systematic search (PROSPERO registration CRD42023432302) was performed in English on MEDLINE, EMBASE, and the Cochrane Library in August 2023, and repeated in February 2024. All randomised and observational studies (not abstracts) reporting on any combination of the aforementioned CPR adjuncts were included. Papers were screened independently by two researchers, with a third reviewer acting as tiebreaker. Out-of-hospital, non-traumatic, cardiac arrests in patients >18 years were eligible for inclusion. Risk of bias was assessed using the Risk of Bias 2 tool and the Newcastle-Ottawa scale., Results: Eight of 1172 unique articles identified in the initial searches were included, with five randomised controlled trials and three observational studies. No randomised trial investigated a bundle of all three interventions. All randomised controlled trials were at intermediate or high risk of bias. Neurologically favourable survival was greater in patients treated with an impedance threshold device and active compression-decompression CPR when compared to standard CPR (8.9% vs 5.8%, p  = 0.019) in the largest existing randomised trial. Conflicting results were found in observational studies comparing the complete neuroprotective bundle to standard CPR., Conclusions: This review was limited by small study numbers and overlapping samples, which precluded a meta-analysis. Limited data suggests that combinations of adjuncts to improve cerebral perfusion during CPR may improve survival with favourable neurological outcome. A randomised controlled trial is required to establish whether combining all three together results in improved outcomes., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors. Published by Elsevier B.V.)

Background: Early cardiopulmonary resuscitation and defibrillation is key to increasing survival following an out-of-hospital-cardiac-arrest (OHCA). However, automated external defibrillators (AEDs) are used in a very small percentage of cases. Despite large numbers of AEDs in the community, the absence of a unified system for registering their locations across the UK's ambulance services may have resulted in missed opportunities to save lives. Therefore, representatives from the resuscitation community worked alongside ambulance services to develop a single repository for data on the location of AEDs in the UK., Methods: A national defibrillator network, "The Circuit", was developed by the British Heart Foundation in collaboration with the Association of Ambulance Chief Executives, the UK ambulance services, the Resuscitation Council UK and St John Ambulance. The database allows individuals or organisations to record information about AED location, accessibility, and availability. The database synchronises with ambulance computer aided dispatch systems to provide UK ambulance services with real-time information on the nearest, available AED., Results: The Circuit was successfully rolled out to all 14 UK ambulance services. Since 2019, 82,108 AEDs have been registered. Of the AED data collected by The Circuit, 54% were not previously registered to any ambulance service, and are therefore new registrations., Conclusion: The Circuit provides ambulance services with a single point of access to AED locations in the UK. Since the launch of the system the number of defibrillators registered has doubled. Linking the Circuit data with patient outcome data will help understand whether improving the accessibility to AEDs is associated with increased survival., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: ‘Authors listed as affiliated to the BHF are employees of the BHF, a registered charity in England and Wales, Scotland and the Isle of Man. The BHF is the main funder of The Circuit and responsible for its administration. The author listed as affiliated to NHS England (NHSE) is a former employee of NHSE. NHSE is a co-funder of The Circuit. Authors listed as affiliated to the Resuscitation Council UK (RCUK) are employees of the Resuscitation Council UK a registered charity in England and Wales. The RCUK is a co-funder of The Circuit. Authors listed as affiliated to St John Ambulance (SJA) are employees of St John Ambulance a registered charity in England. SJA is a co-funder of The Circuit. Simon Dunn, Steve Irving, Sue Hampshire, Michael Bradfield, Charles Deakin, Simon Holmes, Stephanie Leckey, Nick Linker, Greg Lloyd, Julian Mark, Lisa McInnes, Simon Walsh, George Woods, Judy O’Sullivan and Gavin D Perkins are current or former members of The Circuit National Advisory Board. GDP holds research grants from the BHF, Resuscitation Council UK and the Laerdal Foundation, is a Trustee for the Resuscitation Council UK and Editor for Resuscitation and Resuscitation Plus journals.’., (© 2024 The Authors.)

