Resuscitation

OBJECTIVE:To examine the incidence, trends, characteristics, and patient outcomes associated with cardiopulmonary resuscitation induced consciousness (CPRIC) in out-of-hospital cardiac arrest (OHCA). METHODS:We conducted a retrospective cohort study of adult (≥16 years) OHCA events between 1st January 2008 and 31st December 2024. Patients with CPRIC were identified from prehospital patient care records and linked to data from the Victorian Ambulance Cardiac Arrest Registry (VACAR). Poisson regression was used to assess temporal trends in CPRIC incidence and multivariable logistic regression to examine the association between CPRIC and survival to hospital discharge. RESULTS:Among 43,402 OHCA events, 1,438 patients (3.3%) experienced CPRIC. The annual incidence of CPRIC increased over time in the overall cohort (IRR 1.083, 95% CI 1.07-1.10) and across all arrest rhythms (p < 0.001 for all). Factors independently associated with CPRIC included younger age, calendar year, cardiac aetiology, public location, witnessed arrest, initial shockable rhythm and use of mechanical CPR. In adjusted analysis, CPRIC was independently associated with improved survival to hospital discharge (OR 2.71, 95% CI: 2.38-3.09), with similar findings for both interfering (OR 2.36, 95% CI: 2.04-2.74) and non-interfering phenotypes (OR 4.09, 95% CI: 3.17-5.29). CPRIC was also associated with return of spontaneous circulation and survival to hospital admission. CONCLUSION:Over the 16-year study period, the annual incidence of CPRIC increased, and patients with CPRIC found to have better OHCA survival outcomes. CPRIC may help identify patients with favourable physiology and is associated with improved survival outcomes.

BACKGROUND:We examined the association between cerebral tissue oxygen saturation (SctO2) at each patient's first defibrillation after in-hospital monitoring began and return of spontaneous circulation (ROSC) after that defibrillation in patients requiring continued resuscitation after out-of-hospital cardiac arrest (OHCA). METHODS:We included adult patients with out-of-hospital cardiac arrest who underwent SctO2 monitoring during ongoing CPR and received in-hospital defibrillation for ventricular fibrillation or pulseless ventricular tachycardia. The first monitored defibrillation per patient was analyzed using multivariable Firth penalized logistic regression. All 194 monitored defibrillations were analyzed secondarily using a logistic generalized linear mixed-effects model (GLMM) with a patient-level random intercept. Both models adjusted for site. RESULTS:Nineteen patients achieved ROSC after the first monitored defibrillation. Median SctO2 was 48.8% [interquartile range, 47.2-53.6] with ROSC and 38.1% [33.8-41.8] without ROSC. After adjusting for site, arrest-to-defibrillation time, and epinephrine within 2 min, the odds ratio (OR) was 1.48 for each 1% increase in SctO2 (95% confidence interval [CI], 1.22-1.80; P<0.001). The area under the receiver operating characteristic curve was 0.961 (95% CI, 0.917-0.991). At an SctO2 cut-off of 44.5%, the sensitivity was 94.7% (18/19; 95% CI, 74.0%-99.9%) and the specificity was 89.7% (61/68; 95% CI, 79.9%-95.8%). In the adjusted GLMM of all 194 defibrillations (41 followed by ROSC), the association remained consistent (OR, 1.56; 95% CI, 1.34-1.82; P<0.001). CONCLUSIONS:In this selected population, higher SctO2 at defibrillation was associated with ROSC. This indirect marker and exploratory cutoff need external validation and should not delay guideline-directed defibrillation.

