Prognostic values of blood ammonia and partial pressure of ammonia on hospital arrival in out-of-hospital cardiac arrests,,,,
|
|
- Blaze Richard
- 5 years ago
- Views:
Transcription
1 American Journal of Emergency Medicine (2013) 31, Original Contribution Prognostic values of blood ammonia and partial pressure of ammonia on hospital arrival in out-of-hospital cardiac arrests,,,, Chih-Hao Lin MD a,, Chih-Hsien Chi MD, PhD a, Shyu-Yu Wu MS b, Hsiang-Chin Hsu MD a, Ying-Hsin Chang MD a, Yao-Yi Huang MD a, Chih-Jan Chang MD a, Ming-Yuan Hong MD a, Tsung-Yu Chan MD a, Hsin-I Shih MD a a Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan b Department of Electrical Engineering, National Sun Yat-Sen University, Kaohsiung 80424, Taiwan Received 4 March 2012; revised 4 April 2012; accepted 28 April 2012 Abstract Purposes: Outcome prediction for out-of-hospital cardiac arrest (OHCA) is of medical, ethical, and socioeconomic importance. We hypothesized that blood ammonia may reflect tissue hypoxia in OHCA patients and conducted this study to evaluate the prognostic value of ammonia for the return of spontaneous circulation (ROSC). Methods: This prospective, observational study was conducted in a tertiary university hospital between January 2008 and December The subjects consisted of OHCA patients who were sent to the emergency department (ED). The primary outcome was ROSC. The prognostic values were calculated for ammonia levels and the partial pressure of ammonia (pnh 3 ), and the results were depicted as a receiver operating characteristics curve with an area under the curve. Results: Among 119 patients enrolled in this study, 28 patients (23.5%) achieved ROSC. Ammonia levels and pnh 3 in the non-rosc group were significantly higher than those in the ROSC group (167.0 μmol/l vs 80.0 μmol/l, P b.05; vs mm Hg, P b.05, respectively). The predictive capacity of area under the curve for ammonia and pnh 3 for non-rosc was 0.85 (95% confidence interval, ) and 0.73 (95% confidence interval, ), respectively. The multivariate analysis confirmed that ammonia and pnh 3 are independent predictors of non-rosc. The prognostic value of ammonia was better than that of pnh 3. The cutoff level for ammonia of 84 μmol/l was 94.5% sensitive and 75.0% specific for predicting non-rosc with a diagnostic accuracy of 89.9%. Disclosures of conflict of interest: The authors disclose no conflicts. Ethical adherence: The study procedures were in accordance with the ethical standards and were approved by the institutional review board in the hospital. Funding and support: No financial support was granted. Writing assistance: None. Author contributions: CHL conceived and supervised the study. All authors were involved in acquisition of data. CHL and SYW interpreted the data and performed statistical analysis. CHL drafted the manuscript, and all authors contributed substantially to its revision. CHL and CHC offered administrative and technical supports. CHL is the corresponding author who takes responsibility for the manuscript as a whole. Corresponding author. Tel.: x2237, ; fax: addresses: emergency.lin@gmail.com (C.-H. Lin) /$ see front matter 2013 Elsevier Inc. All rights reserved.
2 Prognostic values of blood ammonia and partial pressure of ammonia 9 Conclusions: Hyperammonemia on ED arrival is independently predictive of non-rosc for OHCA patients. The findings may offer useful information for clinical management Elsevier Inc. All rights reserved. 1. Introduction Outcome prediction for out-of-hospital cardiac arrest (OHCA) is of medical, ethical, and socioeconomic importance. The early management of OHCA is complicated by the lack of readily available prognostic predictors of the possible spontaneous return of circulation (ROSC). Higher survival rates have been observed in patients with witnessed ventricular tachycardia/ventricular fibrillation, bystander cardiopulmonary resuscitation (CPR), and early defibrillation [1-4]. Several assessment tools or biomarkers, including Glasgow Coma Score [5], brain stem reflex [6], somatosensory-evoked potentials [7], end-tidal carbon dioxide [8,9], S-100 protein [10], neuron-specific enolase [11], serum glucose [12], serum lactate [13], and brain natriuretic peptide [14], have been used to evaluate the outcome of cardiac arrest after ROSC. However, no single biomarker has been identified to reliably predict whether the cardiac arrest patient can or cannot achieve ROSC. Hepatic dysfunction is a common finding in critically ill patients and is associated with longer intensive