Background: We explored the feasibility of a large-scale UK ambulance services trial of optimal defibrillation shock energy for out-of-hospital cardiac arrest. The primary objective of this feasibility study was to establish the number of eligible patients and the number recruited. Secondary outcomes were adherence to allocated treatment and data completeness., Methods: We conducted a three-arm parallel group cluster randomised controlled feasibility study in a single ambulance service in southern England. Adult patients in out-of-hospital cardiac arrest treated for a shockable rhythm were included. Zoll X series defibrillators (clusters) were randomised to deliver 120-150-200 J, 150-200-200 J, or 200-200-200 J shock strategies., Results: Between March 2022 and February 2023, we randomised 38 eligible patients (120-150-200 J (n = 12), 150-200-200 J (n = 10), 200-200-200 J (n = 16)) to the study. The recruitment rate per cluster was 0.07 per month. The median patient age was 71 years (IQR 59-81 years); 79% were male. Twenty-eight cardiac arrests (74%) occurred in a private residence, 29 (76%) were witnessed and 32 (84%) patients received bystander CPR. Treatment adherence was 93% and completeness of clinical and electrical outcomes was 86%. At 30 days, 3/36 (8.3%) patients survived; we were unable to collect survival outcomes for two patients. Defibrillation data collection became difficult when defibrillators became separated from their allocated vehicles., Conclusion: We have demonstrated the feasibility of a cluster randomised controlled trial of optimal shock energy for defibrillation in a UK ambulance service. We have identified possible solutions to issues relating to trial design., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: HP is a member of the International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support task force committee. She holds a grant from the National Institute for Health and Social Care Research (NIHR)/Health Education England. GDP is Editor for Resuscitation and Resuscitation Plus and holds grants from the NIHR, British Heart Foundation, Resuscitation Council UK (RCUK) and Laerdal. He is an employee of University of Warwick, University Hospital of Coventry and Warwick, University Hospital Birmingham and West Midlands Ambulance Service and holds Leadership roles with ILCOR, the European Resuscitation Council, and RCUK. CDD, RL, DS, CS, FM, CH, JR, KS, MB, IR: Nil., (© 2024 The Author(s).)

Aims: The PARAMEDIC-3 trial evaluates the clinical and cost-effectiveness of an intraosseous first strategy, compared with an intravenous first strategy, for drug administration in adults who have sustained an out-of-hospital cardiac arrest., Methods: PARAMEDIC-3 is a pragmatic, allocation concealed, open-label, multi-centre, superiority randomised controlled trial. It will recruit 15,000 patients across English and Welsh ambulance services. Adults who have sustained an out-of-hospital cardiac arrest are individually randomised to an intraosseous access first strategy or intravenous access first strategy in a 1:1 ratio through an opaque, sealed envelope system. The randomised allocation determines the route used for the first two attempts at vascular access. Participants are initially enrolled under a deferred consent model.The primary clinical-effectiveness outcome is survival at 30-days. Secondary outcomes include return of spontaneous circulation, neurological functional outcome, and health-related quality of life. Participants are followed-up to six-months following cardiac arrest. The primary health economic outcome is incremental cost per quality-adjusted life year gained., Conclusion: The PARAMEDIC-3 trial will provide key information on the clinical and cost-effectiveness of drug route in out-of-hospital cardiac arrest.Trial registration: ISRCTN14223494, registered 16/08/2021, prospectively registered., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: GDP is co-chair of the International Liaison Committee on Resuscitation (ILCOR). CD and JPN are emeritus members of the ILCOR Advanced Life Support task force. KC and HP are current members of the ILCOR Advanced Life Support task force. GDP is editor-in-chief and JPN is founding editor of Resuscitation Plus. KC is associate editor of Resuscitation Plus and guest editor for the research methodology special edition., (© 2023 The Authors.)

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.

Aims: The Prehospital Optimal Shock Energy for Defibrillation (POSED) study will assess the feasibility of conducting a cluster randomised controlled study of clinical effectiveness in UK ambulance services to identify the optimal shock energy for defibrillation., Methods: POSED is a pragmatic, allocation concealed, open label, cluster randomised, controlled feasibility study. Defibrillators within a single UK ambulance service will be randomised in an equal ratio to deliver one of three shock strategies 120-150-200 J, 150-200-200 J, 200-200-200 J. Consecutive adults (≥18 years) presenting with out of hospital cardiac arrest requiring defibrillation will be eligible. The study plans to enrol 90 patients (30 in each group). Patients (or their relatives for non-survivors) will be informed about trial participation after the initial emergency has resolved. Survivors will be invited to consent to participate in follow-up (i.e., at 30 days or discharge).The primary feasibility outcome is the proportion of eligible patients who receive the randomised study intervention. Secondary feasibility outcomes will include recruitment rate, adherence to allocated treatment and data completeness. Clinical outcomes will include Return of an Organised Rhythm (ROOR) at 2 minutes post-shock, refibrillation rate, Return of Spontaneous Circulation (ROSC) at hospital handover, survival and neurological outcome at 30 days ., Conclusion: The POSED study will assess the feasibility of a large-scale trial and explore opportunities to optimise the trial protocol. Trial registration: ISRCTN16327029., Competing Interests: HP reports research funding from National Institute for Health and Care Research. CDD, RL, FM, AC, MAS, PK, AD, DES report no conflicts of interest. GDP reports research funding from National Institute for Health and Care Research, British Heart Foundation and Resuscitation Council UK. He has volunteer roles with Resuscitation Council UK, European Resuscitation Council and the International Liaison Committee on Resuscitation. He is an editor for the journals Resuscitation and Resuscitation Plus., (© 2022 The Author(s).)