Objective Evaluating if employee instigated deletion of newborn resuscitation videos resulted in selection bias compromising the validity of the NeoBeat trial. Method The NeoBeat randomized clinical trial was conducted at Stavanger University Hospital, Norway, to evaluate if continuously displayed ECG heart rate starting from birth resulted in a higher proportion of treated newborns receiving ventilation within 60 seconds. Videos of resuscitations were used to evaluate time to ventilation. Employees could request deletion of videos by e-mail. Halfway through the trial, protests over video recordings led to 12-month pause in data collection. An anonymous solution for employee video deletion request was implemented, resulting in a surge of video deletions. To investigate possible selection bias, proxies for severity of birth asphyxia before and after introduction of the anonymous opt-out solution were compared. Result In total, 7343/10,362 (71%) newborns of gestational age ≥34 weeks were enrolled before and 2566/4417 (58%) after implementation of the anonymous opt-out solution.Time of birth and video were available for 171 and 80 newborns, respectively. Implementation of an anonymous deletion request solution resulted in loss of 0 and 14 cases before and after, leaving 171 and 66 cases for comparison. There were no differences in participant characteristics, but significantly higher Apgar scores, shorter duration of ventilation, and fewer admissions after implementation of the anonymous opt-out solution. Conclusion The introduction of anonymous employee deletion of videos resulted in systematic differences among included newborns, strongly suggesting a selection bias. The trial was terminated halfway without power to conclude on outcomes.

Aim To assess cognitive function, health-related quality of life (HRQoL), reintegration into daily life, and psychological outcomes among out-of-hospital cardiac arrest (OHCA) survivors. Methods Data were obtained from the multicenter German Cardiac Arrest Registry (G-CAR). Survivors completed standardized assessments at 6- and 12-month follow-up (6M-FU; 12M-FU), including 1.) Mini Montreal Cognitive Assessment (Mini-MoCA), 2.) EuroQol 5 Dimension 5 Level (EQ-5D-5L), 3.) Hospital Anxiety and Depression Scale (HADS), 4.) Reintegration to Normal Living Index (RNLI), and 5.) Posttraumatic Stress Symptoms-14 (PTSS-14). Results Among 1,644 OHCA patients enrolled between July 2021 and August 2024, 416 survived to hospital discharge. Follow-up data were available for 354 patients at 6 months and 307 at 12 months. Cognitive impairment was identified in 30.5% and 33.6% of respondents at 6 and 12 months, respectively. HRQoL was generally favorable, with at least 75% reporting no or slight limitations across EQ-5D-5L dimensions and mean index values comparable to those of the age-matched German population (6M-FU: 0.83 ± 0.24; 12M-FU: 0.84 ± 0.23). Reintegration into normal living was high (RNLI; 6M-FU 37.9 ± 7.3; 12M-FU: 38.4 ± 6.9). Most participants had normal HADS scores, although 13% reported abnormal depressive symptom scores. Mean PTSS-14 scores remained below the threshold suggestive of post-traumatic stress disorder at both follow-ups (6M-FU: 30.9; 12M-FU: 31.3). Conclusion OHCA survivors generally reported good long-term quality of life, successful social reintegration, and low psychological distress. However, persistent cognitive impairment and depressive symptoms affected a substantial proportion of survivors, highlighting the importance of structured long-term follow-up after OHCA.ClinicalTrials.gov identifier: NCT05142124

BACKGROUND:We evaluated the impact of a regional, year-long bystander hands-only cardiopulmonary resuscitation (CPR) education and training initiative conducted at the community level on bystander CPR rates after out-of-hospital cardiac arrest (OHCA). METHODS:We used a difference-in-differences framework to estimate the association between the intervention and bystander CPR rates in a single large county compared with two other counties as controls. We used data from January 2022 to December 2024 from Cardiac Arrest Registry to Enhance Survival (CARES). We excluded OHCA events at health care facilities. Our primary outcome was the change in bystander CPR rates associated with the intervention; this analysis was stratified by home and public locations. Additionally, we evaluated the secondary outcomes of survival to hospital discharge and neurologically intact survival. We fit logistic regression models for each of these outcomes with fixed effects for each county. RESULTS:Of 20,414 included patients; 15,417 were from the intervention region. Overall, bystander CPR rates increased from 37.4% to 42.5% in the intervention region between the pre- and post-intervention periods; however, our adjusted model did not identify a significant intervention effect (2.94 percentage-points; 95% CI -0.95 to 6.83). In public locations, our adjusted model identified a significant 8.59 percentage-point increase in bystander CPR rates associated with the intervention (95% CI 0.22-16.96), and no significant effect in home locations. We did not find a significant intervention effect on survival to hospital discharge and neurologically intact survival between the pre- and post-intervention periods. CONCLUSIONS:While we observed an increasing trend in bystander CPR rates in all regions, this change was not associated with the intervention. However, we found that the intervention was associated with a significant increase in bystander CPR rates for public OHCAs.

