Background:Out-of-hospital cardiac arrest (OHCA) is a major cause of death in the USA and Europe, with survival rates around 10%. Lipoprotein(a) [Lp(a)] is an established cardiovascular risk factor, but its temporal profile following OHCA is unknown. Methods:In this retrospective study at a tertiary cardiac arrest center, 50 adult patients with OHCA of presumed cardiac origin were included and stratified by 6-month neurological outcome (CPC 1-2 vs. CPC 3-5). Longitudinal Lp(a) concentrations were analyzed using a linear mixed-effects model with fixed effects for time point, neurological outcome, and their interaction. Exploratory logistic regression assessed associations between Lp(a) at ROSC and neurological outcome. Results:26 patients had a favorable outcome, and 22 had an unfavorable outcome (two patients were excluded after analysis due to problems with the sample). Baseline characteristics were similar, except for longer low-flow duration (p = 0.005), higher cummulative epinephrine dosage (p = 0.025) and lower pH (p = 0.013) in the unfavorable group. Absolute Lp(a) concentrations at ROSC did not differ between groups (p = 0.646) and were not associated with outcome. In the mixed-effects model, both timepoint (p < 0.0001) and the timepoint × outcome interaction (p = 0.020) were significantly associated with Lp(a) concentrations. Lp(a) remained relatively stable in patients with a favorable outcome, whereas it declined significantly over 48 h in those with an unfavorable outcome. Conclusion:Lp(a) exhibits a time-dependent trajectory after OHCA that differs by neurological outcome. While baseline levels are not predictive, patients with unfavorable outcomes show a significant decline over time, suggesting a dynamic response possibly linked to disease severity.
Introduction When hospital staff perform cardiopulmonary resuscitation, patients are usually lying on a bed or stretcher, and chest compressions are therefore commonly performed while standing. Current resuscitation guidelines do not provide recommendations regarding standing chest compressions. The aim of this study was to identify a favourable working height for high-quality standing chest compressions. Material and methods This prospective study included ten healthcare professionals and twenty medical students and was conducted in two parts. Firstly, chest compressions were performed at seven different working heights, starting from knee height as a reference mark. Additional heights were set at 10, 15, and 20 cm above (+) and below (-) knee height. Secondly, knee height setting was then evaluated by comparing chest compression quality with two clinically relevant reference conditions: kneeling on the floor and standing at the lowest stretcher height. Results In Part 1, the highest values for the primary outcome measures – mean compression depth (52.7 ± 7.9 mm) and the percentage of correct compression depth (80.6 ± 38.5%) – were achieved at knee height. Working heights of 15 and 20 cm above knee height yielded significantly lower compression depth results than at knee height. In Part 2, no significant differences in chest compression depth were observed between the three evaluated positions. Conclusion Setting the patient’s bed or stretcher to the rescuers’ knee height enables high-quality chest compressions to be delivered while standing. The working height should be adjusted accordingly, with great emphasis placed on avoiding heights that are too high. The findings suggest that the performance of chest compressions while standing may warrant greater attention in future resuscitation guidelines.