Aim: To determine the optimal first-shock energy level for biphasic defibrillation and whether fixed or escalating protocols for subsequent shocks are most effective., Methods: We searched Medline, Embase, Cochrane CENTRAL, CINAHL, the Web of Science and national and international trial registry databases for papers published from database inception to January 2022. We reviewed reference lists of key papers to identify additional references. The population included adults sustaining non traumatic out-of-hospital cardiac arrest subject to attempted defibrillation. Studies of internal or monophasic defibrillation and studies other than randomised controlled trials or prospective cohorts were excluded. Two reviewers assessed study relevance. Data extraction and risk of bias assessment, using the ROBINS-I tool, were conducted by one reviewer and checked by a second reviewer. Data underwent intention-to-treat analysis., Results: We identified no studies evaluating first shock energy. Only one study ( n  = 738) comparing fixed versus escalating energy met eligibility criteria: a prospective cohort analysis of a randomised controlled trial of manual versus mechanical CPR. High fixed (360 J) energy was compared with an escalating (200-200/300-360 J) strategy. Researchers found 27.5% (70/255) of patients in the escalating energy group and 27.61% (132/478) in the fixed high energy group survived to hospital discharge (unadjusted risk ratio 0.99, 95% CI 0.73, 1.23). Results were of very low certainty as the study was at serious risk of bias., Conclusion: This systematic review did not identify an optimal first-shock energy for biphasic defibrillation. We identified no survival advantage at 30 days when comparing 360 J fixed with 200 J escalating strategy., (© 2022 The Author(s).)

Out-of-hospital cardiac arrest is a global public health issue experienced by ≈3.8 million people annually. Only 8% to 12% survive to hospital discharge. Early defibrillation of shockable rhythms is associated with improved survival, but ensuring timely access to defibrillators has been a significant challenge. To date, the development of public-access defibrillation programs, involving the deployment of automated external defibrillators into the public space, has been the main strategy to address this challenge. Public-access defibrillator programs have been associated with improved outcomes for out-of-hospital cardiac arrest; however, the devices are used in <3% of episodes of out-of-hospital cardiac arrest. This scientific statement was commissioned by the International Liaison Committee on Resuscitation with 3 objectives: (1) identify known barriers to public-access defibrillator use and early defibrillation, (2) discuss established and novel strategies to address those barriers, and (3) identify high-priority knowledge gaps for future research to address. The writing group undertook systematic searches of the literature to inform this statement. Innovative strategies were identified that relate to enhanced public outreach, behavior change approaches, optimization of static public-access defibrillator deployment and housing, evolved automated external defibrillator technology and functionality, improved integration of public-access defibrillation with existing emergency dispatch protocols, and exploration of novel automated external defibrillator delivery vectors. We provide evidence- and consensus-based policy suggestions to enhance public-access defibrillation and guidance for future research in this area.

The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

Background: Pain is a common symptom among patients presenting to ambulance services and is often associated with traumatic injury. Assessment and management of pain in children in the pre-hospital setting is suboptimal. This study aimed to understand the facilitators and barriers experienced by paramedics in their assessment and management of pain in children who have sustained traumatic injuries., Methods: Face-to-face, audio-recorded semi-structured interviews using a piloted topic guide were conducted with paramedics employed by South Central Ambulance Service NHS Foundation Trust. Interviews were professionally transcribed, coded manually and analysed using thematic analysis., Results: Eleven interviews were conducted; three themes related to assessment and three related to management were identified. Previous positive experiences of utilising pain scoring tools were identified as a facilitator to pain assessment, whereas a lack of confidence in using pain scoring tools was a barrier. Patients' understanding of and compliance with the tools were both a facilitator and a barrier to assessment. Facilitators to management included personal sub-themes of colleagues/others, exposure, being a parent, technology, severity of the injury and subjective pain scoring. Organisational facilitators included medicines, routes, and alternative methods. Situational facilitators included patient-specific solutions and parents. Five personal barriers to management included medicines, skill, consequences to self or patient, negative interactions, and limited exposure. Three organisational barriers included medicines and routes, equipment issues and choices, and training and culture. Within the theme of situation, two sub-themes emerged: patient-specific issues and environment-specific issues. Novel facilitators to emerge were those of alternative methods and being a parent., Conclusion: A multitude of factors incorporating situational, organisational, and personal all combine to determine how paramedics treat paediatric trauma patients. A multi-stakeholder approach to providing clearer assessment tools, improved education, equipment, and pharmacy options may improve assessment and management compliance for the benefit of the patient., Competing Interests: All authors work for the Trust in question. The lead researcher was known to several of the participants., (© 2021 The Author(s).)

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for 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.

