Elevated gamma glutamyl transferase levels are associated with the location of acute pulmonary embolism. Cross-sectional evaluation in hospital setting

ABSTRACT CONTEXT AND OBJECTIVE: The location of embolism is associated with clinical findings and disease severity in cases of acute pulmonary embolism. The level of gamma-glutamyl transferase increases under oxidative stress-related conditions. In this study, we investigated whether gamma-glutamyl transferase levels could predict the location of pulmonary embolism. DESIGN AND SETTING: Hospital-based cross-sectional study at Cumhuriyet University, Sivas, Turkey. METHODS : 120 patients who were diagnosed with acute pulmonary embolism through computed tomography-assisted pulmonary angiography were evaluated. They were divided into two main groups (proximally and distally located), and subsequently into subgroups according to thrombus localization as follows: first group (thrombus in main pulmonary artery; n = 9); second group (thrombus in main pulmonary artery branches; n = 71); third group (thrombus in pulmonary artery segmental branches; n = 34); and fourth group (thrombus in pulmonary artery subsegmental branches; n = 8). RESULTS : Gamma-glutamyl transferase levels on admission, heart rate, oxygen saturation, right ventricular dilatation/hypokinesia, pulmonary artery systolic pressure and cardiopulmonary resuscitation requirement showed prognostic significance in univariate analysis. The multivariate logistic regression model showed that gamma-glutamyl transferase level on admission (odds ratio, OR = 1.044; 95% confidence interval, CI: 1.011-1.079; P = 0.009) and pulmonary artery systolic pressure (OR = 1.063; 95% CI: 1.005-1.124; P = 0.033) remained independently associated with proximally localized thrombus in pulmonary artery. CONCLUSIONS : The findings revealed a significant association between increased existing embolism load in the pulmonary artery and increased serum gamma-glutamyl transferase levels.


Abstract
In the treatment of sudden cardiac arrest (SCA) immediate resuscitation with chest compressions and ventilation is crucial for survival.As manual resuscitation is associated with several drawbacks, mechanical resuscitation devices have been developed to support resuscitation teams.These devices are able to achieve better perfusion of heart and brain in laboratory settings, but real world experience showed no significant improved survival in comparison to manual resuscitation.This review will focus on two mechanical resuscitation devices, the Lund University Cardiac Assist System (LUCAS) and AutoPulse devices and the actual literature available.In conclusion, the general use of mechanical resuscitation devices cannot be recommended at the moment.This study aims to describe and compare traumatic and medical out-of-hospital cardiac arrest (OHCA) occurring in Perth, Western Australia, between 1997 and 2014.

METHODS:
The St John Ambulance Western Australia (SJA-WA) OHCA Database was used to identify all adult (≥16 years) cases.We calculated annual crude and age-sex standardised incidence rates (ASIRs) for traumatic and medical OHCA and investigated trends over time.RESULTS: Over the study period, SJA-WA attended 1,354 traumatic OHCA and 16,076 medical OHCA cases.The mean annual crude incidence rate of traumatic OHCA in adults attended by SJA-WA was 6.0 per 100,000 (73.9 per 100,000 for medical cases), with the majority resulting from motor vehicle collisions (56.7%).We noted no change to either incidence or mechanism of injury over the study period (p>0.05).Compared to medical OHCA, traumatic OHCA cases were less likely to receive bystander cardiopulmonary resuscitation (CPR) (20.4% vs. 24.5%,p=0.001) or have resuscitation commenced by paramedics (38.9% vs. 44.8%,p<0.001).However, rates of bystander CPR and resuscitation commenced by paramedics increased significantly over time in traumatic OHCA (p<0.001).In cases where resuscitation was commenced by paramedics there was no difference in the proportion who died at the scene (37.2% traumatic vs. 34.3%medical, p=0.17), however, fewer traumatic OHCAs survived to hospital discharge (1.7% vs. 8.7%, p<0.001).CONCLUSIONS: Despite temporal increases in rates of bystander CPR and paramedic resuscitation, traumatic OHCA survival remains poor with only nine patients surviving from traumatic OHCA over the 18-year period.
Nishiyama T1, Nishiyama A2, Negishi M2, Kashimura S1, Katsumata Y1, Kimura T1, Nishiyama N1, Tanimoto Y1, Aizawa Y1, Mitamura H3, Fukuda K1, Takatsuki S1. Abstract BACKGROUND: Although automated external defibrillators (AEDs) have contributed to a better survival of outof-hospital cardiac arrests, there have been reports of their malfunctioning.We investigated the diagnostic accuracy of commercially available AEDs using surface ECGs of ventricular fibrillation (VF), ventricular tachycardia (VT), and supraventricular tachycardia (SVT).METHODS AND RESULTS: ECGs (VF 31,VT 48,SVT 97) were stored during electrophysiological studies and transmitted to 4 AEDs, the LifePak CR Plus (CR Plus), HeartStart FR3 (FR3), and CardioLife AED-2150 (CL2150) and -9231 (CL9231), through the pad electrode cables.For VF, the CL2150 and CL9231 advised shocks in all cases, and the CR Plus and FR3 advised shocks in all but one VF case.For VTs faster than 180 bpm, the ratios for advising shocks were 79%, 36%, 89%, and 96% for the CR Plus, FR3, CL2150, and CL9231, respectively.The FR3 and CR Plus did not advise shocks for narrow QRS SVTs, whereas the CL9231 tended to treat high-rate tachycardias faster than 180 bpm even with narrow QRS complexes.The characteristics of the shock advice for the FR3 differed from that for the CL9231 (kappa coefficient [κ]=0.479,P<0.001), and the CR Plus and CL2150 had characteristics somewhere between the 2 former AEDs (κ=0.818,P<0.001).CONCLUSIONS: Commercially available AEDs diagnosed VF almost always correctly.For VT and SVT diagnoses, a discrepancy was evident among the 4 investigated AEDs.The differences in the arrhythmia diagnosis algorithms for differentiating SVT from VT were thought to account for these differences.Perman SM1, Grossestreuer AV2, Wiebe DJ2, Carr BG2, Abella BS2, Gaieski DF2.Abstract BACKGROUND: Therapeutic hypothermia (TH) attenuates reperfusion injury in comatose survivors of cardiac arrest.The utility of TH in patients with nonshockable initial rhythms has not been widely accepted.We sought to determine whether TH improved neurological outcome and survival in postarrest patients with nonshockable rhythms.