care unit stays and increased hospital mortality [15]. Hypoxic hepatitis, also known as ischemic hepatitis or shock liver, is caused by the insufficient uptake of oxygen by the hepatocytes. Hypoxic hepatitis causes several complications, such as spontaneous hypoglycemia, respiratory insufficiency, and hyperammonemia. Blood ammonia is predictive of mortality for hospitalized patients with acute hepatic failure and can be used for risk stratification [16,17]. Recent studies have also suggested that blood ammonia levels at hospital arrival predict the neurologic outcome of patients with OHCA after ROSC [18]. We hypothesized that blood ammonia levels may reflect tissue hypoxia and that blood ammonia levels can thus be used to predict the likelihood of ROSC achievement for OHCA patients. Ammonium (NH 4+ ), also known as ammonium ion, is an ionized form of ammonia (NH 3 ). Ammonia exists predominantly as ammonium in the blood, whereas a small phdependent fraction exists in a nonionized form (b 2%). The nonionized form of ammonia, reflected by the partial pressure of ammonia (pnh 3 ) [19], permeates cell membranes and is more toxic than the ionized form of ammonia. Because acidemia is one of the causes of cardiac arrests [20] and a decrease in ph may influence the value of pnh3, pnh3 should also be considered a predictive tool for ROSC. Blood ammonia and blood gas analysis are diagnostic tests that are available in most emergency department (ED) settings. We conducted this study to evaluate the relationship between ROSC and blood ammonia as well as pnh3 in OHCA patients. 2. Materials and methods 2.1. Study setting This prospective, observational study was conducted in the ED of a tertiary university hospital in Taiwan between January 2008 and December The subjects of the study consisted of consecutive OHCA patients sent to the ED. Patients with a known pregnancy, severe hypothermia (defined as a body temperature b30 C), a valid do-notattempt-resuscitation order, or obvious signs of irreversible death and patients who were younger than 18 years old were excluded from the study. The signs of irreversible death included decapitation, hemicorporectomy, dependent lividity, rigor mortis, decomposition, and thermal carbonization without detectable vital signs. There were no rules concerning the termination of resuscitation in prehospital settings in Taiwan at the time of our study. All patients with witnessed and unwitnessed cardiac arrests assessed by emergency medical technicians (EMTs) were sent to hospitals unless obvious signs of irreversible death were present. Demographic data were obtained from a prospective registry database. Basic and advanced life support measures were carried out by EMTs at the scene and/or emergency physicians in the ED according to standard protocols. The data comprise all of the information required for the international Utstein-style criteria [21,22], such as the patient's history, cardiac risk factors, response intervals, initial cardiac rhythms, and the extent and amount of emergency care. The definitive cause of cardiac arrest was documented on discharge from the hospital or after the patient's death in the hospital. Emergency medical technicians may place intravenous lines, use advanced airway management devices, administer doses of epinephrine, and apply automated external defibrillators for OHCA patients before ED arrival. Basic and advanced cardiovascular life support was provided according to the 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care [23] during the study period. Resuscitation was terminated if the patient exhibited persistent asystole after 30 minutes of advanced cardiovascular life support. All patients with sustained ROSC were admitted to the intensive care units and received standard intensive care treatment.
3 10 C.-H. Lin et al. The study procedures were in accordance with the ethical standards and were approved by the institutional review board of the hospital Assessment of the blood ammonia levels and the pnh 3 Blood samples were collected from the femoral vessels of OHCA patients within 5 minutes after ED arrival. The blood sample of each patient was divided into several tubes or syringes for analysis. The blood samples in tubes containing lithium heparin were cooled in ice-cold water before analysis and were transported to the clinical laboratory immediately. Ammonia levels were measured using Vitros NH 3 DT Slides with Vitros Fusion 5.1 FS Automated Chemistry Analyzer (Ortho Clinical Diagnostics, Johnson & Johnson Co., NJ). The