Objectives: To construct a highly detailed yet practical, attainable roadmap for enhancing the likelihood of neurologically intact survival following sudden cardiac arrest., Design Setting and Patients: Population-based outcomes following out-of-hospital cardiac arrest were collated for 10 U.S. counties in Alaska, California, Florida, Ohio, Minnesota, Utah, and Washington. The 10 identified emergency medical services systems were those that had recently reported significant improvements in neurologically intact survival after introducing a more comprehensive approach involving citizens, hospitals, and evolving strategies for incorporating technology-based, highly choreographed care and training. Detailed inventories of in-common elements were collated from the ten 9-1-1 agencies and assimilated. For reference, combined averaged outcomes for out-of-hospital cardiac arrest occurring January 1, 2017, to February 28, 2018, were compared with concurrent U.S. outcomes reported by the well-established Cardiac Arrest Registry to Enhance Survival., Interventions: Most commonly, interventions and components from the ten 9-1-1 systems consistently included extensive public cardiopulmonary resuscitation training, 9-1-1 system-connected smart phone applications, expedited dispatcher procedures, cardiopulmonary resuscitation quality monitoring, mechanical cardiopulmonary resuscitation, devices for enhancing negative intrathoracic pressure regulation, extracorporeal membrane oxygenation protocols, body temperature management procedures, rapid cardiac angiography, and intensive involvement of medical directors, operational and quality assurance officers, and training staff., Measurements and Main Results: Compared with Cardiac Arrest Registry to Enhance Survival ( n = 78,704), the cohorts from the 10 emergency medical services agencies examined ( n = 2,911) demonstrated significantly increased likelihoods of return of spontaneous circulation (mean 37.4% vs 31.5%; p < 0.001) and neurologically favorable hospital discharge, particularly after witnessed collapses involving bystander cardiopulmonary resuscitation and shockable cardiac rhythms (mean 10.7% vs 8.4%; p < 0.001; and 41.6% vs 29.2%; p < 0.001, respectively)., Conclusions: The likelihood of neurologically favorable survival following out-of-hospital cardiac arrest can improve substantially in communities that conscientiously and meticulously introduce a well-sequenced, highly choreographed, system-wide portfolio of both traditional and nonconventional approaches to training, technologies, and physiologic management. The commonalities found in the analyzed systems create a compelling case that other communities can also improve out-of-hospital cardiac arrest outcomes significantly by conscientiously exploring and adopting similar bundles of system organization and care., Competing Interests: Dr. Lurie who is a coinventor of multiple CPR devices and founder of Advanced CPR Solutions LLC, that develops novel resuscitation technologies. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Background: The 'Prehospital Assessment of the Role of Adrenaline: Measuring the Effectiveness of Drug Administration In Cardiac Arrest' (PARAMEDIC2) trial showed that adrenaline improves overall survival, but not neurological outcomes. We sought to determine the within-trial and lifetime health and social care costs and benefits associated with adrenaline, including secondary benefits from organ donation., Methods: We estimated the costs, benefits (quality-adjusted life years (QALYs)) and incremental cost-effectiveness ratios (ICERs) associated with adrenaline during the 6-month trial follow-up. Model-based analyses explored how results altered when the time horizon was extended beyond 6 months and the scope extended to include recipients of donated organs., Results: The within-trial (6 months) and lifetime horizon economic evaluations focussed on the trial population produced ICERs of £1,693,003 (€1,946,953) and £81,070 (€93,231) per QALY gained in 2017 prices, respectively, reflecting significantly higher mean costs and only marginally higher mean QALYs in the adrenaline group. The probability that adrenaline is cost-effective was less than 1% across a range of cost-effectiveness thresholds. Combined direct economic effects over the lifetimes of survivors and indirect economic effects in organ recipients produced an ICER of £16,086 (€18,499) per QALY gained for adrenaline with the probability that adrenaline is cost-effective increasing to 90% at a £30,000 (€34,500) per QALY cost-effectiveness threshold., Conclusions: Adrenaline was not cost-effective when only directly related costs and consequences are considered. However, incorporating the indirect economic effects associated with transplanted organs substantially alters cost-effectiveness, suggesting decision-makers should consider the complexity of direct and indirect economic impacts of adrenaline., Trial Registration: ISRCTN73485024 . Registered on 13 March 2014.

Background: Some resuscitation services advocate or teach routine manual defibrillator charging prior to a rhythm check during cardiopulmonary resuscitation., Objectives: We aimed to review the evidence for anticipatory defibrillator charging compared with charging after a shockable rhythm is confirmed., Methods: This scoping review was performed according to a specific methodological framework and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. Grey literature was also reviewed using similar methodology and included in the results., Results: There are no randomized clinical trials studying anticipatory manual defibrillator charging. The limited available data does not address critical or important patient outcomes such as defibrillation success, return of spontaneous circulation, survival to hospital discharge or neurological outcomes. Evidence primarily from manikin studies and the grey literature suggests that anticipatory charging is feasible, safe, and can reduce the total pause duration during the period of chest compression between rhythm checks, but can increase the pre-shock pause and total peri-shock pause duration., Conclusions: Anticipatory manual defibrillator charging appears to be feasible in the clinical setting, although its impact on clinical outcomes is uncertain. Future studies of anticipatory charging should focus on clinical outcomes., Competing Interests: QO None declared. SM None declared. CD Defibrillation domain lead, ILCOR. Trustee, RCUK. PM Chair of Australian Resuscitation Council. JS Chair of ILCOR ALS Task Force. Chair of the European Resuscitation Council ALS Science Committee. Executive committee, RCUK., (© 2020 The Author(s).)

