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Background Out-of-hospital cardiac arrest (OHCA) remains a leading cause of death and a 2010 meta-analysis concluded that outcomes have not improved over several decades. However, guidelines have changed to emphasize CPR quality, minimization of interruptions, and standardized post-resuscitation care. We sought to evaluate whether OHCA outcomes have improved over time among agencies participating in the Resuscitation Outcomes Consortium (ROC) cardiac arrest registry (Epistry) and randomized clinical trials (RCTs). Methods Observational cohort study of 47,148 EMS-treated OHCA cases in Epistry from 139 EMS agencies at 10 ROC sites that participated in at least one RCT between 1/1/2006 and 12/31/2010. We reviewed patient, scene, event characteristics, and outcomes of EMS-treated OHCA over time, including subgroups with initial rhythm of pulseless ventricular tachycardia or ventricular fibrillation (VT/VF). Results Mean response interval, median age and male proportion remained similar over time. Unadjusted survival to discharge increased between 2006 and 2010 for treated OHCA (from 8.2% to 10.4%), as well as for subgroups of VT/VF (21.4% to 29.3%) and bystander witnessed VT/VF (23.5% to 30.3%). Compared with 2006, adjusted survival to discharge was significantly higher in 2010 for treated cases (OR = 1.72; 95% CI 1.53, 1.94), VT/VF cases (OR = 1.69; 95% CI 1.45, 1.98) and bystander witnessed VT/VF cases (OR = 1.65; 95% CI 1.36, 2.00). Tests for trend in each subgroup were significant (p < 0.001). Conclusions ROC-wide survival increased significantly between 2006 and 2010. Additional research efforts are warranted to identify specific factors associated with this improvement.

Background Functionally favorable survival remains low after out-of-hospital cardiac arrest (OHCA). When initial interventions fail to achieve return of spontaneous circulation (ROSC), they are repeated with little incremental benefit. Patients without rapid ROSC do not typically survive with good functional outcome. Novel approaches to OHCA have yielded functionally favorable survival in patients who failed traditional measures, but the optimal transition point from traditional measures to novel therapies is ill defined. Our objective was to estimate the dynamic probability of survival and functional recovery as a function of resuscitation effort duration, in order to identify this transition point. Methods and Results Retrospective cohort study of a cardiac arrest database at a single site. We included 1,014 adult (≥18 years) patients suffering non-traumatic OHCA between 2005–2011, defined as receiving CPR or defibrillation from a professional provider. We stratified by functional outcome at hospital discharge (modified Rankin scale–mRS). Survival to hospital discharge was 11%, but only 6% had mRS 0–3. Within 16.1 minutes of CPR, 89.7% (95%CI: 80.3%, 95.8%) of patients with good functional outcome had achieved ROSC, and the probability of good functional recovery fell to 1%. Adjusting for prehospital and inpatient covariates, CPR duration (minutes) is independently associated with favorable functional status at hospital discharge (OR 0.84; 95%CI 0.72, 0.98;p=0.02). Conclusions Probability of survival to hospital discharge with mRS 0–3 declines rapidly with each minute of CPR. Novel strategies should be tested early after cardiac arrest rather than after complete failure of traditional measures.

Objective We tested the hypothesis that there are readily classifiable electroencephalographic phenotypes of early post-anoxic multifocal myoclonus (PAMM) that develop after cardiac arrest. Methods We studied a cohort of consecutive comatose patients treated after cardiac arrest from January 2012 to February 2015. For patient with clinically evident myoclonus before awakening, two expert physicians reviewed and classified all EEG recordings. Major categories included: Pattern 1: Suppression-burst background with high-amplitude polyspikes in lock-step with myoclonic jerks; Pattern 2: Continuous background with narrow, vertex spike-wave discharges in lock-step with myoclonic jerks. Other patterns were subcortical myoclonus; and, unclassifiable. We compared population characteristics and outcomes across these electroencephalographic subtypes. Results Overall, 401 patients were included, of which 69 (16%) had early myoclonus. Among these patients, Pattern 1 was the most common, occurring in 48 patients (74%), whereas Pattern 2 occurred in 8 patients (12%). The remaining patients had subcortical myoclonus (n=2, 3%) or other patterns (n=7, 11%). No patients with Pattern 1, subcortical myoclonus or other patterns survived with favorable outcome (Table 2). By contrast, 4 of 8 patients (50%) with Pattern 2 on EEG survived, and 4 of 4 (100%) of survivors had favorable outcomes despite remaining comatose for 1–2 weeks post-arrest Interpretation Early PAMM is common after cardiac arrest. We describe two distinct patterns with distinct prognostic significances. For patients with Pattern 1 EEGs, it may be appropriate to abandon our current clinical standard of aggressive therapy with conventional antiepileptic therapy in favor of early limitation of care or novel neuroprotective strategies.