Vitros NH 3 DT Slide is a multilayered, analytical element that is coated on a polyester support. Water and nonproteinaceous components travel to the underlying buffered reagent layer, and the ammonium ions are converted to gaseous ammonia. The semipermeable membrane allows only ammonia to pass through, which prevents buffer or hydroxyl ions from reaching the indicator layer and thus avoids the influence of possible acidemia. The detection range for blood ammonia in the assay was 1 to 500 μmol/l, and the institutional reference range was 9 to 33 μmol/l. Blood ammonia levels of 500 μmol/l were considered beyond the upper limits of detection. The blood gas samples in Luer slip syringes containing heparin were analyzed to obtain the ph value. The blood gas analysis was determined using i-stat EG7 + cartridges with i-stat System (Abbott Point of Care Inc., NJ). The detection range for blood ph was 6.5 to 8.2. Combining the mass balance equation and Henry's law [24], the partial pnh 3 can be calculated as follows: p[nh 3 ] = (K H [NH 3 ] T )/(1 + [H + ]/K a ), where [NH 3 ] T = total blood ammonia, K H for ammonia = ,K a = , and [H + ] is derived from the ph values as the antilog ( ph). The patients who did not follow the aforementioned blood sampling procedures were excluded. Patients whose laboratory results were not available were also excluded. The physicians who provided medical care during the study period had no knowledge of the study results. Therapeutic decisions were not biased by assay measurements Outcome measures The primary outcome was ROSC. Return of spontaneous circulation was defined as an organized electrocardiogram with a palpable pulse. Patients with the return of a palpable pulse for less than 5 minutes were considered to not have achieved ROSC Statistical analysis Data were collected by the designated registered nurses and were entered into an Excel (Microsoft Corp, Redmond, WA) spreadsheet. The study physicians performed manual checks on the accuracy of data entry monthly for further analysis. The skewness of data distribution was checked before the analysis. Categorical variables are shown as a number with a percentage, and quantitative data are shown as a median value with an interquartile range (IQR). The ROSC achievement group and the non-rosc group were compared using the Mann-Whitney U test for continuous variables and the χ 2 test or Fisher test for discrete variables, wherever applicable. The sensitivity and specificity of the prediction of non-rosc were calculated for different cutoff values of blood ammonia levels and the pnh 3, and the results were depicted as a receiver operating characteristics (ROC) curve with an area under the curve (AUC). We carried out univariate analysis of the clinical and biochemical variables that could influence ROSC. The variables available on ED admission were considered for inclusion in the logistic regression. The significant variables were dichotomized using discriminant values derived by constructing ROC curves for each variable. The odds ratio with a 95% confidence interval (95% CI) was calculated for each variable. The predicted probability of non-rosc was derived from the variables found to be significant after logistic regression analysis. Two-tailed P b.05 was considered significant. We used the SPSS software (version 17; SPSS Inc, Chicago, IL) for the statistical analysis. 3. Results A total of 175 consecutive OHCA patients sent to the ED during the study period were evaluated for inclusion. Fiftysix patients were excluded because of an age of younger than 18 years (n = 4), obvious signs of irreversible death (n = 12), severe hypothermia (n = 2), valid do-not-attempt-resuscitation orders (n = 16), inconsistent blood sampling procedures (n = 14), or unavailable laboratory data (n = 8). A final total of 119 OHCA patients (60 men and 59 women) were included in this study. The median age of the included patients was 74.0 years. Of the 119 patients, 28 patients (23.5%) achieved ROSC, and 91 (76.5%) did not. Table 1 compares the baseline characteristics between the 2 groups. The 10 clinical and biochemical variables that proved to be significantly different between the 2 groups are as follows: the etiology of cardiac arrest, initial cardiac rhythm, the presence of bystander CPR, ammonia, pnh 3, alanine aminotransferase (ALT), creatinine, potassium, ph, and PCO 2.