METHODS AND RESULTS:
We identified 519 patients after in-and out-of-hospital cardiac arrest with nonshockable initial rhythms from the Penn Alliance for Therapeutic Hypothermia (PATH) registry between 2000 and 2013.Propensity score matching was used.Patient and arrest characteristics used to estimate the propensity to receive TH were age, sex, location of arrest, witnessed arrest, and duration of arrest.To determine the association between TH and outcomes, we created 2 multivariable logistic models controlling for confounders.Of 201 propensity score-matched pairs, mean age was 63±17 years, 51% were male, and 60% had an initial rhythm of pulseless electric activity.Survival to hospital discharge was greater in patients who received TH (17.6% versus 28.9%; P<0.01), as was a discharge Cerebral Performance Category of 1 to 2 (13.7% versus 21.4%; P=0.04).In adjusted analyses, patients who received TH were more likely to survive (odds ratio, 2.8; 95% confidence interval, 1.6-4.7)and to have better neurological outcome (odds ratio, 3.5; 95% confidence interval, 1.8-6.6)than those that did not receive TH. CONCLUSIONS: Using propensity score matching, we found that patients with nonshockable initial rhythms treated with TH had better survival and neurological outcome at hospital discharge than those who did not receive TH.Our findings further support the use of TH in patients with initial nonshockable arrest rhythms.
2. Medicine (Baltimore).2015 Nov;94(47):e2152.doi: 10.1097/MD.0000000000002152.Therapeutic Hypothermia and the Risk of Hemorrhage: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.Wang CH1, Chen NC, Tsai MS, Yu PH, Wang AY, Chang WT, Huang CH, Chen WJ. Abstract Current guidelines recommend a period of moderate therapeutic hypothermia (TH) for comatose patients after cardiac arrest to improve clinical outcomes.However, in-vitro studies have reported platelet dysfunction, thrombocytopenia, and coagulopathy, results that might discourage clinicians from applying TH in clinical practice.We aimed to quantify the risks of hemorrhage observed in clinical studies.Medline and Embase were searched from inception to October 2015.Randomized controlled trials (RCTs) comparing patients undergoing TH with controls were selected, irrespective of the indications for TH.There were no restrictions for language, population, or publication year.Data on study characteristics, which included patients, details of intervention, and outcome measures, were extracted.Forty-three trials that included 7528 patients were identified from 2692 potentially relevant references.Any hemorrhage was designated as the primary outcome and was reported in 28 studies.The pooled results showed no significant increase in hemorrhage risk associated with TH (risk difference [RD] 0.005; 95% confidence interval [CI] -0.001-0.011;I, 0%).Among secondary outcomes, patients undergoing TH were found to have increased risk of thrombocytopenia (RD 0.109; 95% CI 0.038-0.179;I 57.3%) and transfusion requirements (RD 0.021; 95% CI 0.003-0.040;I 0%).The meta-regression analysis indicated that prolonged duration of cooling may be associated with increased risk of hemorrhage.TH was not associated with increased risk of hemorrhage despite the increased risk of thrombocytopenia and transfusion requirements.Clinicians should cautiously assess each patient's risk-benefit profile before applying TH.
3. BMC Health Serv Res.2015 Dec 2;15(1):533.doi: 10.1186/s12913-015-1199-z. Prehospital transportation to therapeutic hypothermia centers and survival from out-ofhospital cardiac arrest.DeLia D1, Wang HE2, Kutzin J3, Merlin M4, Nova J5, Lloyd K6, Cantor JC7.Abstract BACKGROUND: Clinical trials supporting the use of therapeutic hypothermia (TH) in the treatment of out-ofhospital cardiac arrest (OHCA) are based on small patient samples and do not reflect the wide variation in patient selection, cooling methods, and other elements of post-arrest care that are used in everyday practice.This study provides a real world evaluation of the effectiveness of post-arrest care in TH centers during a time of growing TH dissemination in the state of New Jersey (NJ).METHODS: Using a linked database of prehospital, hospital, and mortality records for NJ in 2009-2010, we compared rates of neurologically intact survival at discharge and at 30 days for OHCA patients transported to TH centers (N = 2363) versus other hospitals (N = 2479).We used logistic regression to adjust for patient and hospital covariates.To account for potential endogeneity in prehospital transportation decisions, we used an instrumental variable (IV) based on differential distance to the nearest TH and non-TH hospitals.RESULTS: Patients taken to TH centers were older, more likely to have a witnessed arrest, more likely to receive defibrillation, and waited a shorter amount of time for initial EMS response.Also, TH hospitals were larger, more likely to be teaching facilities, and operated in a service area with a relatively lower poverty rate compared to hospitals statewide.A Stock-Yogo test confirmed the strength of our IV (F = 2349.91,p < 0.0001).Nevertheless, the data showed no evidence of endogenous transportation to TH centers related to in-hospital survival (Z = -0.08,p = 0.934) or 30-day survival (Z = 0.94, p = 0.349).In logistic regression models, treatment at a TH center was associated with greater odds of 30-day neurologically intact survival (OR = 1.70; 95 % CI: 1.19 -2.42) but not associated with the odds of neurologically intact survival to hospital discharge (OR = 0.90; 95 % CI: 0.61 -1.31).