Aim To evaluate the feasibility, safety, and operational challenges of human-supervised flight drone-delivered automated external defibrillator (AED) operations during nighttime for out-of-hospital cardiac arrest (OHCA), using a convergent mixed-methods design integrating quantitative performance metrics with qualitative human factors analysis. Methods A quasi-experimental study with 24 controlled flights (12 daytime, 12 nighttime) was conducted in a semi-urban area using a DJI M30T drone carrying a lightweight CellAED (480 g) over 877meters. Advanced-rated paramedic drone pilots executed human-supervised flight flights under extended visual line of sight (EVLOS), using automated waypoint navigation and manual final approach and landing. protocols. Quantitative data included flight times and safety incidents, analyzed using paired t-tests. Qualitative data from semi-structured pilot interviews were analyzed thematically using the SHELL (Software-Hardware-Environment-Liveware-Liveware) human factors framework. Integration occurred through convergent triangulation comparing quantitative duration metrics with pilot-reported operational themes. Results All 24 flights completed successfully without safety incidents or obstacle-avoidance triggers. Mean flight times were comparable (day: 136.00 ± 8.71 s vs. night: 139.92 ± 14.16 s; paired mean difference 3.92 s, S.D. 16.49, p = 0.43, Cohen’s d = 0.24). Qualitative analysis identified eight major themes: night-mode interface challenges, GPS routing reliability, infrared sensor performance, pilot fatigue and stress, communication coordination, cognitive workload, landing zone conditions, and regulatory constraints. Triangulation of quantitative and qualitative findings showed thatdespite comparable flight performance, pilots reported significantly increased cognitive demands and environmental complexity during nighttime operations. Conclusion Under controlled, early-night, open-area conditions, all human-supervised flight drone-delivered AED operations missions were completed without observed safety incidents. However, successful nighttime implementation requires addressing pilot workload, interface design, and operational protocols. These findings support development of 24/7 drone AED services while highlighting critical human factors considerations for sustainable operations.
Background Traumatic cardiac arrest (TCA) has a high mortality, and its pathophysiology differs markedly from non-traumatic arrest. Although blood transfusion is pivotal for hypovolemia, prehospital storage and transport are challenging, making fluid resuscitation common yet its impact unclear. We established a rat TCA model combining hemorrhage and asphyxia to examine the efficacy of different fluids on outcomes. Methods Rats underwent graded hemorrhage (0-40%) to assess shock/arrest. Then a combined TCA model with the same blood loss followed by asphyxia was used to identify the lethal threshold. Cardiopulmonary resuscitation (CPR) started 5 min after arrest. In the 30% hemorrhage + asphyxia model, after the return of spontaneous circulation (ROSC), animals received normal saline (NS), lactated Ringer’s solution (LR), hydroxyethyl starch (HES) or whole blood (WB). Hemodynamics, 96‑hour survival and tissue injury were then assessed. Results Hemorrhage exceeding 30% induced shock in 86% and over 40% caused arrest in 71%. All TCA animals achieved ROSC with CPR, but 96‑hour survival was 14% and 0% at 30% and 40% hemorrhage. In the lethal threshold model (30% hemorrhage + asphyxia), survival was 90% (WB), 80% (HES), 60% (LR) and 30% (NS), respectively. WB and HES improved hemodynamics and reduced tissue injury versus NS, except for blood pressure in HES. LR showed no hemodynamic benefit and modest tissue protection. Conclusions In this model, fluid resuscitation is needed when hemorrhage exceeds 30%. WB yields the best outcomes; HES is comparably effective but with lower blood pressure. LR and NS do not improve outcomes but prolong survival.
Aim We evaluated the nationwide availability of prehospital termination-of-resuscitation (TOR) policies for out-of-hospital cardiac arrest (OHCA) with do-not-attempt-cardiopulmonary-resuscitation (DNACPR) wishes in Japan, and quantified the implementation gap between policy adoption and operational use. Methods We conducted a nationwide cross-sectional survey of all prefecture-level and regional medical control councils and fire departments in Japan. The primary outcome was the fire-department-level crude operational application rate among departments with a policy in place. Results Responses were obtained from 46 of 47 prefecture-level medical control councils (98%), 129 of 250 regional medical control councils (52%), and 561 of 791 fire departments (71%). A prehospital TOR policy for OHCA patients with DNACPR wishes was available in 265 of 561 fire departments (47%). Among 391 fire departments reporting at least one OHCA with DNACPR wishes in 2024, 156 had a policy in place. Among 151 with evaluable data, 78 (52%) did not apply the policy to any such case during the study year; 35 of these departments reported three or more DNACPR cases. Departments with a policy reported fewer transports with ongoing cardiopulmonary resuscitation than departments without a policy (46% vs. 82%, adjusted OR, 0.17; 95% CI, 0.09–0.30). Conclusion Although prehospital TOR policies for OHCA patients with DNACPR wishes were available in nearly half of fire departments, implementation was highly heterogeneous: more than half of departments with a policy reported a crude operational application rate of 0% during the study year, despite encountering relevant cases. Efforts to improve operational uptake may be as important as policy development itself.