4 Prognostic values of blood ammonia and partial pressure of ammonia 11 Table 1 Clinical and biochemical parameters among patients with OHCA Total OHCA Non-ROSC group ROSC group P Total Age (y) 74 ( ) 74.0 ( ) 73.5 ( ).856 Sex (male) 60 (50.4%) 47 (51.6%) 13 (46.4%).927 Etiology (nontrauma) 94 (79.0%) 70 (76.9%) 24 (85.7%) b.05 Witness cardiac arrest 49 (41.1%) 33 (36.3%) 16 (57.1%).054 Bystander CPR 10 (8.4%) 8 (8.79%) 2 (7.14%) b.05 Initial cardiac rhythm 28 (23.5%) 18 (15.1%) 10 (35.7%) b.05 (shockable) Ammonia (μmol/l) ( ) ( ) 80.0 ( ) b.05 pnh3 (10 5 mm Hg) 2.38 ( ) 2.61 ( ) 1.67 ( ) b.05 White blood counts 10.7 ( ) 10.5 ( ) 11.7 ( ).319 (10 3 /μl) Hemoglobin level (g/dl) 11.3 ( ) 11.2 ( ) 11.5 ( ).694 AST (U/L) 81 ( ) 84 ( ) 52 ( ).06 ALT (U/L) 39 ( ) 42 ( ) 24 ( ) b.05 Creatinine (mg/dl) 1.7 ( ) 1.6 ( ) 2.4 ( ) b.05 Sodium (mmol/l) ( ) ( ) ( ).110 Potassium (mmol/l) 5.6 ( ) 5.8 ( ) 4.9 ( ) b.05 Glucose (mg/dl) ( ) ( ) ( ).497 ph 7.0 ( ) 7.0 ( ) 7.1 ( ) b.05 PO 2 (mm Hg) 20.0 ( ) 20.0 ( ) 21.9 ( ).145 PCO 2 (mm Hg) 67.7( ) 71.6( ) 55.3( ) b.05 Bicarbonate (mmol/l) 19.5 ( ) 20 ( ) 18.6 ( ).34 BE (mmol/l) 10 ( 19.0 to 6.0) 9.7 ( 19.5 to 6.0) 12 ( 17 to 5.6).86 Categorical variables were given as number (percentage), whereas quantitative data were given as median (interquartile range). P value comparing non-rosc achievement group and ROSC achievement group less than.05 was considered significant. AST indicates aspartate aminotransferase; ALT, alanine aminotransferase; BE, base excess Ammonia levels and pnh 3 values at ED arrival The results of blood gas analysis and ammonia levels were obtained within 2 and 15 minutes after blood sampling, respectively. The median ammonia level for OHCA patients at ED arrival was 150 μmol/l (IQR, μmol/l). The blood ammonia levels of 115 patients (96.6%) exceeded the upper institutional normal limit of 33 μmol/l. Ammonia levels and pnh 3 values in the non-rosc group were significantly higher than the levels in the ROSC achievement group (P b.05), as shown in Fig. 1. The median ammonia level was 167 μmol/l (IQR, μmol/l) in the non-rosc group and 80 μmol/l (IQR, μmol/l) in the ROSC achievement group. The median pnh 3 value was mm Hg (IQR, mm Hg) in the non-rosc group and mm Hg (IQR, mm Hg) in the ROSC achievement group The prognostic value of ammonia levels An ROC curve was plotted with the ammonia levels of each patient as the independent variable and non-rosc as the outcome variable, as shown in Fig. 2A. The AUC was 0.85 (95% CI, ). The optimal cutoff level for ammonia was 84 μmol/l and was found to be 94.5% sensitive and 75.0% specific for predicting non-rosc with a diagnostic accuracy of 89.9%. The pretest odds ratio was 3.2, and the posttest odds ratio was Prognostic value of pnh 3 The ROC curve for pnh 3 values and non-rosc is shown in Fig. 2B, with an AUC of 0.73 (95% CI, ). The optimal cutoff pnh 3 value of mm Hg was found to be 74.7% sensitive and 71.4% specific for predicting non- ROSC with a diagnostic accuracy of 73.9%. The posttest odds ratio was Comparison of the non-rosc and the ROSC achievement group The univariate analysis showed that 10 clinical and biochemical variables significantly influenced ROSC achievement. The results are shown in Table 1. These variables were analyzed using logistic regression analysis with non-rosc as the dependent variable. These variables were dichotomized for best discrimination between the non- ROSC and ROSC achievement groups using the cutoff values derived from the construction of individual ROC curves, as shown in Table 2. The following 5 variables were found to be independent predictors of non-rosc: blood ammonia,
5 12 C.-H. Lin et al. Fig. 1 Comparison of blood ammonia levels (A) and the partial pressures of ammonia (B) of the non-rosc group and the ROSC group. pnh 3, ALT, potassium, and PCO 2. The remaining variables, which include the etiology of the cardiac arrest, the presence of bystander CPR, the initial cardiac rhythm, creatinine levels, and ph values, either had no effect or lost their independent predictive capacity in the multivariate model. The blood ammonia level, with an assigned cutoff value of 84 μmol/l, had a much higher odds ratio (51.6; 95% CI, ) compared with the other variables Comparative prognostic value of ammonia levels and pnh 3 The prognostic value of blood ammonia and pnh 3 at ED arrival was analyzed in the 119 OHCA patients. The findings from the ROC curves constructed with non-rosc as the outcome variable showed that the AUC was greater for ammonia levels than for pnh 3 values (0.85 vs 0.73). The Fig. 2 A ROC curve with an AUC for non-rosc was depicted for blood ammonia levels (A) and the partial pressure of ammonia (B).