CONCLUSIONS:
Post-arrest outcomes are more favorable at TH centers but these improved outcomes are not apparent until after hospital discharge.This finding may reflect superior care by TH centers in later stages of post-arrest treatment such as care provided in the intensive care unit, which has greater potential to affect longer term outcomes than initial treatment in the emergency department.
4. Crit Care.2015 Dec 1;19:417.doi: 10.1186/s13054-015-1133-0.The effect of mild induced hypothermia on outcomes of patients after cardiac arrest: a systematic review and meta-analysis of randomised controlled trials.Zhang XW1, Xie JF2, Chen JX3, Huang YZ4, Guo FM5, Yang Y6, Qiu HB7.Abstract INTRODUCTION: Mild induced hypothermia (MIH) is believed to reduce mortality and neurological impairment after out-of-hospital cardiac arrest.However, a recently published trial demonstrated that hypothermia at 33 °C did not confer a benefit compared with that of 36 °C.Thus, a systematic review and meta-analysis of randomised controlled trials (RCTs) was made to investigate the impact of MIH compared to controls on the outcomes of adult patients after cardiac arrest.METHODS: We searched the following electronic databases: PubMed/MEDLINE, the Cochrane Library, Embase, the Web of Science, and Elsevier Science (inception to December 2014).RCTs that compared MIH with controls with temperature >34 °C in adult patients after cardiac arrest were retrieved.Two investigators independently selected RCTs and completed an assessment of the quality of the studies.Data were analysed by the methods recommended by the Cochrane Collaboration.Random errors were evaluated with trial sequential analysis.RESULTS: Six RCTs, including one abstract, were included.The meta-analysis of included trials revealed that MIH did not significantly decrease the mortality at hospital discharge (risk ratio (RR) = 0.92; 95 % confidence interval (CI), 0.82-1.04;p = 0.17) or at 6 months or 180 days (RR = 0.94; 95 % CI, 0.73-1.21;p = 0.64), but it did reduce the mortality of patients with shockable rhythms at hospital discharge (RR = 0.74; 95 % CI, 0.59-0.92;p = 0.008) and at 6 months or 180 days.However, MIH can improve the outcome of neurological function at hospital discharge (RR = 0.80; 95 % CI, 0.64-0.98;p = 0.04) especially in those patients with shockable rhythm but not at 6 months or 180 days.Moreover, the incidence of complications in the MIH group was significantly higher than that in the control group.Finally, trial sequential analysis indicated lack of firm evidence for a beneficial effect.

