Abstract 249: Neurocardiac Triage: A Classification Scheme to Guide Post Resuscitation Cardiac Arrest Care

BackgroundEpinephrine increases the chances of return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA), especially when the initial rhythm is non-shockable. However, this drug could also worsen the post-resuscitation syndrome (PRS). We assessed the association between epinephrine use during cardiopulmonary resuscitation (CPR) and subsequent intensive care unit (ICU) mortality in patients with ROSC after non-shockable OHCA.MethodsWe used data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (capturing OHCA data located in the Greater Paris area, France) between May 2011 and December 2021. All adults with ROSC after medical, cardiac and non-cardiac causes, non-shockable OHCA admitted to an ICU were included. The mode of death in the ICU was categorized as cardiocirculatory, neurological, or other.ResultsOf the 2,792 patients analyzed, there were 242 (8.7%) survivors at hospital discharge, 1,004 (35.9%) deaths from cardiocirculatory causes, 1,233 (44.2%) deaths from neurological causes, and 313 (11.2%) deaths from other etiologies. The cardiocirculatory death group received more epinephrine (4.6 ± 3.8 mg versus 1.7 ± 2.8 mg, 3.2 ± 2.6 mg, and 3.5 ± 3.6 mg for survivors, neurological deaths, and other deaths, respectively; p < 0.001). The proportion of cardiocirculatory death increased linearly (R2 = 0.92, p < 0.001) with cumulative epinephrine doses during CPR (17.7% in subjects who did not receive epinephrine and 62.5% in those who received > 10 mg). In multivariable analysis, a cumulative dose of epinephrine was strongly associated with cardiocirculatory death (adjusted odds ratio of 3.45, 95% CI [2.01–5.92] for 1 mg of epinephrine; 12.28, 95% CI [7.52–20.06] for 2–5 mg; and 23.71, 95% CI [11.02–50.97] for > 5 mg; reference 0 mg; population reference: alive at hospital discharge), even after adjustment on duration of resuscitation. The other modes of death (neurological and other causes) were also associated with epinephrine use, but to a lesser extent.ConclusionsIn non-shockable OHCA with ROSC, the dose of epinephrine used during CPR is strongly associated with early cardiocirculatory death. Further clinical studies aimed at limiting the dose of epinephrine during CPR seem warranted. Moreover, strategies for the prevention and management of PRS should take this dose of epinephrine into consideration for future trials.

Funding Acknowledgements Type of funding sources: None. Introduction Out of hospital cardiac arrest (OHCA) carries a high rate of mortality and can be due to cardiac or non-cardiac causes. We reviewed consecutive patients presenting with OHCA to the emergency department of a regional hospital in Australia, between January 2019 and March 2022. Medical records were reviewed to assess presenting rhythm, final diagnosis, risk factors known at time of presentation, results of cardiac investigations and survival to hospital discharge. Results Over the study period, 107 patients presented with cardiac arrest, with an average age of 67 years (range 29 to 95 years). Most patients were male (70, 67%), although in those with a non-cardiac cause identified only 53% were male. An underlying cardiac cause was identified in 50 (47%), a non-cardiac cause was identified in 18 (17%), and 39 (36%) had no identifiable cause. The most common cardiac causes were ST-elevation myocardial infarction (18, 36%), followed by non-ischaemic cardiomyopathy (9, 18%) and scar-related arrhythmia (7, 14%). Overall, ischaemic heart disease was responsible for 31 (62%) cases. Coronary angiography was performed in 36 (72%) of cardiac cases. Those who were diagnosed with ST-elevation myocardial infarction had an average time from presentation to coronary angiography of 61 minutes while the average was 38 hours for all patients presenting with OHCA. The most common presenting rhythm was ventricular fibrillation (39, 38%). The overall mortality rate was 61% for all OHCA. Among those with a cardiac cause, a non-cardiac cause or no cause identified for the OHCA, the mortality rates were 32%, 87% and 87% respectively. Data published by the regional Ambulance Service show that the survival to discharge from hospital of 39% in our regional hospital is comparable with state-wide outcomes. Discussion These data reflect the significant mortality and wide spectrum of disease underlying OHCA, and thus the challenge of managing patients presenting with OHCA. Cardiac disease accounts for almost half of all cases of OHCA, and also encompasses a wide spectrum of disease. However, the mortality in patients with OHCA due to an underlying cardiac cause, while still significant, is better than those patients in whom no cardiac cause is identified.