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence to Decision Framework Highlights sections. The task forces also listed priority knowledge gaps for further research.

Introduction: Out-of-hospital cardiac arrest trials can prove challenging and there is a need to share learning from those that have recruited successfully. We have just completed three years of recruitment to PARAMEDIC2, a placebo-controlled trial of adrenaline in out-of-hospital cardiac arrest. This study was designed to describe the experience of operational ambulance staff involved in recruiting patients into PARAMEDIC2., Methods: Four focus groups involving trial paramedics and supporting members of the emergency care team were conducted across different geographical regions of a single UK ambulance service participating in the PARAMEDIC2 study. Data analysis was supported by NVivo 12 and themes were identified using a thematic analysis approach., Results: Forty-four participants contributed to the focus groups. Four overarching themes were identified: context for the research , ethical concerns , concerns at the patient's side and ongoing trial support . Participants felt that research such as PARAMEDIC2 is important and necessary to drive medical progress. They valued the opportunity to be part of a large project. Due to the deferred consent model employed, public awareness of the trial was felt to be important. Most expressed equipoise regarding adrenaline, but some felt concerned about enrolling younger patients and there was discussion around what constitutes a successful outcome. Struggles with ethical concerns were overcome through training and one-to-one discussion with research paramedics. Participants valued feedback on their performance of trial tasks, but also wanted feedback on their resuscitation skills. Cardiac arrest places a high cognitive demand on paramedics; simplicity and reinforcement of trial processes were key to facilitating recruitment. Caring for relatives was a high priority for paramedics and some felt conflicted about not discussing the trial with them., Conclusion: This study has provided insights into paramedic experience of a large-scale pre-hospital trial. Investment in time and resource to provide face-to-face training and personalised feedback to paramedics can foster engagement and optimise performance., (© 2019 The Author(s).)

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the second annual summary of International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations that includes the most recent cardiopulmonary resuscitation science reviewed by the International Liaison Committee on Resuscitation. This summary addresses the role of antiarrhythmic drugs in adults and children and includes the Advanced Life Support Task Force and Pediatric Task Force consensus statements, which summarize the most recent published evidence and an assessment of the quality of the evidence based on Grading of Recommendations, Assessment, Development, and Evaluation criteria. The statements include consensus treatment recommendations approved by members of the relevant task forces. Insights into the deliberations of each task force are provided in the Values and Preferences and Task Force Insights sections. Finally, the task force members have listed the top knowledge gaps for further research.

Objectives: There is considerable interest in reducing the cost of clinical trials. Linkage of trial data to administrative datasets and disease-specific registries may improve trial efficiency, but it has not been reported in resuscitation trials conducted in the UK. To assess the feasibility of using national administrative and clinical datasets to follow up patients transported to hospital following attempted resuscitation in a cluster randomised trial of a mechanical chest compression device in out-of-hospital cardiac arrest., Methods: Hospital data on trial participants were requested from Hospital Episode Statistics (HES), the Intensive Care National Audit and Research Centre, and Myocardial Ischaemia National Audit Project and National Audit of Percutaneous Coronary Interventions, using unique patient identifiers. Linked data were received between June 2014 and June 2015., Results: Of 4471 patients randomised in the pre-hospital randomised assessment of a mechanical compression device in cardiac arrest (PARAMEDIC) trial, 2398 (53.6%) were not known to be deceased at emergency department arrival and were eligible for linkage. We achieved an overall match rate of 86.7% in the combined HES accident and emergency, inpatient and critical care dataset, with variable match rates (4.2%-80.4%) in individual datasets. Patient demographics, cardiac arrest-related characteristics and major outcomes were predominantly similar between HES matched and unmatched groups, in the linkage apart from location, response time and return of spontaneous circulation (ROSC) at handover., Conclusions: This study shows that it is feasible to track patients from the prehospital setting through to hospital admission using routinely available administrative datasets with a moderate to high degree of success. This approach has the potential to complement the trial data with the demographic and clinical management information about the studied cohort, as well as to improve the efficiency and reduce the costs of follow-up in cardiac arrest trials., Clinical Trial Registration: ISRCTN08233942; Post-results., Competing Interests: Competing interests: GDP, RL, TQ, CDD and SG report grants from NIHR HTA Programme during the conduct of the study. The other authors declare no competing interests., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY. Published by BMJ.)