CONCLUSION:
The available RCTs suggest that MIH does not appear to improve the mortality of patients with cardiac arrest while it may have a beneficial effect for patients with shockable rhythms.Although MIH may result in some adverse events, it helped lead to better outcomes regarding neurological function at hospital discharge.Large-scale ongoing trials may provide data better applicable to clinical practice.5. Bosn J Basic Med Sci.2015 Nov 12;15(4):60-3.doi: 10.17305/bjbms.2015.565.

Optimization of induction of mild therapeutic hypothermia with cold saline infusion: A laboratory experiment.
Fluher J1, Markota A, Stožer A, Sinkovič A.

Abstract
Cold fluid infusions can be used to induce mild therapeutic hypothermia after cardiac arrest.Fluid temperature higher than 4°C can increase the volume of fluid needed, prolong the induction phase of hypothermia and thus contribute to complications.We performed a laboratory experiment with two objectives.The first objective was to analyze the effect of wrapping fluid bags in ice packs on the increase of fluid temperature with time in bags exposed to ambient conditions.The second objective was to quantify the effect of insulating venous tubing and adjusting flow rate on fluid temperature increase from bag to the level of an intravenous cannula during a simulated infusion.The temperature of fluid in bags wrapped in ice packs was significantly lower compared to controls at all time points during the 120 minutes observation.The temperature increase from the bag to the level of intravenous cannula was significantly lower for insulated tubing at all infusion rates (median temperature differences between bag and intravenous cannula were: 8.9, 4.8, 4.0, and 3.1°C, for noninsulated and 5.9, 3.05, 1.1, and 0.3°C, for insulated tubing, at infusion rates 10, 30, 60, and 100 mL/minute, respectively).The results from this study could potentially be used to decrease the volume of fluid infused when inducing mild hypothermia with an infusion of cold fluids.

METHODS AND RESULTS:
-Consecutive patients <18 years old with CPR events ≥ 10 minutes duration reported to GWTG-R between January 2000 and December 2011 were identified.Hospitals were grouped by teaching status and location.Primary outcome was survival to discharge.Regression modeling was performed conditioning on hospital groups.A secondary analysis was performed using propensity-score matching.Of 3,756 evaluable patients, 591 (16%) received E-CPR and 3,165 (84%) received C-CPR only.Survival to hospital discharge and survival with favorable neurologic outcome (Pediatric Cerebral Performance Category score of 1-3 or unchanged from admission) were greater for E-CPR [40% (237/591) and 27% (133/496)] versus C-CPR patients [27% (862/3,165) and 18% (512/2,840)].Odds ratios for survival to hospital discharge and survival with favorable neurologic outcome were greater for E-CPR versus C-CPR.After adjusting for covariates, patients receiving E-CPR had higher odds of survival to discharge [OR 2.80, 95% CI 2.13-3.69,p <0.001] and survival with favorable neurologic outcome [OR 2.64, 95% CI 1.91-3.64,p < 0.001] than patient who received C-CPR.This association persisted when analyzed by propensity-score matched cohorts [OR 1.70, 95% CI 1.33-2.18,p < 0.001 and OR 1.78, 95% CI 1.31-2.41,p < 0.001 respectively].CONCLUSIONS: -For children with in-hospital CPR ≥ 10 minutes duration, E-CPR was associated with improved survival to hospital discharge and survival with favorable neurologic outcome when compared to C-CPR.We evaluated the decrease in chest compression depth during 30 : 2 compression-toventilation ratio one-handed chest compression (OHCC) in an out-of-hospital pediatric arrest setting, and whether switching hands every other cycle could maintain compression depth.

RESULTS:
Current evidence is derived from mathematical models, manikin and animal studies, and small case series.No randomised clinical trials examining neonatal CC have been performed.There is no evidence to refute a CC to ventilation (C:V) ratio of 3:1.Raising the intrathoracic pressure, for example, by superimposing a sustained inflation on uninterrupted CC, and a CC rate >120/min may be beneficial.The optimal neonatal CC depth is unknown, but factors influencing depth and consistency include the C:V ratio.Incomplete chest wall recoil can cause less negative intrathoracic pressure between CC and reduced CPR effectiveness.CC should be performed with the two-thumb method over the lower third of the sternum.The optimal dose, route and timing of adrenaline administration remain to be determined.CONCLUSIONS: Successful CPR requires the delivery of high-quality CC, encompassing optimal (A) C:V ratio (B) rate, (C) depth, (D) chest recoil between CC, (E) technique and (F) adrenaline dosage.More animal studies with high translational value and randomised clinical trials are needed.