AIM This study aimed to evaluate the accuracy of two commercially available ventilation feedback devices (VFD) in measuring ventilation rate and tidal volume during simulated cardiopulmonary resuscitation (CPR) with continuous chest compressions and asynchronous ventilations in the presence of reversed airflow. Methods Prospective, simulation-based, non-randomized cross-over study. Twenty emergency department nurse practitioners performed manual ventilation on an intubated high-fidelity manikin during two 1-minute trials (one per device), targeting 10 breaths/min during continuous chest compressions (100–120/min). Ventilation parameters displayed by EOLifeX® and AccuVent® were compared with measurements from a high-fidelity pneumotachograph (HFRP). Data is presented as mean (standard deviation, min-max range). CI = confidence interval. Results EOLifeX®: From HFRP flow data, 254 ventilations were identified (rate 12/min [1; 8–14], tidal volume 544 mL [32; 482–604]). All showed reversed airflow with an average of 49 mL [13;19–72]. VFD displayed values overestimated ventilation rate and underestimated tidal volume (111/min [5; 99–121] and 104 mL [14; 68–240]; biases +99 breaths/min, 95% CI 96.6–101.4, and −440 mL, 95% CI −456.3 to −423.7). AccuVent®: From HFRP flow data, a total of 222 ventilations were identified (rate 12/min [1; 8–13], tidal volume 532 mL [35; 460–614]). All showed reversed airflow with an average of 56 mL [15; 22–78]. VFD displayed values were similar for rate (12/min [1; 8–13]) but underestimated tidal volume (360 mL [24; 292–398]; bias −172 mL, 95% CI −191.9 to −152.1). Conclusion During simulated CPR with continuous compressions and asynchronous ventilations, VFDs demonstrated clinically relevant inaccuracies. Validation under realistic resuscitation conditions are needed.
Background Women are less likely than men to receive bystander cardiopulmonary resuscitation (CPR). CPR training has traditionally relied on manikins depicting a lean, white male chest, which may reinforce disparities. This quality improvement initiative evaluated healthcare staff perceptions of sex/gender differences in CPR and the impact of diverse skin-toned female manikins on provider confidence. Methods Six female CPR manikins representing diverse skin tones were introduced into basic life support training at two Covenant Health hospitals. Participants completed anonymous pre- and post-training surveys assessing perceptions of sex/gender disparities, confidence performing CPR across different body types, and experiences with the manikins. Data were collected from July to October 2025. Staff were grouped by years of clinical practice (1–5, 5–10, 10–20, and ≥20 years). Between-group comparisons were performed using Kruskal–Wallis tests with post hoc pairwise comparisons. Open-text responses were analyzed using summary template analysis. Results A total of 573 healthcare staff participated; most were nurses (83.6%), women (85.9%), and had ≥10 years of practice (58.5%). Staff with ≥20 years of practice were less likely to believe sex differences exist in CPR administration. Fewer years of practice were associated with greater hesitation to perform CPR due to body differences (p < 0.001). Pre-training confidence differed significantly across groups, with greater confidence reported among more experienced staff (all p < 0.001). Following training, 73.1% of participants reported increased confidence performing CPR on someone with breasts. Conclusions Using manikins with breasts during CPR training increased healthcare staff confidence in providing CPR to people with breasts. Incorporating diverse female CPR manikins into hospital training may improve provider confidence and support more equitable, inclusive resuscitation education.