Syncope is a common clinical presentation in emergency departments (ED), often posing significant diagnostic challenges due to its broad differential and the potential for life-threatening underlying causes. Accurate risk stratification is essential to differentiate patients requiring urgent intervention from those who can be safely discharged. The San Francisco syncope rule (SFSR) was developed to aid clinicians in identifying patients at risk of short-term serious outcomes. Despite its widespread adoption, evidence regarding its reliability and predictive accuracy remains mixed. External validation studies have reported variable sensitivity and specificity, with some highlighting its failure to detect neurologic or subtle cardiac causes of syncope. Comparative analysis with other stratification tools such as the OESIL score, ROSE rule, and EGSYS score reveals key differences in design and clinical utility. Each model offers unique strengths but also exhibits important limitations when applied across heterogeneous patient populations. Inconsistent definitions of serious outcomes and variable study methodologies have contributed to difficulty in standardizing syncope assessment across settings. Additionally, neurologic causes are frequently underrepresented in many tools, reducing their diagnostic reach. Biomarkers and imaging have been proposed as adjuncts but are limited by access, cost, and timing. Recent interest has turned to machine learning models capable of integrating broader clinical variables to generate personalized risk profiles. Although early results are encouraging, such approaches require rigorous external validation before widespread clinical use. Overall, existing models offer useful guidance but are not definitive. Risk stratification in syncope should remain a dynamic process informed by evidence-based tools, clinician experience, and ongoing research into more adaptable, data-rich strategies capable of addressing the complexity of syncope presentations in modern emergency care.

The absence of the pupillary light reflex (PLR) 3days after cardiac arrest predicts poor outcome, but quantitative PLR assessment with pupillometry early after recovery of spontaneous circulation (ROSC) and throughout targeted temperature management (TTM) has rarely been evaluated. Fifty-five adult patients treated with TTM with available pupillometry data from the NeurOptics NPi-200 were studied. Discharge outcome was classified good if the cerebral performance category score was 1-2, poor if 3-5. Pupil size, PLR percent constriction (%PLR), and constriction velocity (CV) were determined at TTM start and 6 (± 2)-h post-ROSC ("early"), and throughout TTM using data from the worst eye at each assessment. The Neurological Pupil index (NPi) was also determined at each pupil assessment; the NPi is scored from 0 (nonreactive) to 5 (brisk) with values < 3 considered sluggish or abnormal. Prognostic performance to predict poor outcome was assessed with receiver operator characteristic curves. All nine patients with ≥ 1 nonreactive pupil (NPi = 0) within 6 (± 2) h after ROSC died, and 12/14 (86%) with sluggish pupils (0 < NPi < 3) had poor outcomes. 15/29 (52%) patients with normal pupil reactivity (NPi ≥ 3) had poor outcomes, four survived with cerebral performance category = 3, three died of cardiac causes, and eight died of neurologic causes. During TTM, 20/21 (95%) patients with nonreactive pupils had poor outcomes, 9/14 (64%) of patients with sluggish pupils had poor outcomes, and 9/20 (45%) with normal pupil reactivity had poor outcomes. Pupil size did not predict outcome, but NPi (AUC = 0.72 [0.59-0.86], p < 0.001), %PLR (AUC = 0.75 [0.62-0.88], p < 0.001) and CV (AUC = 0.78 [0.66-0.91], p < 0.001) at 6h predicted poor outcome. When nonreactive pupils were first detected, 75% were < 5mm. Very early after resuscitation from cardiac arrest, abnormal Neurological Pupil index and pupillary light reflex measurements by pupillometer are predictive of poor outcome, and are not usually associated with dilated pupils.

There is a significant association between cardiac dysfunction and ischemic stroke. The serious cardiac adverse events (SCAEs) after decompressive craniectomy for malignant cerebral infarction from ischemic stroke were studied retrospectively. Retrospective data were collected for preexisting cardiac risk factors, baseline clinical measures, and perioperative SCAEs including life-threatening arrhythmias, myocardial ischemia, cardiac failure, and cardiac arrest. The association between perioperative SCAEs and mortality was assessed using the χ(2) test. Data from 42 patients were analyzed. Mortality occurred in 19 (45.2%) patients. Eleven (57.9% of deaths) suffered mortality because of neurological causes, 7 patients (36.8% of mortality) because of cardiac causes, and 1 because of other causes. Mortality in patients who developed SCAEs was significantly higher than in those without SCAEs [75% mortality with SCAEs vs. 18.2% without SCAEs (P<0.0001)]. The odds ratio for mortality with SCAEs was 13.5 (3.1 to 59.5). There was a significant correlation between the number of SCAEs and mortality (Spearmans ρ=0.738 (P<0.0001). Serious cardiac events are common in the acute period after stroke and decompressive craniectomy, and are important contributors to mortality.

Predicting a pulse: Can monitoring heart rate and end-tidal carbon dioxide minimize compression pauses and impact outcomes in out-of-hospital cardiac arrest?