Background: Several different defibrillators are currently used for cardioversion and defibrillation of cardiac arrhythmias. The efficacy of a novel pulsed biphasic (PB) waveform has not been compared to other biphasic waveforms. Accordingly, this study aims to compare the efficacy and safety of PB shocks with biphasic truncated exponential (BTE) shocks in patients undergoing cardioversion of atrial fibrillation or -flutter., Methods and Results: This prospective, randomized study included patients admitted for elective direct current cardioversion. Patients were randomized to receive cardioversion using either PB or BTE shocks. We used escalating shocks until sinus rhythm was obtained or to a maximum of 4 shocks. Patients randomized to PB shocks received 90, 120, 150, and 200 J and patients randomized to BTE shocks received 100, 150, 200, and 250 J, as recommended by the manufacturers. In total, 69 patients (51%) received PB shocks and 65 patients (49%) BTE shocks. Successful cardioversion, defined as sinus rhythm 4 hours after cardioversion, was achieved in 43 patients (62%) using PB shocks and in 56 patients (86%) using BTE shocks; ratio 1.4 (95% CI 1.1-1.7) ( P =0.002). There was no difference in safety (ie, myocardial injury judged by changes in high-sensitive troponin I levels; ratio 1.1) (95% CI 1.0-1.3), P =0.15. The study was terminated prematurely because of an adverse event., Conclusions: Cardioversion using a BTE waveform was more effective when compared with a PB waveform. There was no difference in safety between the 2 waveforms, as judged by changes in troponin I levels., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02317029., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: Mechanical chest compression devices may help to maintain high-quality cardiopulmonary resuscitation (CPR), but little evidence exists for their effectiveness. We evaluated whether or not the introduction of Lund University Cardiopulmonary Assistance System-2 (LUCAS-2; Jolife AB, Lund, Sweden) mechanical CPR into front-line emergency response vehicles would improve survival from out-of-hospital cardiac arrest (OHCA)., Objective: Evaluation of the LUCAS-2 device as a routine ambulance service treatment for OHCA., Design: Pragmatic, cluster randomised trial including adults with non-traumatic OHCA. Ambulance dispatch staff and those collecting the primary outcome were blind to treatment allocation. Blinding of the ambulance staff who delivered the interventions and reported initial response to treatment was not possible. We also conducted a health economic evaluation and a systematic review of all trials of out-of-hospital mechanical chest compression., Setting: Four UK ambulance services (West Midlands, North East England, Wales and South Central), comprising 91 urban and semiurban ambulance stations. Clusters were ambulance service vehicles, which were randomly assigned (approximately 1 : 2) to the LUCAS-2 device or manual CPR., Participants: Patients were included if they were in cardiac arrest in the out-of-hospital environment. Exclusions were patients with cardiac arrest as a result of trauma, with known or clinically apparent pregnancy, or aged < 18 years., Interventions: Patients received LUCAS-2 mechanical chest compression or manual chest compressions according to the first trial vehicle to arrive on scene., Main Outcome Measures: Survival at 30 days following cardiac arrest; survival without significant neurological impairment [Cerebral Performance Category (CPC) score of 1 or 2]., Results: We enrolled 4471 eligible patients (1652 assigned to the LUCAS-2 device and 2819 assigned to control) between 15 April 2010 and 10 June 2013. A total of 985 (60%) patients in the LUCAS-2 group received mechanical chest compression and 11 (< 1%) patients in the control group received LUCAS-2. In the intention-to-treat analysis, 30-day survival was similar in the LUCAS-2 (104/1652, 6.3%) and manual CPR groups [193/2819, 6.8%; adjusted odds ratio (OR) 0.86, 95% confidence interval (CI) 0.64 to 1.15]. Survival with a CPC score of 1 or 2 may have been worse in the LUCAS-2 group (adjusted OR 0.72, 95% CI 0.52 to 0.99). No serious adverse events were noted. The systematic review found no evidence of a survival advantage if mechanical chest compression was used. The health economic analysis showed that LUCAS-2 was dominated by manual chest compression., Limitations: There was substantial non-compliance in the LUCAS-2 arm. For 272 out of 1652 patients (16.5%), mechanical chest compression was not used for reasons that would not occur in clinical practice. We addressed this issue by using complier average causal effect analyses. We attempted to measure CPR quality during the resuscitation attempts of trial participants, but were unable to do so., Conclusions: There was no evidence of improvement in 30-day survival with LUCAS-2 compared with manual compressions. Our systematic review of recent randomised trials did not suggest that survival or survival without significant disability may be improved by the use of mechanical chest compression., Future Work: The use of mechanical chest compression for in-hospital cardiac arrest, and in specific circumstances (e.g. transport), has not yet been evaluated., Triai Registration: Current Controlled Trials ISRCTN08233942., Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 21, No. 11. See the NIHR Journals Library website for further project information.

Utstein-style guidelines contribute to improved public health internationally by providing a structured framework with which to compare emergency medical services systems. Advances in resuscitation science, new insights into important predictors of outcome from out-of-hospital cardiac arrest, and lessons learned from methodological research prompted this review and update of the 2004 Utstein guidelines. Representatives of the International Liaison Committee on Resuscitation developed an updated Utstein reporting framework iteratively by meeting face to face, by teleconference, and by Web survey during 2012 through 2014. Herein are recommendations for reporting out-of-hospital cardiac arrest. Data elements were grouped by system factors, dispatch/recognition, patient variables, resuscitation/postresuscitation processes, and outcomes. Elements were classified as core or supplemental using a modified Delphi process primarily based on respondents' assessment of the evidence-based importance of capturing those elements, tempered by the challenges to collect them. New or modified elements reflected consensus on the need to account for emergency medical services system factors, increasing availability of automated external defibrillators, data collection processes, epidemiology trends, increasing use of dispatcher-assisted cardiopulmonary resuscitation, emerging field treatments, postresuscitation care, prognostication tools, and trends in organ recovery. A standard reporting template is recommended to promote standardized reporting. This template facilitates reporting of the bystander-witnessed, shockable rhythm as a measure of emergency medical services system efficacy and all emergency medical services system-treated arrests as a measure of system effectiveness. Several additional important subgroups are identified that enable an estimate of the specific contribution of rhythm and bystander actions that are key determinants of outcome., (© 2014 by the American Heart Association, Inc., and European Resuscitation Council.)