Abstract
Postanoxic coma after cardiac arrest is one of the most serious acute cerebral conditions and a frequent cause of admission to critical care units.Given substantial improvement of outcome over the recent years, a reliable and timely assessment of clinical evolution and prognosis is essential in this context, but may be challenging.In addition to the classic neurologic examination, EEG is increasingly emerging as an important tool to assess cerebral functions noninvasively.Although targeted temperature management and related sedation may delay clinical assessment, EEG provides accurate prognostic information in the early phase of coma.Here, the most frequently encountered EEG patterns in postanoxic coma are summarized and their relations with outcome prediction are discussed.This article also addresses the influence of targeted temperature management on brain signals and the implication of the evolution of EEG patterns over time.Finally, the article ends with a view of the future prospects for EEG in postanoxic management and prognostication.
2. Eur Heart J Acute Cardiovasc Care.2015 Nov 30.pii: 2048872615620904.[Epub ahead of print] Progress in the chain of survival and its impact on outcomes of patients admitted to a specialized high-volume cardiac arrest center during the past two decades.Sulzgruber P1, Sterz F2, Schober A1, Uray T1, Van Tulder R1, Hubner P1, Wallmüller C1, El-Tattan D1, Graf N1, Ruzicka G1, Schriefl C1, Zajicek A3, Buchinger A3, Koller L4, Laggner AN1, Spiel A1. Abstract AIM: Cardiac arrest (CA) is still associated with high mortality and morbidity.Data on the changes in management and outcomes over a long period of time are limited.Using data from a single emergency department (ED), we assessed changes over two decades.METHODS: In this single-center observational study, we prospectively included 4133 patients receiving cardiopulmonary resuscitation and being admitted to the ED of a tertiary care hospital between January 1992 and December 2012.RESULTS: There was a significant improvement in both 6-month survival rates (+10.8%;p < 0.001) and favorable neurological outcome (+4.7%; p < 0.001).While the number of witnessed CA cases decreased (-4.7%; p < 0.001) the proportion of patients receiving bystander basic life support increased (+8.3%; p < 0.001).The proportion of patients with initially shockable ECG rhythms remained unchanged, but cardiovascular causes of CA decreased (-9.6%; p < 0.001).Interestingly, the time from CA until ED admission increased (+0.1 hours; p = 0.024).The use of percutaneous coronary intervention and therapeutic hypothermia were significantly associated with survival.CONCLUSIONS: Outcomes of patients with CA treated at a specialized ED have improved significantly within the last 20 years.Improvements in every link in the chain of survival were noted.ECOGRAFIA 1. Semin Intervent Radiol.2015 Dec;32(4):384-387.Endovascular Management of Acute Pulmonary Embolism Using the Ultrasound-Enhanced EkoSonic System.Garcia MJ1.Abstract Acute, symptomatic pulmonary embolism (PE) in the massive and submassive categories continues to be a healthcare concern with significant risk for increased morbidity and mortality.Despite increased awareness and venous thromboembolism prophylaxis, endovascular treatment is still an important option for many of these patients.There are a variety of techniques and devices used for treating PE, but none have been evaluated as extensively as the EkoSonic endovascular system that is also currently the only FDA-approved device for the treatment of pulmonary embolism.This article describes the use of the EkoSonic device for this patient population.

CASE REPORTS
1. Korean J Anesthesiol.2015 Dec;68(6):617-621.Epub 2015 Nov 25.Management of cardiac arrest in a parturient with Eisenmenger's syndrome and complete atrioventricular block during Cesarean section: a case report.Kim GS1, Yang M1, Chang CH1, Lee EK1, Choi JY1.Abstract A 26-year-old parturient with Eisenmenger's syndrome and complete atrioventricular block was presented for emergency Cesarean section due to preterm labor.Ventricular tachycardia (VT), which progressed to ventricular fibrillation (VF), started immediately after the incision.Cardiopulmonary resuscitation with electric shocks was given by anesthesiologists while the obstetrician delivered the baby between the shocks.A cardiac surgeon was ready for extracorporeal membrane oxygenation institution in case of emergency but spontaneous circulation of the patient returned after the 3rd shock and the delivery of the baby.The newborn's Apgar score was 4 at 1 minute and 8 at 5 minutes.An implantable cardioverterdefibrillator was inserted before the discharge because the patient had recurrent episodes of VT and VF postoperatively.

Abstract
We report a case of severe fulminant myocarditis that closely mimicked acute inferior STsegment elevation myocardial infarction (STEMI) and presented with refractory cardiogenic shock, multiple life-threatening arrhythmias and rapidly progressive liver failure.This case was successfully differentiated from STEMI by emergency coronary angiography.Recurrent cardiogenic shock was reversed by intra-aortic balloon pumping (IABP).Life-threatening arrhythmias including ventricular tachycardia, ventricular fibrillation, and high-degree atrioventricular block (AVB) were terminated by immediate cardioversion and temporary pacemaker.High-dose hydrocortisone effectively attenuated the inflammatory injury to the myocardium.The patient recovered and was well at the follow-up visit four months after discharge.