BACKGROUND:Transoesophageal echocardiography (TEE) enables continuous cardiac imaging during cardiopulmonary resuscitation (CPR) without interrupting chest compressions, but its impact on patients' outcomes remains uncertain. We performed a scoping review to comprehensively map the evidence on intra-arrest TEE in cardiac arrest. METHODS:We searched PubMed, Embase, CENTRAL, ClinicalTrials.gov, and grey literature from inception to March 2026. Studies evaluating TEE during CPR in adults with in- or out-of-hospital cardiac arrest were included. Outcomes comprised survival, neurological status, return of spontaneous circulation, CPR quality metrics, diagnostic findings, impact on management, feasibility, and safety. RESULTS:Twenty-two studies including 1254 patients (84% out-of-hospital cardiac arrest) were identified; most were single-centre observational studies without comparators. Two randomized trials reported no difference between TEE-guided and conventional CPR in return of spontaneous circulation, survival, or favourable neurological outcome. Observational data suggested associations between TEE-defined compression location and outcomes, with compressions over the left ventricular outflow tract or aortic valve associated with less frequent return of spontaneous circulation and short-term survival. TEE-guided modification of chest compression position occurred in 19-76% of cases. TEE influenced management in 31-48% of patients and identified potential arrest aetiology in 20-86%. TEE was associated with shorter pauses compared with transthoracic echocardiography. Feasibility was high (successful insertion 80-100%), with few reported complications. Knowledge gaps include lack of long-term outcomes, standardized protocols, and evidence on safety and effectiveness across different clinical settings. CONCLUSIONS:Intra-arrest TEE appears feasible and frequently alters resuscitation management, but current evidence does not demonstrate improved patient-centred outcomes. Further studies are required to inform appropriate integration into resuscitation practice.

AIMS:To characterize management, outcomes, and donation trajectories of pediatric extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA), and to describe early features observed among survivors and non-survivors. METHODS:We conducted a retrospective single-center observational cohort study including all consecutive children (<18 years) treated with ECPR for OHCA at a tertiary pediatric ECMO referral center between 1 January 2013 and 31 December 2025. Survivors were compared with non-survivors, and among non-survivors, patients with brain death diagnosis were compared with those without brain death diagnosis. RESULTS:Among 155 pediatric OHCA patients managed at our institution during the study period, 42 (27.1%) underwent ECPR and were included in the present analysis. Median age was 9 years, median low-flow time 85 min, and median ECMO duration 55 h. Survival to hospital discharge was 19.0% (8/42). In exploratory comparisons, survivors more often received bystander CPR (100.0% vs 52.9%, p = 0.016), had more frequent transient pre-hospital ROSC (62.5% vs 20.6%, p = 0.031), and shorter low-flow duration (53 vs 90 min, p = 0.006) than non-survivors. Survivors also had lower initial lactate (11.18 vs 18.00 mmol/L, p = 0.003), lower 24-h vasoactive-inotropic score (5 vs 18, p = 0.0053), and lower 24-h transfusion burden (12 vs 40 mL/kg, p = 0.029). Non-survivors had more severe and persistent early organ injury. Of 34 deaths, 12 had a brain death diagnosis (35.3% of non-survivors; 28.6% of the total cohort), and 4 became effective organ donors. At last follow-up (median, 412 days), 7 of 8 hospital survivors were alive, and 6 of 7 had PCPC ≤2. CONCLUSIONS:Pediatric OHCA-ECPR yielded limited but meaningful survival. Measures of early resuscitation quality, low-flow duration, and early metabolic and organ-injury profiles may help distinguish different clinical trajectories after pediatric OHCA-ECPR.