Background Out-of-hospital cardiac arrests are associated with high mortality. Despite lay rescuer automated external defibrillator (AEDs) use being crucial for improving outcomes, public utilization of AEDs remains low. Signage characteristics directing lay rescuers to AEDs in public areas vary. We describe AED signage variability across six continents, focusing on shape, color, text, and symbols. Methods A convenience sample of 120 publicly available online AED signage, collected between December 2024 and May 2025, was analyzed. Six continents were included: Europe (38.3%), North America (23.3%), Africa (14.2%), Australia (12.5%), Asia (7.5%), and South America (4.2%). Separately, 90 crowd-sourced images of airport AED signage were collected from 71 airports across six continents between January and November 2025: Europe (37.8%), North America (36.7%), Africa (1.1%), Australia (6.7%), Asia (15.6%), and South America (5.6%). We reported frequencies and proportions of signage characteristics for the samples and stratified by continent. Results The distribution of signage characteristics in the publicly available signage varied across six continents (p<0.05). In the airport sample, the distribution of sign shape; cross symbol color; and the presence of heart, lightning bolt, and arrow symbols did not differ across continents. However, background color, text color, presence of the cross symbol, and colors of the heart and lightning bolt symbols differed across continents (p<0.05). Over 90% of all signs analyzed contained a heart and lightning bolt symbol. Conclusions There appears to be significant variation in public AED signage globally. Further research is needed to determine if specific signage characteristics improve AED recognition and utilization.
This journal club article was part of the Young European Resuscitation Council Masterclass 2025-2026. It reviews the paper "Performance of Universal TOR rule for out-of-hospital cardiac arrest in the Pan-Asian Resuscitation Outcomes Study" by Onoe et al. (2025).
The European Resuscitation Council (ERC) Guidelines 2025 continue to summarize the causes of cardiac arrest that should be sought during advanced life support (ALS) as “4Hs and 4Ts”. While well established, this list-based mnemonic does not map onto the airway–breathing–circulation–disability–exposure (ABCDE) sequence that emergency teams use for every other patient assessment, and it excludes causes that are clinically treatable but not classically “reversible” in the prehospital phase. We present SETA (Structured Evaluation and Treatment of cardiac arrest via the ABCDE approach), a concept developed within the Emergency Medical Service Vienna that restructures both cause-finding during cardiopulmonary resuscitation (CPR) and evaluation of high-performance CPR around the ABCDE sequence, embeds protocol-linked actions at each step, and is designed to run within ongoing chest compressions without interrupting them. We outline its rationale, its relationship to existing pit-crew and ABCDE-based resuscitation models, and the prospective evaluation now needed before considered for wider use.
Background:Calcium administration during cardiac arrest has historically been used for its potential inotropic effects, despite limited evidence of benefit. Prior studies in out‑of‑hospital cardiac arrest suggest harm, but data specific to in‑hospital cardiac arrest (IHCA) remain limited. Methods:We conducted a retrospective cohort study of adult IHCA events occurring at a single academic tertiary‑care medical center in the United States between 2011 and 2024, identified from a prospective registry. IHCA events lasting at least 5 min were included. The primary exposure was intravenous calcium gluconate administration during resuscitation. The primary outcome was sustained return of spontaneous circulation (ROSC ≥20 min). Secondary outcomes were survival to hospital discharge and favorable neurological outcome at discharge (Glasgow Outcome Scale score 4-5). Multivariable logistic regression analyses were performed. Results:Among 599 IHCA events, 234 patients (39.1%) received calcium. Calcium administration was associated with significantly lower rates of sustained ROSC (31.6% vs 57.8%), survival to hospital discharge (6.8% vs 18.9%), and favorable neurological outcome (3.0% vs 14.3%; p < 0.0001 for all). After multivariable adjustment, calcium use remained associated with lower odds of sustained ROSC (OR 0.46; 95% CI 0.31-0.68), survival to hospital discharge (OR 0.36; 95% CI 0.19-0.68), and favorable neurological outcome (OR 0.20; 95% CI 0.08-0.49). No interaction was observed between calcium administration and CPR duration. Conclusion:Calcium administration during IHCA was independently associated with lower rates of sustained ROSC, survival to hospital discharge, and favorable neurological outcome. These findings support current guideline recommendations against routine calcium use during undifferentiated IHCA.