REGISTRES I REVISIONS
Les conclusions d'aquest semblen òbvies.To review all episodes where an emergency code was called in a cancer-specialized hospital in Pakistan and to assess survival to discharge among patients who received a cardiopulmonary resuscitation (CPR).

METHODS:
We reviewed demographic and clinical data related to all "code blue" calls over 3 years.Multivariate logistic regression analyses were used to test the association of clinical characteristics with the primary outcome of survival to discharge.RESULTS: A total of 646 code blue calls were included in the analysis.The CPR was performed in 388 (60%) of these calls.For every 20 episodes of CPR among patients with cancer of all ages, only 1 resulted in a patient's survival to discharge, even though in 52.2% episodes there was a return of spontaneous circulation.No association was found between the type of rhythm at initiation of CPR and likelihood of survival to discharge.

CONCLUSIONS:
The proportion of patients with advanced cancer surviving to discharge after in-hospital CPR in a low-income country was in line with the reported international experience.Most patients with cancer who received in-hospital CPR did not survive to discharge and did not appear to benefit from resuscitation.Advance directives by patients with cancer limiting aggressive interventions at end of life and proper documentation of these directives will help in provision of care that is humane and consonant with patients' wishes for a dignified death.Patients' early appreciation of the limited benefits of CPR in advanced cancer is likely to help them formulate such advance directives.

CONCLUSIONS:
In this experimental study, only ∼30% of manual chest compressions were performed correctly compared to ∼90% of mechanical chest compressions, regardless of the underlying surface.Backboard use did not influence the mean compression depth during manual CPR.Chest compressions were deeper with mechanical CPR.The mean hands-off time was shorter with manual CPR.Abstract STUDY OBJECTIVE: Mechanical chest compression devices have been developed to facilitate continuous delivery of high-quality cardiopulmonary resuscitation (CPR).Despite promising hemodynamic data, evidence on clinical outcomes remains inconclusive.With the completion of 3 randomized controlled trials, we conduct a meta-analysis on the effect of in-field mechanical versus manual CPR on clinical outcomes after out-of-hospital cardiac arrest.METHODS: With a systematic search (PubMed, Web of Science, EMBASE, and the Cochrane Libraries), we identified all eligible studies (randomized controlled trials and nonrandomized studies) that compared a CPR strategy including an automated mechanical chest compression device with a strategy of manual CPR only.Outcome variables were survival to hospital admission, survival to discharge, and favorable neurologic outcome.RESULTS: Twenty studies (n=21,363) were analyzed: 5 randomized controlled trials and 15 nonrandomized studies, pooled separately.For survival to admission, the pooled estimate of the randomized controlled trials did not indicate a difference (odds ratio 0.94; 95% confidence interval 0.84 to 1.05; P=.24) between mechanical and manual CPR.In contrast, meta-analysis of nonrandomized studies demonstrated a benefit in favor of mechanical CPR (odds ratio 1.42; 95% confidence interval 1.21 to 1.67; P<.001).No interaction was found between the endorsed CPR guidelines (2000 versus 2005) and the CPR strategy (P=.27).Survival to discharge and neurologic outcome did not differ between strategies.CONCLUSION: Although there are lower-quality, observational data that suggest that mechanical CPR used at the rescuer's discretion could improve survival to hospital admission, the cumulative highquality randomized evidence does not support a routine strategy of mechanical CPR to improve survival or neurologic outcome.These findings are irrespective of the endorsed CPR guidelines during the study periods.

BACKGROUND:
Out-of-hospital cardiac arrest is a leading cause of mortality and serious neurological morbidity in Europe.We aim to investigate the effect of 3 cardiopulmonary resuscitation (CPR) feedback devices on effectiveness of chest compression during CPR.METHODS: This was prospective, randomized, crossover, controlled trial.Following a brief didactic session, 140 volunteer nurses with feedback CPR devices attempted chest compression on a manikin using 3 CPR feedback devices (TrueCPR, CPR-Ezy, and iCPR) and standard basic life support (BLS) without feedback.RESULTS: Comparison of standard BLS, TrueCPR, CPR-Ezy, and iCPR showed differences in the effectiveness of chest compression (compressions with correct pressure point, correct depth, and sufficient decompression), which are, respectively, 37.5%, 85.6%, 39.5%, and 33.4%; compression depth (44.6 vs 54.5 vs 45.6 vs 39.6 mm); and compression rate (129.4vs 110.2 vs 101.5 vs 103.5 min-1).CONCLUSIONS: During the simulated resuscitation scenario, only TrueCPR significantly affected the increased effectiveness compression compared with standard BLS, CPR-Ezy, and iCPR.Further studies are required to confirm the results in clinical practice.Reducing pauses during cardiopulmonary resuscitation (CPR) compressions result in better outcomes in cardiac arrest.Artefact filtering technology (AFT) gives rescuers the opportunity to visualize the underlying electrocardiogram (ECG) rhythm during chest compressions, and reduces the pauses that occur before and after delivering a shock.We conducted a simulation study to measure the reduction of peri-shock pause and impact on chest compression fraction (CCF) through AFT.METHODS: In a simulator setting, participants were given a standardized cardiac arrest scenario and were randomly assigned to perform CPR/defibrillation using the protocol from one of three experimental arms: 1) Standard of Care (pauses for rhythm analysis and shock delivery); 2) AFT (no pauses for rhythm analysis, but a pause for defibrillation); or 3) AFT with hands-on defibrillation (no pauses for rhythm analysis or defibrillation).The primary outcomes were CCF and peri-shock pause duration, with secondary outcomes of pre-and post-shock pause duration.RESULTS: AFT with hands-on defibrillation was found to have the highest CCF (86.4%), as compared to AFT alone (83.8%, p<0.001), and both groups significantly improved CCF in comparison with the Standard of Care (76.7%,p<0.001).AFT with hands-on defibrillation was associated with a reduced peri-shock pause (2.6 seconds) as compared to AFT alone (5.3 seconds, p<0.001), and the Standard of Care (7.4seconds, p<0.001).