6 Prognostic values of blood ammonia and partial pressure of ammonia 13 Table 2 Clinical and biochemical variables significantly influencing achievement of ROSC were dichotomized using discriminant values derived by constructing ROC curves for each variable Non-ROSC group (n = 91) ROSC group (n = 28) P Odds ratio (95% CI) Etiology ( ) Nontrauma 70 (76.9%) 24 (85.7%) Trauma 21 (23.1%) 4 (14.3%) Bystander CPR ( ) Absent 83 (91.2%) 26 (92.6%) Present 8 (8.8%) 2 (7.4%) Initial cardiac rhythm ( ) Nonshockable 73 (80.2%) 18 (64.3%) Shockable 18 (19.8%) 10 (35.7%) Ammonia (μmol/l) b ( ) b (5.5%) 21 (75.0%) (94.5%) 7 (25.0%) pnh 3 (10 5 mm Hg) b ( ) b (25.3%) 20 (71.4%) (74.7%) 8 (28.6%) ALT (U/L) b ( ) b (40.7%) 19 (67.9%) (59.3%) 9 (32.1%) Creatinine (mg/dl) ( ) b (7.7%) 3 (10.7%) (92.3%) 25 (89.3%) Potassium (mmol/l) b ( ) b (42.8%) 19 (67.9%) (58.2%) 9 (32.1%) ph.33 N/A b (96.7%) 28 (100%) (3.3%) 0 (0%) PCO 2 (mm Hg) b ( ) b (52.7%) 26 (92.9%) (47.3%) 2 (7.1%) Odds ratio with 95% CI for each variable was listed. N/A indicates not applicable. diagnostic accuracy and posttest odds ratio of ammonia levels for non-rosc were also better than those of pnh 3 (89.9% vs 73.9% and 12.3 vs 8.5, respectively). The multivariate analysis confirmed that the odds ratio of ammonia for non-rosc was much higher than that of pnh 3 (51.6 vs 7.4), as shown in Table Discussion We found that the ammonia levels at ED arrival were significantly higher among non-rosc patients than among ROSC patients. The optimal cutoff level for ammonia that was predictive for non-rosc in this study was 84 μmol/l. Our findings are consistent with the results of previous studies. Nagamine [25] found that a blood ammonia level of less than 180 μg/dl (105.6 μmol/l) was predictive for full neurologic recovery in witnessed OHCA patients. Yanagawa et al [26] showed that ammonia levels were significantly higher among the survivors with higher cerebral performance category (CPC) scores 1 month after cardiac arrest than among survivors with lower CPC scores (327 vs 124 μg/dl, P =.001). Shinozaki et al [18] also reported that a blood ammonia level above 170 μg/dl (99.8 μmol/l) was independently predictive of higher CPC scores 6 months of cardiac arrest. The pkbh of ammonia, which is approximately 8.90 at 37 C [24], is close to the normal blood ph of 7.4. Any change in blood ph would significantly affect the ratio of nonionized to ionized ammonia. A greater percentage of ammonia may enter the brain as the blood ph rises because of an increase in the amount of ammonia present in its nonionized form. Bhatia et al [17] demonstrated that an arterial ammonia level greater than over equal to 124 μmol/ L had a diagnostic accuracy of 77.5% for predicting mortality in patients with acute hepatic failure. However, their study showed no significant difference in prognostic values between the total blood ammonia level and pnh 3.In our study, we found that the blood ammonia level was superior to pnh 3 for predicting non-rosc among OHCA patients. The blood ammonia level alone may then suffice for predictive purposes. Hyperammonemia may result from an increased production of ammonia. In mammals, skeletal muscle and
7 14 C.-H. Lin et al. intestinal mucosa are major contributors to ammonia production [27]. Protein is broken down, and glutamate is transaminated to form glutamine in the skeletal muscles. Glutamine is the temporary storage form of waste nitrogen and is a major source of ammonia if deaminated by glutaminase. In the intestinal mucosa, ammonia is produced after the uptake of amino acids because of glutamine deamination. 5 -adenosine monophosphate deaminase, which can destroy adenosine [28,29] and cause systolic arrest or arrhythmia [30], generates ammonia from adenosine monophosphate during muscle contraction and rigor mortis [31]. Nagamine [25] found that the blood ammonia level of OHCA patients at hospital arrival was positively correlated with the time elapsed from confirmation of cardiac arrest to hospital arrival. Previous studies have also shown a strong correlation between the processes of blood lactate and ammonia production in anaerobic exercise [32,33]. Ishida et al [34] reported that the development of respiratory and metabolic acidosis during cardiac arrest may induce the release of ammonia from red blood cells. Because of these findings, we hypothesize that hyperammonemia may result from an increase in the production of ammonia when the tissues are in a state of oxygen depletion due to cardiac arrest. The amount of ammonia production may correlate with the time elapsed from cardiac arrest. The blood ammonia level can then be predictive of non-rosc of OHCA patients. Hyperammonemia may also result from a decrease in the elimination of ammonia. The liver and kidney are responsible for the detoxification of portal ammonia and the export of ammonia. In the kidney, ammonia is formed from glutamine deamination. However, renal ammonia production mainly contributes to the buffering of H+ ions, whereas the excretion of ammonia