Resuscitation
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Out of hospital cardiac arrest (OHCA) results in a significant mortality and neurological disability in survivors. The application of mild therapeutic hypothermia (MTH) to patients who have suffered an OHCA with a ventricular rhythm results in a significant reduction in mortality and neurological disability in survivors. The optimal timing of this intervention has not been clearly established; however there is emerging evidence to suggest that maximal benefit is gained from initiation at the earliest time point. Despite this, recent surveys have shown a considerable delay in initiating MTH, with variable uptake in emergency departments (EDs), where a number of impediments to delivery have been identified. ⋯ ED staff need to be aware that the use of ice-cold fluids is an inexpensive, readily available and easy to perform method of inducing MTH in patients who suffer an out-of hospital cardiac arrest with a ventricular rhythm. We therefore suggest that ice-cold crystalloid is routinely stocked in emergency departments and, unless contraindicated, is used to induce MTH. Optimal post-resuscitation care also includes timely treatment of the cause of the OHCA and maintenance of MTH. Staff education and care bundles may help to facilitate optimal inter-departmental management of the patient.
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Comparative Study
Circulating cell-free DNA levels correlate with postresuscitation survival rates in out-of-hospital cardiac arrest patients.
Early prediction of prognosis is helpful in cardiac arrest patients. Plasma cell-free DNA, which increases rapidly after cell death, is a novel biomarker for the prognosis of critical ill patients. Changes in the plasma cell-free DNA level and its role for the early prognosis of cardiac arrest patients remain unclear. ⋯ The optimal cutoff value of plasma cell-free DNA for predicting survival-to-discharge was 1,170 g.e./mL by ROC curve analysis (area under curve 0.752, p=0.010). A plasma cell-free DNA level higher than 1,170 g.e./mL and was an independent predictor for in-hospital mortality by multiple logistic regression analysis (adjusted odds ratio of 12.35, p=0.023) and was also associated with higher 90 day mortality (p=0.021 by log-rank test). In conclusion, the plasma cell-free DNA level increases during the early post-cardiac arrest phase and can be an early prognostic factor for OHCA patients.
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Comparative Study
The effectiveness of ERC advanced life support (ALS) provider courses for the retention of ALS knowledge.
Out-of-hospital emergency physicians in Austria need mandatory emergency physician training, followed by biennial refresher courses. Currently, both standardized ERC advanced life support (ALS) provider courses and conventional refresher courses are offered. This study aimed to compare the retention of ALS-knowledge of out-of-hospital emergency physicians depending on whether they had or had not participated in an ERC-ALS provider course since 2005. ⋯ Out-of-hospital emergency physicians that had attended an ERC-ALS provider course since 2005 had a higher retention of ALS knowledge compared to non-ERC-ALS course participants.
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Comparative Study
Relationship between blood, nasopharyngeal and urinary bladder temperature during intravascular cooling for therapeutic hypothermia after cardiac arrest.
Therapeutic hypothermia improves survival and neurological outcome in patients successfully resuscitated after cardiac arrest. Accurate temperature control during cooling is essential to prevent cooling-related side effects. ⋯ In 12 post-cardiac arrest patients undergoing intravascular cooling, both nasopharyngeal and urinary bladder temperature measurements were similar to blood temperatures measured using a pulmonary artery catheter.
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Standard hospital CPR policies in many countries require CPR to be attempted on all patients having a cardiac arrest unless a Not-for-CPR order is in place. It has recently been shown that this approach is legally inappropriate in New Zealand. It appears that this argument may also potentially apply in other common law countries given the role that 'best interests' has in these jurisdictions in providing treatment to patients lacking decision-making capacity. ⋯ However, advanced planning is not always possible and it is legally inappropriate to require CPR to be performed when it is not in the patient's best interests. Notwithstanding the difficult practical balance that exists at the time of arrest between initiating CPR without delay or interruption for it to be effective for those whom CPR is in their best interests, and recognising as quickly as possible those patients for who CPR is not appropriate, it is argued that policies should be modified to allow clinicians to consider whether CPR is appropriate at time of arrest. Such a change may require ALS training to include a stronger emphasis on early recognition of patients for whom CPR is not in their best interests.