CONCLUSIONS:
In this cardiac arrest model, AFT results in a greater CCF by reducing peri-shock pause duration.There is also a small but detectable improvement in CCF with the addition of handson defibrillation.Nielsen AK1, Jeppesen AN2, Kirkegaard H2, Hvas AM3.Abstract AIM: Therapeutic hypothermia improves neurological outcome in patients resuscitated after out-ofhospital cardiac arrest.The aim was to investigate whether therapeutic hypothermia induced impaired coagulation.METHODS: Changes in coagulation were investigated in 22 out-of-hospital cardiac arrest patients treated with therapeutic hypothermia (33±1°C).Blood samples were obtained after 22±2hours of hypothermia and compared with normothermic samples drawn 48hours later.The coagulation was evaluated with thromboelastometry (ROTEM®) using a sensitive low-tissue-factor assay.Leukocytes, haemoglobin, haematocrit, platelet count, activated partial thromboplastin time (aPTT), thrombin time, international normalised ratio (INR) and fibrinogen were also measured.Clinical information including use of anti thrombotic drugs was systematically collected.RESULTS: No significant changes were found in clotting time (p=0.21),clot formation time (p=0.26),time to maximum velocity (p=0.52) or maximum velocity (p= 0.17) when results obtained at hypothermia were compared with results obtained at normothermia.Maximum clot firmness (p<0.01) and fibrinogen levels (p <0.01) were significantly higher in patients at normothermia.However, the fibrinogen levels were within the reference interval for all patients at both hypothermia and normothermia.Values of aPTT, thrombin time and INR at hypothermia and normothermia were not significantly different.CONCLUSIONS: No substantial difference in coagulation was found in hypothermia compared with normothermia in out-of-hospital cardiac arrest patients.The results indicate that treatment with hypothermia does not impair coagulation.The aim of this study was to assess whether there was a significant difference in the complications of cardiopulmonary resuscitation (CPR) between out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) survivors using multidetector computed tomography (MDCT).

SUBJECTS AND METHODS:
We performed a retrospective analysis of prospective registry data.We enrolled both OHCA and IHCA patients who underwent successful CPR.We classified chest injuries secondary to chest compression into rib fractures, sternum fractures, and uncommon complications such as lung contusions and extrathoracic complications.We compared these complications according to CPR locations.We also analysed risk factors for CPR complications using multiple regression analysis and classification and regression tree analysis.RESULTS: During the study period, a total of 148 patients were included in the primary analysis.Rib fractures were detected more in OHCA survivors than in IHCA survivors (74 patients (83.2%) vs. 37 patients (62.7%), p=0.05), and frequency of multiple rib fractures was higher in OHCA survivors than IHCA survivors (69 patients (77.5%) vs. 34 patients (57.6%), p=0.01).Although other complications were not significantly different between the groups, there was a trend for OHCA survivors to sustain more serious and direct high-energy related complications.Older age, longer CPR, and OHCA were significantly associated with incidence of rib fractures, multiple rib fractures, and number of rib fractures.CONCLUSIONS: Rib fractures were more likely to occur in OHCA survivors, and serious complications tended to occur more often in OHCA compared to IHCA survivors