Background: Out-of-hospital cardiac arrest (OHCA) is a major cause of death in the USA and Europe, with survival rates around 10%. Lipoprotein (a) [Lp(a)] is an established cardiovascular risk factor, but its temporal profile following OHCA is unknown.Methods: In this retrospective study at a tertiary cardiac arrest center, 50 adult patients with OHCA of presumed cardiac origin were included and stratified by 6-month neurological outcome (CPC 1-2 vs. CPC 3-5). Longitudinal Lp(a) concentrations were analyzed using a linear mixed-effects model with fixed effects for time point, neurological outcome, and their interaction. Exploratory logistic regression assessed associations between Lp(a) at ROSC and neurological outcome.Results: 26 patients had a favorable outcome, and 22 had an unfavorable outcome (two patients were excluded after analysis due to problems with the sample). Baseline characteristics were similar, except for longer low-flow duration in the unfavorable group (p=0.005). Absolute Lp(a) concentrations at ROSC did not differ between groups (p=0.646) and were not associated with outcome. In the mixed-effects model, both timepoint (p < 0.0001) and the timepoint x outcome interaction (p = 0.020) were significantly associated with Lp(a) concentrations. Lp(a) remained relatively stable in patients with a favorable outcome, whereas it declined significantly over 48 hours in those with an unfavorable outcome.ConclusionLp(a) exhibits a time-dependent trajectory after OHCA that differs by neurological outcome. While baseline levels are not predictive, patients with unfavorable outcomes show a significant decline over time, suggesting a dynamic response possibly linked to disease severity.
Background Adult survivors of cardiac arrest (CA) with favourable neurological recovery often experience persistent cognitive and psychological difficulties that impact quality of life and functional independence. However, post-discharge interventions remain heterogeneous, and evidence to support the prioritisation and implementation of specific cognitive and psychological interventions is limited. Objective To systematically review the evidence on psychological and cognitive support interventions delivered after hospital discharge in adult CA survivors with good neurological recovery. Methods A systematic review was conducted following PRISMA 2020 guidelines (PROSPERO CRD420251267160). Eligible studies included adults surviving CA with favourable neurological recovery who received structured post-discharge interventions. Outcomes were assessed across multiple domains, including: psychological well-being; cognitive performance; functional status and participation; health-related and global quality of life; and feasibility and implementation. Results Six studies (n=352 survivors) were included: two randomized controlled trials, two feasibility/pre-post studies, one single-case experimental design, and one process evaluation. Interventions varied in content and delivery (face-to-face, remote, home-based) and included nurse-led follow-up, psychotherapy, cognitive rehabilitation, and mindfulness-based strategies. Small improvements were observed in anxiety, depression, post-traumatic stress symptoms, and selected health-related quality-of-life domains, whereas cognitive, functional, and participation in daily and social activities showed limited or short-term gains in small uncontrolled studies. Interventions were feasible and well-tolerated. Conclusions Post-discharge psychological and cognitive interventions are feasible and associated with modest improvements in psychological well-being and selected quality-of-life domains. Further rigorous research using standardised outcomes is needed.
Purpose:A population-based survey on opinions about CPR education, willingness to act, and awareness of AEDs location. Method:A survey was compiled by the commercial Novus Group International, Stockholm, Sweden in January 2026. Novus use their Sweden Panel, which aim to mirror the public opinion and consist of about 60,000 people aged 18-84 years. Novus uses purposeful recruitment of representative participants until the target 1000 people have replied to the survey. Results:Among the 1026 responders, there was an equal distribution of age, gender and one third reported training CPR within 24 months. The majority (n = 820,80%) stated that they would be willing to act if an unknown person gets a cardiac arrest, while 7% (n = 69) stated that would not be willing to act. Those with recent CPR training were more prone to act and contradictory, those who had never done CPR training (12% of the participants) were most unsure if they would be willing to act. Around half (n = 539) feel confident using an AED. Those with a lower degree of comfort was older women (57%), retired (52%) and never have taken CPR training (81%). Half (n = 538) know where the closest AED is at their workplace compared to one fifth when they are at home. The majority (n = 870) believe it should be mandatory to have government AEDs available 24/7. Conclusions:A representative sample of the Swedish population is trained in CPR, propose that they are willing to act in a cardiac arrest, but few know where their nearest AED is located when at home. Recent CPR training adds confidence and awareness, but any training seems to have a lifelong effect.