in urine plays only a minor role in the overall ammonia detoxification [27]. The liver plays a vital role in the detoxification of ammonia because the urea cycle located in periportal hepatocytes detoxifies a vast amount of surplus nitrogen [35]. Pneumatosis intestinalis and hepatic portal venous gas, which most commonly occur secondary to intestinal ischemia and necrosis, have been observed in patients after CPR [36,37] and are associated with grave outcomes [38]. The poor mesenteric and portal perfusion in patients during cardiac arrest even with CPR may cause hypoxic hepatocytic necrosis and thus impair ammonia elimination. Pneumatosis intestinalis may affect the intestinal microorganisms with enzymes, which may enable protein and urea degradation and lead to hyperammonemia [39]. The pathogenesis of hyperammonemia may include impaired bioenergetics, altered neurotransmission, glutamate-mediated excitotoxicity, electrophysiologic derangements, oxidative and nitrosative stress, and mitochondrial dysfunction [40-43]. Ammonia is mainly toxic to the brain, and most of the complications associated with hyperammonemia are neurologic. Hypothermia has been reported to decrease cerebral edema and improve encephalopathy in patients with acute hepatic failure through reducing cerebral uptake of ammonia [40]. Hyperammonemia was also reported to be predictive of poor neurologic outcomes in nontraumatic OHCA patients [18,25]. We found that hyperammonemia was independently predictive of non-rosc in OHCA patients. The findings of this study may offer useful information on the clinical management of OHCA patients. Physicians should consider terminating resuscitation efforts for OHCA patients if the initial ammonia levels are extremely high. Further studies are also needed to clarify the pathophysiologic significance of ammonia and the mechanism of hyperammonemia in patients with cardiac arrest Limitations The blood samples were collected from the femoral vessels of OHCA patients on ED arrival. However, we could not be sure whether the blood was arterial or venous due to the technical difficulties of blood sampling during resuscitation. To our knowledge, the difference in the ammonia levels of arterial and venous blood during resuscitation has not been determined. The blood samples in this study were obtained from patients within 5 minutes after ED arrival. We did not analyze the correlation of the blood ammonia level with the time elapsed from confirmation of cardiac arrest to ED arrival. Our study included both witnessed and unwitnessed cardiac arrest patients, and thus, the time between arrest and laboratory sampling was unknown in some patients. An awareness of the laboratory reports of biomarkers in this study was not blinded. However, therapeutic decisions were not biased because the physicians in charge of OHCA patients could not know the optical cutoff values until the study was completed. The results of ammonia levels were obtained within 15 minutes in this study. Using ammonia levels to predict ROSC would be more feasible and practical if the results were obtained sooner. 5. Conclusions A blood ammonia level on ED arrival greater than 84 μmol/l was 94.5% sensitive and 75.0% specific for predicting non-rosc in OHCA patients with a diagnostic accuracy of 89.9%. The predictive value of the blood ammonia level for non-rosc is better than that of the pnh 3. References [1] Eisenberg MS, Cummins RO, Larsen MP. Numerators, denominators, and survival rates: reporting survival from out-of-hospital cardiac arrest. Am J Emerg Med 1991;9:544-6.
8 Prognostic values of blood ammonia and partial pressure of ammonia 15 [2] Pepe PE, Levine RL, Fromm Jr RE, et al. Cardiac arrest presenting with rhythms other than ventricular fibrillation: contribution of resuscitative efforts toward total survivorship. Crit Care Med 1993;21: [3] Weston CF, Wilson RJ, Jones SD. Predicting survival from out-ofhospital cardiac arrest: a multivariate analysis. Resuscitation 1997;34: [4] Mashiko K, Otsuka T, Shimazaki S, et al. An outcome study of out-ofhospital cardiac arrest using the Utstein template a Japanese experience. Resuscitation 2002;55: [5] Booth CM, Boone RH, Tomlinson G, et al. Is this patient dead, vegetative, or severely neurologically impaired? Assessing outcome for comatose survivors of cardiac arrest. JAMA 2004;291: [6] Edgren E, Hedstrand U, Kelsey S, et al. Assessment of neurological prognosis in comatose survivors of cardiac arrest. BRCT I Study Group. Lancet 1994;343: [7] Madl C, Grimm G, Kramer L, et al. Early prediction of individual outcome after cardiopulmonary resuscitation. Lancet 1993;341: [8] Levine RL, Wayne MA, Miller CC. End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest. N Engl J Med 1997;337: [9] Ahrens T, Schallom L, Bettorf K, et al. End-tidal carbon dioxide measurements as a prognostic indicator of outcome in cardiac arrest. Am J Crit Care 2001;10: [10] Bottiger BW, Mobes S, Glatzer R, et al. Astroglial protein S-100 is an early and sensitive marker of hypoxic brain