Objective: In the last few years the genetic influence on health and disease outcome has become more apparent. The ACE genotype appears to play a significant role in the pathophysiology of several disease processes. This pilot study aims at showing the feasibility to examine the genetic influence of the ACE genotype on return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA)., Methods: We performed a prospective observational study of all OHCAs of presumed cardiac origin in a well-defined population. We collected prehospital blood samples for the determination of ACE genotype and used this information together with Utstein template parameters in a multivariable analysis to examine the relationship between ROSC and ACE genotype., Results: We collect blood samples in 156 of 361 patients with OHCA of presumed cardiac origin, 127 samples were analysed (mean age 67 years, 86% male, 79% witnessed OHCA, 80% bystander CPR, 62% had a shockable rhythm, ROSC 77%). Distribution of the ACE gene polymorphisms: insertion polymorphism (II) n=22, 17%, insertion/deletion polymorphism (ID) n=66, 52% and deletion polymorphism (DD) n=39, 31%. We found no significant association between ACE II vs ACE DD/DI and ROSC (OR 1.72; CI 0.52 to 5.73; p=0.38). Other ACE genotype groupings (II/ID vs DD or II vs DD) did not change the overall finding of lack of impact of ACE genotype on ROSC., Conclusions: This pilot study did not indicate a significant association between ACE gene polymorphism and ROSC. However, it has demonstrated that prehospital genetic studies including blood sampling are feasible and ethically acceptable.

Prehospital cervical spine (c-spine) immobilisation is common, despite c-spine injury being relatively rare. Unnecessary immobilisation results in a significant burden on limited prehospital and emergency department (ED) resources. This study aimed to determine whether the incidence of unnecessary c-spine immobilisation by ambulance personnel could be safely reduced through the implementation of an evidence-based algorithm. Following a training programme, complete forms on 103 patients were identified during the audit period, of which 69 (67%) patients had their c-spines cleared at scene. Of these, 60 (87%) were discharged at scene, with no clinical adverse events reported, and 9 (13%) were taken to the local ED with non-distracting minor injuries, all being discharged home the same day. 34 (33%) patients could not have their c-spines safely cleared at scene according to the algorithm. Of these, 4 (12%) patients self-discharged at scene and 30 (88%) were conveyed to an ED as per the normal procedure. C-spine clearance at scene by ambulance personnel may have positive impacts on patient care, efficient use of resources and cost to healthcare organisations.

Background: Prompt ambulance attendance is aimed at improving patient care. With finite resources struggling to meet performance targets, unforeseen demand precludes the ability to tailor resources to cope with increased call volumes, and can have a marked detrimental effect on performance and hence patient care. The effects of the 2006 World Cup football matches on call volumes and profiles were analysed to understand how public events can influence demands on the ambulance service., Methods: All emergency calls to the Hampshire Ambulance Service NHS Trust (currently the Hampshire Division of South Central Ambulance Service, Winchester, UK) during the first weekend of the 2006 World Cup football matches were analysed by call volume and classification of call (call type)., Results: On the day of the first football match, call volume was over 50% higher than that on a typical Saturday, with distinct peaks before and after the inaugural match. Call profile analysis showed increases in alcohol-related emergencies, including collapse, unconsciousness, assault and road traffic accidents. The increase in assaults was particularly marked at the end of each match and increased again into the late evening., Conclusion: A detailed mapping of call volumes and profiles during the World Cup football shows a significant increase in overall emergency calls, mostly alcohol related. Mapping of limited resources to these patterns will allow improved responses to emergency calls.