ESTUDIS EXPERIMENTALS
Alteracions microcirculatòries durant la ressuscitació en el shock hemorràgic.To evaluate changes on microcirculatory parameters during haemorrhagic shock and resuscitation in a paediatric animal model.To determine correlation between microcirculatory parameters and other variables routinely used in the monitoring of haemorrhagic shock.METHODS: Experimental study on 17 Maryland pigs.Thirty minutes after haemorrhagic shock induction by controlled bleed animals were randomly assigned to three treatment groups receiving 0.9% normal saline, 5% albumin with 3% hypertonic saline, or 5% albumin with 3% hypertonic saline plus a bolus of terlipressin.Changes on microcirculation (perfused vessel density (PVD), microvascular blood flow (MFI) and heterogeneity index (HI)) were evaluated and compared with changes on macrocirculation and tisular perfusion parameters.RESULTS: Shock altered microcirculation: PVD decreased from 13.5 to 12.3mmmm-2 (p=0.05),MFI decreased from 2.7 to 1.9 (p<0.001) and HI increased from 0.2 to 0.5 (p<0.001).After treatment, microcirculatory parameters returned to baseline (PVD 13.6mmmm-2 (p<0.05),MFI 2.6 (p<0.001) and HI 0.3 (p<0.05)).Microcirculatory parameters showed moderate correlation with other parameters of tissue perfusion.There were no differences between treatments.CONCLUSIONS: Haemorrhagic shock causes important microcirculatory alterations, which are reversed after treatment.Microcirculation should be assessed during haemorrhagic shock providing additional information to guide resuscitation.Yuan W, Wu JY, Wang GX, Zhang Q, Li CS1.Abstract BACKGROUND: Shen-Fu injection (SFI) can attenuate ischemia-reperfusion injury, protect cardiac function, and improve microcirculation during cardiopulmonary resuscitation.We hypothesized that SFI may also have an influence on myocardial metabolism during ventricular fibrillation (VF).In this study, we used SFI pretreatment prior to VF to discuss the changes of myocardial metabolism and catecholamine (CA) levels during untreated VF, trying to provide new evidence to the protection of SFI to myocardium.METHODS: Twenty-four pigs were divided into three groups: Saline group (SA group), SFI group, and SHAM operation group (SHAM group).Thirty minutes prior to the induction of VF, the SFI group received 0.24 mg/ml SFI through an intravenous injection; the SA group received an equal amount of sodium chloride solution.The interstitial fluid from the left ventricle (LV) wall was collected through the microdialysis tubes during VF.Adenosine diphosphate (ADP), adenosine triphosphate (ATP), and Na + -K + -ATPase and Ca2 + -ATPase enzyme activities were measured after untreated VF.Peak-to-trough VF amplitude and median frequency were analyzed for each of these 5-s intervals.

RESULTS:
The levels of glucose and glutamate were lower after VF in both the SA and SFI groups, compared with baseline, and the levels in the SFI group were higher than those in the SA group.Compared with baseline, the levels of lactate and the lactate/pyruvate ratio increased after VF in both SA and SFI groups, and the levels in the SFI group were lower than those in the SA group.In both the SA and SFI groups, the levels of dopamine, norepinephrine, and epinephrine increased significantly.There were no statistical differences between the two groups.The content of ATP, ADP, and phosphocreatine in the SFI group was higher than those in the SA group.The activity of LV Na + -K + -ATPase was significantly higher in the SFI group than in the SA group.Amplitude mean spectrum area (AMSA) was significantly lower in the SA and SFI groups at 8-and 12-min compared with 4-min.The AMSA in the SFI group was higher than that in the SA group at each time point during untreated VF.CONCLUSIONS: SFI pretreatment can improve myocardial metabolism and reduce energy exhaustion during VF, and it does not aggravate the excessive secretion of endogenous CAs.

review of approaches to optimise chest compressions in the resuscitation of asphyxiated newborns.
Child Fetal Neonatal Ed. 2015 Dec 1. pii: fetalneonatal-2015-309761. doi: 10.1136/archdischild-2015-309761.[Epub ahead of print] A Solevåg AL1, Cheung PY2, O'Reilly M2, Schmölzer GM2.Provision of chest compressions (CCs) and/or medications in the delivery room is associated with poor outcomes.Based on the physiology of perinatal asphyxia, we aimed to provide an overview of current recommendations and explore potential determinants of effective neonatal cardiopulmonary resuscitation (CPR): balancing ventilations and CC, CC rate, depth, full chest recoil, CC technique and adrenaline.DESIGN: A search in the databases MEDLINE (Ovid) and EMBASE until 10 April 2015.

versus Mechanical Chest Compressions on Surfaces of Varying Softness with or without Backboards: A Randomized, Crossover Manikin Study.
Chest compression quality is decisive for overall outcome after cardiac arrest.Chest compression depth may decrease when cardiopulmonary resuscitation (CPR) is performed on a mattress, and the use of a backboard does not necessarily improve compression depth.Mechanical chest compression devices may overcome this problem.

of complications secondary to cardiopulmonary resuscitation between out-of- hospital cardiac arrest and in-hospital cardiac arrest.
Sobre les complicacions de les RCP en PCR extra i intrahospitalaris.Trencar costelles sembla anar lligat al bon pronòstic.