damage and outcome after cardiac arrest in humans. Circulation 2001;103: [11] Fogel W, Krieger D, Veith M, et al. Serum neuron-specific enolase as early predictor of outcome after cardiac arrest. Crit Care Med 1997;25: [12] Mullner M, Sterz F, Binder M, et al. Blood glucose concentration after cardiopulmonary resuscitation influences functional neurological recovery in human cardiac arrest survivors. J Cereb Blood Flow Metab 1997;17: [13] Mullner M, Sterz F, Domanovits H, et al. The association between blood lactate concentration on admission, duration of cardiac arrest, and functional neurological recovery in patients resuscitated from ventricular fibrillation. Intensive Care Med 1997;23: [14] Sodeck GH, Domanovits H, Sterz F, et al. Can brain natriuretic peptide predict outcome after cardiac arrest? An observational study. Resuscitation 2007;74: [15] Kramer L, Jordan B, Druml W, et al. Incidence and prognosis of early hepatic dysfunction in critically ill patients a prospective multicenter study. Crit Care Med 2007;35: [16] Clay AS, Hainline BE. Hyperammonemia in the ICU. Chest 2007;132: [17] Bhatia V, Singh R, Acharya SK. Predictive value of arterial ammonia for complications and outcome in acute liver failure. Gut 2006;55: [18] Shinozaki K, Oda S, Sadahiro T, et al. Blood ammonia and lactate levels on hospital arrival as a predictive biomarker in patients with outof-hospital cardiac arrest. Resuscitation 2011;82: [19] Warren KS, Nathan DG. The passage of ammonia across the bloodbrain-barrier and its relation to blood ph. J Clin Invest 1958;37: [20] Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122:S [21] Cummins RO, Chamberlain DA, Abramson NS, et al. Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein Style. Task Force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council. Ann Emerg Med 1991;20: [22] Jacobs I, Nadkarni V, Bahr J, et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries. A statement for healthcare professionals from a task force of the international liaison committee on resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa). Resuscitation 2004;63: [23] 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005; 112:IV [24] Manning RT. A nomogram for estimation of pnh 3. J Lab Clin Med 1964;63: [25] Nagamine K. Does blood ammonia level at time of initial treatment predict the outcome of patients in cardiopulmonary arrest on arrival? J Jpn Assoc Acute Med 2005;16: [26] Yanagawa Y, Sakamoto T, Sato H. Relationship between laboratory findings and the outcome of cardiopulmonary arrest. Am J Emerg Med 2009;27: [27] Haberle J. Clinical practice: the management of hyperammonemia. Eur J Pediatr 2011;170: [28] Baer HP, Drummond GI, Duncan EL. Formation and deamination of adenosine by cardiac muscle enzymes. Mol Pharmacol 1966;2: [29] Clarke DA, Davoll J, Philips FS, et al. Enzymatic deamination and vasodepressor effects of adenosine analogs. J Pharmacol Exp Ther 1952;106: [30] Askari A, Rao SN. Regulation of AMP deaminase by 2,3-diphosphoglyceric acid: a possible mechanism for the control of adenine nucleotide metabolism in human erythrocytes. Biochim Biophys Acta 1968;151: [31] Bendall JR, Davey CL. Ammonia liberation during rigor mortis and its relation to changes in the adenine and inosine nucleotides of rabbit muscle. Biochim Biophys Acta 1957;26: [32] Itoh H, Ohkuwa T. Ammonia and lactate in the blood after short-term sprint exercise. Eur J Appl Physiol Occup Physiol 1991;62:22-5. [33] Itoh H, Ohkuwa T, Yamazaki Y, et al. Human blood lactate and ammonia levels after supramaximal uphill and downhill running. Nagoya J Med Sci 1996;59: [34] Ishida H, Mastuoka T, Yokota J, et al. The clinical significance of an increase in the blood concentration of ammonia in cases with cardiopulmonary arrest on arrival. J Jpn Soc Emerg Med 2002;5: [35] Haussinger D. Nitrogen metabolism in liver: structural and functional organization and physiological relevance. Biochem J 1990;267: [36] Lai CF, Chang WT, Liang PC, et al. Pneumatosis intestinalis and hepatic portal venous gas after CPR. Am J Emerg Med 2005;23: [37] Reuter H, Bangard C, Gerhardt F, et al. Extensive hepatic portal venous gas and gastric emphysema after successful resuscitation. Resuscitation 2011;82: [38] Lien WC, Chang WT, Huang SP, et al. Hepatic portal venous gas associated with poor outcome in out-of-hospital cardiac arrest patients. Resuscitation 2004;60: [39] Windmueller HG. Glutamine utilization by the small intestine. Adv Enzymol Relat Areas Mol Biol 1982;53: [40] Felipo V, Butterworth RF. Neurobiology of ammonia. Prog Neurobiol 2002;67: [41] Norenberg MD. Oxidative and nitrosative stress in ammonia neurotoxicity. Hepatology 2003;37: [42] Norenberg MD, Rama Rao KV, Jayakumar AR. Signaling factors in the mechanism of ammonia neurotoxicity. Metab Brain Dis 2009;24: [43] Rose C, Michalak A, Pannunzio M, et al. Mild hypothermia delays the onset of coma and prevents brain edema and extracellular brain glutamate accumulation in rats with acute liver failure. Hepatology 2000;31:872-7.