Background Cerebral edema is one physical change associated with brain injury and decreased survival after cardiac arrest. Edema appears on computed tomography (CT) scan of the brain as decreased x-ray attenuation by gray matter. This study tested whether the gray matter attenuation to white matter attenuation ratio (GWR) was associated with survival and functional recovery. Methods Subjects were patients hospitalized after cardiac arrest at a single institution between 1/1/2005 and 7/30/2010. Subjects were included if they had non-traumatic cardiac arrest and a non-contrast CT scan within 24 hours after cardiac arrest. Attenuation (Hounsfield Units) was measured in gray matter (caudate nucleus, putamen, thalamus, and cortex) and in white matter (internal capsule, corpus callosum and centrum semiovale). The GWR was calculated for basal ganglia and cerebrum. Outcomes included survival and functional status at hospital discharge. Results For 680 patients, 258 CT scans were available, but 18 were excluded because of hemorrhage (10), intravenous contrast (3) or technical artifact (5), leaving 240 CT scans for analysis. Lower GWR values were associated with lower initial Glasgow Coma Scale motor score. Overall survival was 36%, but decreased with decreasing GWR. The average of basal ganglia and cerebrum GWR provided the best discrimination. Only 2/58 subjects with average GWR<1.20 survived and both were treated with hypothermia. The association of GWR with functional outcome was completely explained by mortality when GWR<1.20. Conclusions Subjects with severe cerebral edema, defined by GWR<1.20, have very low survival with conventional care, including hypothermia. GWR estimates pre-treatment likelihood of survival after cardiac arrest.

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Background Therapeutic hypothermia (TH) improves outcomes in comatose patients resuscitated from cardiac arrest. However, nonconvulsive status epilepticus (NCSE) may cause persistent coma. The frequency and timing of NCSE after cardiac arrest is unknown. Methods Review of consecutive subjects treated with TH and receiving continuous EEG (cEEG) monitoring between 8/1/2009 and 11/16/2010. Demographic data, survival, and functional outcome were prospectively recorded. Each cEEG file was analyzed using standard definitions to define NCSE. Data were analyzed using descriptive and non-parametric statistics. Results Mean age of the 101 subjects was 57 years (SD 15) with most subjects being male (N = 55, 54%) and experiencing out-of-hospital cardiac arrest (N = 78; 77%). Ventricular fibrillation was the initial cardiac rhythm in 39 (38%). All subjects received TH. Thirty subjects (30%) awoke at a median of 41 h (IQR 30, 61) after cardiac arrest. A total of 29/30 (97%) subjects surviving to hospital discharge were awake. Median interval from arrest to placement of cEEG was 9 h (IQR 6, 12), at which time the mean temperature was 33.9°C. NCSE occurred in 12 (12%) subjects. In 3/12 (25%) subjects, NCSE was present when the cEEG recording began. In 4 subjects, NCSE occurred within 8 h of cEEG recording. One (8%) subject with NCSE survived in a vegetative state. Conclusions NCSE is common in comatose post-cardiac arrest subjects receiving TH. Most seizures occur within the first 8 h of cEEG recording and within the first 12 h after resuscitation from cardiac arrest. Outcomes are poor in those who experience NCSE.