Timing of brain computed tomography and accuracy of outcome prediction after cardiac arrest

Comment on: “Usefulness of cerebral rSO2 monitoring during CPR to predict the probability of return of spontaneous circulation”

EDITORIAL article Front. Physiol., 25 November 2013Sec. Cardiac Electrophysiology Volume 4 - 2013 | https://doi.org/10.3389/fphys.2013.00339

Risk Factors for Cardiac Causes of Death in Males with Duchenne Muscular Dystrophy

Characteristics of intracranial hemorrhage and acute aortic syndromes resuscitated with ECPR

INTRODUCTION: Octogenarians comprise an increasing proportion of patients undergoing coronary angiography and percutaneous coronary interventional (PCI). Most interventional studies have focused on patients aged 50-65 years and as such there is paucity of scientific evidence regarding interventions in octogenarians. While there have been some improvements in intervention techniques with more octogenarians undergoing PCI safely, many physicians are still reluctant to recommend invasive treatment for this group. We sought to compare the clinical outcomes in the treatment options (PCI vs medical therapy) among octogenarians requiring urgent cardiac catheterization (CC). METHODS: This was a single center retrospective study of 1184 consecutive patients requiring urgent CC. Urgent CC was defined as catheterization within 24 hours of the admission symptom onset. Patients were categorized according to either PCI group (PCIG) versus medical treatment group (MTG) after coronary angiography. Patients were then followed for cardiovascular and all cause mortality as well as cardiovascular and all cause readmissions at 30 days and 1 year from the index event. RESULTS: There were 1184 patients that met inclusion criteria. Thirty five percent (416) underwent PCI and 65% (768) had medical treatment. Mean age was 84+/-3 for PCIG versus 83 +/- 3 for the medical group. (p=NS), 53% (220) of PCIG were male versus 51% (391) MTG (p =NS), 86% (358) of PCIG had HTN versus 87% (668) MTG. Hyperlipidemia was present in 79% (328) of PCIG vs 77% (591) of MTG. Ninety seven percent(403) of the PCIG presented with chest pain versus 94%(722) in the MTG (p=NS) Length of stay for both groups was 3+/-2 days (p=NS). Thirty-day mortality for PCIG was 3% (12) vs. 2 % (23) in the MTG (p=NS). One year mortality in the PCIG was 5 % (21) vs. 3% (23) in the MTG (p=NS) Thirty day all cause readmission for the PCIG was 8% (33) vs. 9% (69) in the MTG (p=NS) .One year all cause readmission for the PCIG was 18% (75) vs. 16% (122) for the MTG (p=NS). Thirty day cardiovascular readmission for the PCIG was 8% (33) vs. 10%(77) (p=NS) in the MTG. One year cardiovascular readmission for PCIG was 18% (75) vs. 21% (161) in the MTG (p=NS). Readmissions at one year for revascularization for both (PCI and coronary artery bypass graft surgery) was 13% (54) in the PCIG vs. 12%(92) in the MTG (p=NS). CONCLUSION: Percutanous intervention in octogenarians presenting for urgent cardiac catherterization had similar short and intermediate term outcomes when compared to those undergoing medical management.

Part 12.1: Cardiac Arrest Associated With AsthmaAsthma 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. 1Annually 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. 3This 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

Ethnic disparities in out-of-hospital cardiac arrest: A population-based cohort study among adult Danish immigrants.

We studied the effects of diabetes on ventricular repolarization parameters and sudden cardiac death in patients with dilated cardiomyopathy (DCM). We enrolled 132 consecutive patients in New York Heart Association (NYHA) heart failure functional classes II or III and left ventricular ejection fraction <40% without evidence of coronary artery disease. In 45 patients (34%), diabetes was diagnosed according to standard criteria (study group), and the remaining 87 (66%) had no diabetes (controls). All patients underwent a 5-minute high-resolution electrocardiogram recording for determination of QT variability (QTV) index and were followed for 1 year thereafter. At baseline, the two groups did not differ in age, gender, left ventricular ejection fraction, NYHA functional class, or plasma brain natriuretic peptide levels. Similarly, QTV index did not differ between the study group (-0.51 +/- 0.55) and controls (-0.48 +/- 0.51; P = 0.48). During follow-up, 18 patients (14%) died of cardiac causes. Of the 18 deaths, eight were attributed to heart failure, and 10 to sudden cardiac death. Mortality was higher in the study group (10/45, 20%) than in controls (8/87, 10%) (P = 0.03). The same was true of the heart failure mortality (6/45 [13%] vs 2/87 [2%], P = 0.01), but not of the sudden cardiac death rate (3/45 [7%] vs 7/87 [8%], P = 0.78). By multiple variable analyses, diabetes predicted total and heart failure mortality, and a high QTV predicted sudden cardiac death. Diabetes appears to increase the risk of heart failure in patients with DCM without affecting ventricular repolarization parameters and sudden cardiac death risk.