Introduction: The National Service Framework for Coronary Heart Disease requires identification of patients with an acute coronary syndrome (ACS) to enable prompt identification of those who may subsequently require pre-hospital thrombolysis. The Advanced Medical Priority Dispatch System (AMPDS) with Department of Health (DH) call prioritisation is now the common triage tool for emergency ('999') calls in the UK. We retrospectively examined patients with ACS to identify whether this triage tool had been able to allocate an appropriate emergency response., Methods: All emergency calls to Hampshire Ambulance Service NHS Trust (HAST) from the Southampton area over an 8 month period (January to August 2004) were analysed. The classification allocated to the patient by AMPDS (version 10.4) was specifically identified. Data from the Myocardial Infarct National Audit Project) were obtained from the receiving hospital in Southampton to identify the actual number of patients with a true ACS., Results: In total, 42 657 emergency calls were made to HAST from the Southampton area. Of these, 263 patients were subsequently diagnosed in hospital as having an ACS. Of these 263 patients, 76 presented without chest pain. Sensitivity of AMPDS for detecting ACS in this sample was 71.1% and specificity 92.5%. Positive predictive value was 5.6% (95% confidence interval 4.8 to 6.4%), and 12.5% (33/263) of patients with confirmed ACS were classified as non-life threatening (category B) incidents., Conclusion: Only one of approximately every 18 patients with chest pain has an ACS. AMPDS with DH call prioritisation is not a tool designed for clinical diagnosis, and its extension into this field does not enable accurate identification of patients with ACS.

Background: The transfusion of allogeneic red blood cells and allogeneic coagulation products is associated with risk to the patient and the depletion of an increasingly scarce resource. This prospective, randomized, double-blind, placebo-controlled trial investigated practices to avoid transfusion in patients undergoing first-time cardiac surgery., Methods: Patients were randomized to one of three treatment groups: an aprotinin group, a tranexamic acid group, and a control group receiving normal saline. Intra-operative cell salvage was used for all patients. The primary outcomes were the number of patients exposed to allogeneic red blood cells, allogeneic coagulation products or any allogeneic transfusion (allogeneic red blood cells and/or allogeneic coagulation products)., Results: Patients were 2.5 times more likely to receive any allogeneic transfusion in the tranexamic group than in the aprotinin group (21 patients out of 60 compared with nine out of 60, respectively). The relative risk of any allogeneic transfusion comparing aprotinin with tranexamic acid was 0.43 (95% confidence interval 0.21-0.86; P=0.019). Patients in the control group were four times more likely to receive any allogeneic transfusion when compared with the aprotinin group (37 patients out of 60 compared with nine out of 60, respectively). The relative risk of any allogeneic transfusion comparing aprotinin with control was 0.24 (95% confidence interval 0.13-0.46; P<0.001)., Conclusions: When used in addition to intra-operative cell salvage, aprotinin is the most efficacious pharmacological therapy for reducing patient exposure to any allogeneic transfusion during first-time cardiac surgery.

Objectives: The recent introduction of a disposable laryngeal mask airway has provided paramedics with an alternative to endotracheal intubation. Time taken to secure the airway with each device was compared in patients undergoing elective surgery., Methods: Patients undergoing general anaesthesia were studied. Paramedics trained in laryngeal mask use and endotracheal intubation participated in the study. A Portex disposable laryngeal mask was inserted and removed, followed by a Portex endotracheal tube. Time taken from beginning of the procedure to ventilation of the patient was recorded., Results: Laryngeal mask insertion and endotracheal intubation was attempted on 52 patients. Median age was 63.5 years (range 39-83). Laryngeal mask insertion was successful in 88.5% (46 of 52) patients; endotracheal intubation was successful in 71.2% (37 of 52) patients (after no more than two attempts), p = 0.049. Intubation success was related to laryngoscopic view (87.5% grade 1, 56.3% grade 2, 0.0% grade 3. p<0.0001). When laryngeal mask/endotracheal tube insertion were both successful (n = 35 of 52), there was no significant difference in median time to secure the airway (laryngeal mask 47.0 seconds (range 24-126) compared with endotracheal tube 52.0 seconds (range 27-148) p = 0.22). Laryngeal mask insertion was successful in 80.0% (12 of 15) patients in whom endotracheal intubation had failed., Conclusions: Even under optimal conditions, 30% of attempts at intubation by paramedics were unsuccessful. A disposable laryngeal mask has a higher success rate in securing the airway and overall, secures the airway more reliably than endotracheal intubation.

Objectives: Most emergency department (ED) intubations are to prevent gastric contents aspiration. The incidence of aspiration is unknown and intubation has complications. Balancing these risks requires an idea of the incidence of aspiration. This study assessed one technique for investigating the aspiration risk in ED patients. Cricoid pressure is used to reduce this risk and the technique may also examine this manoeuvre., Methods: Cohorts of unconscious adult ED and elective surgical patients were recruited. The posterior pharyngeal wall pH was measured immediately before and after intubation. Pharyngeal pH was used to indicate risk of aspiration, and pH change to assess the efficacy of cricoid pressure., Results: Eight ED and 48 control patients were recruited. In the ED cohort, pH ranged from 6.0 to 8.0 before intubation and 4.7 to 8.0 after intubation: a mean decrease of 0.3 (95% CI 1.5 decrease to 0.9 increase). In the control cohort pH ranged from 5.8 to 8.0 before intubation and 6.0 to 8.0 after intubation: a mean increase of 0.4 (95% CI 0.1 to 0.6 increase)., Conclusions: This is a simple, cheap, and repeatable technique for assessing aspiration risk in emergency intubations. A larger study is required to assess the efficacy of cricoid pressure.