Introduction:Optimizing cerebral blood flow after return of spontaneous circulation (ROSC) is key to neuroprotection in out-of-hospital cardiac arrest (OHCA) patients. Randomized trials comparing fixed mean arterial pressure (MAP) targets have been uniformly neutral, as between- and within-patient heterogeneity in cerebral autoregulation renders uniform targets inadequate. An individualized blood pressure strategy targeting patient-specific cerebral perfusion may reduce secondary brain injury. Methods:NEUROprotectIoN via optimizing cerebral blood flow afTer cArdiaC arresT (NEURO-INTACT) is a single-center, single-arm, phase II proof-of-concept trial enrolling 49 comatose OHCA survivors within 12 h post-ROSC. With constant ventilatory settings and continuous electrographic, pulse oximeter and end-tidal carbon dioxide monitoring, MAP is actively manipulated via vasopressor titration to generate slow MAP fluctuations. Changes in cerebral oxygenation (near-infrared spectroscopy) and blood flow velocities (transcranial Doppler) are continuously correlated with MAP by ICM+ software to characterize each patient's cerebral autoregulation and derive an individualized optimal MAP (MAPopt). MAP is then actively titrated to MAPopt, with this assess-and-titrate cycle repeated at three timepoints across 72 h post-ROSC. Primary endpoint is the mean change in neuron-specific enolase from baseline to 72 h. Secondary endpoints include peak cardiac and renal injury biomarkers within 72 h, neurological outcome at discharge, and health-related quality of life at six months, compared against historical controls. Conclusion:This study will explore the effect of individualized, autoregulation-guided hemodynamic management on a validated surrogate marker of brain injury, demonstrate protocol feasibility and safety, and generate effect-size estimates to inform a definitive multicenter trial. Trial registration: ClinicalTrials.gov ID NCT05679739.
Background:Before a trial testing prehospital teleconsultation for children, we studied acceptability, feasibility, and workload after integrating teleconsultation into Emergency Medical Service (EMS) workflows. Methods:We randomized paramedic-physician teams to teleconsultation (audio/video call, intervention) or usual care (audio call, control) for three simulated pediatric transports using mixed methods. Paramedic dyads provided in-ambulance simulated care while remote pediatric emergency physicians offered real-time consultation. In the intervention group, we used the Telehealth Usability Questionnaire to measure acceptability [primary; Total Usability Score (TUS), maximum = 7] and feasibility [secondary; Interaction Quality Score (IQS)]; and interviews for Technology Acceptance Model themes. Between groups, we calculated descriptive statistics and compared connection success and workload. Results:Twenty-four teams (12/group) completed 72 simulated transports. Intervention paramedics attempted physician contact in 94% (34/36) of transports versus 47% (17/36) in control; 92% connected in ≤2 attempts. In the intervention group, mean TUS was 5.6 (95% CI 5.2, 6.0) for physicians and 5.8 (95% CI 5.5, 6.0) for paramedics; mean IQS was 5.2 (95% CI 4.6, 6.0) and 5.9 (95% CI 5.4, 6.3) respectively. Intervention paramedics reported similar workload to controls (p = 0.26) but less frustration (p = 0.03); physicians experienced higher workload (p = 0.01). Interviews identified improved communication and physician involvement, alongside uncertainty about physician roles and impact on paramedic autonomy. Video quality was adequate, but concerns about real-world audio and broadband reliability remained. Conclusions:In simulations, teleconsultation for pediatric EMS transports was acceptable and feasible with minor technical modifications. Implementation should balance physician workload and clarify roles through training. Future trials should evaluate patient outcomes.