In the past decade, two large randomized
Mild therapeutic hypothermia improves outcomes compared with normothermia in cardiac-arrest patients a retrospective chart review* David Hörburger, MD; Christoph Testori, MD; Fritz Sterz, MD; Harald Herkner,
More informationx = ( A) + (3.296 B) (0.070 C) (1.006 D) + (2.426 E) Receiver Operating Characteristic ROC
7 1... 4. 5. 6. 7. 8. 9. 1. 000 1 01 11 006 01 1 11 6 Glasgow outcome scale GOS GOS 4 n=477 55 A C D 5 ph B E = 1/(1 + e x) x = ( 0.0 A) + (.96 B) (0.070 C) (1.006 D) + (.46 E) 19.489 estimated probability
More informationClinical Significance of Plasma Ammonia in Patients with Generalized Convulsion
ORIGINAL ARTICLE Clinical Significance of Plasma Ammonia in Patients with Generalized Convulsion Kouichi Tomita 1,NorioOtani 2,FumioOmata 3,4 and Shinichi Ishimatsu 1,2 Abstract Background Plasma ammonia
More informationPatient Case. Post cardiac arrest pathophysiology 10/19/2017. Disclosure. Objectives. Patient Case-TM
Disclosure TARGETED TEMPERATURE MANAGEMENT POST CARDIAC ARREST I have nothing to disclose concerning possible financial or personal relationships with commercial entities that may have a direct or indirect
More informationCPR What Works, What Doesn t
Resuscitation 2017 ECMO and ECLS April 1, 2017 Corey M. Slovis, M.D. Vanderbilt University Medical Center Metro Nashville Fire Department Nashville International Airport Nashville, TN Circulation 2013;128:417-35
More informationUpdate on Sudden Cardiac Death and Resuscitation
Update on Sudden Cardiac Death and Resuscitation Ashish R. Panchal, MD, PhD Medical Director Center for Emergency Medical Services Assistant Professor Clinical Department of Emergency Medicine The Ohio
More informationDisclosures. Pediatrician Financial: none Volunteer :
Brain Resuscitation Neurocritical Care Monitoring & Therapies CCCF November 2, 2016 Anne-Marie Guerguerian Critical Care Medicine, The Hospital for Sick Children University of Toronto Disclosures Pediatrician
More informationSupplementary Online Content
Supplementary Online Content Hasegawa K, Hiraide A, Chang Y, Brown DFM. Association of prehospital advancied airway management with neurologic outcome and survival in patients with out-of-hospital cardiac
More informationLesson learnt from big trials. Sung Phil Chung, MD Gangnam Severance Hospital, Yonsei Univ.
Lesson learnt from big trials Sung Phil Chung, MD Gangnam Severance Hospital, Yonsei Univ. Trend of cardiac arrest research 1400 1200 1000 800 600 400 200 0 2008 2009 2010 2011 2012 2013 2014 2015 2016
More informationKiehl EL, 1,2 Parker AM, 1 Matar RM, 2 Gottbrecht M, 1 Johansen MC, 1 Adams MP, 1 Griffiths LA, 2 Bidwell KL, 1 Menon V, 2 Enfield KB, 1 Gimple LW 1
C-GRApH: A Validated Scoring System For The Early Risk Stratification Of Neurologic Outcomes After Out-of-hospital Cardiac Arrest Treated With Therapeutic Hypothermia Kiehl EL, 1,2 Parker AM, 1 Matar RM,
More informationAmmonia level at admission predicts in-hospital mortality for patients with alcoholic hepatitis
Gastroenterology Report, 5(3), 2017, 232 236 doi: 10.1093/gastro/gow010 Advance Access Publication Date: 1 May 2016 Original article ORIGINAL ARTICLE Ammonia level at admission predicts in-hospital mortality
More informationOut-of-hospital cardiac arrest: incidence, process of care, and outcomes in an urban city, Korea
Clin Exp Emerg Med 2014;1(2):94-100 http://dx.doi.org/10.15441/ceem.14.021 Out-of-hospital cardiac arrest: incidence, process of care, and outcomes in an urban city, Korea Hanjin Cho 1, Sungwoo Moon 1,
More informationUpdate on Sudden Cardiac Death and Resuscitation
Update on Sudden Cardiac Death and Resuscitation Ashish R. Panchal, MD, PhD Medical Director Center for Emergency Medical Services Assistant Professor Clinical Department of Emergency Medicine The Ohio
More informationChapter 19 Detection of ROSC in Patients with Cardiac Arrest During Chest Compression Using NIRS: A Pilot Study
Chapter 19 Detection of ROSC in Patients with Cardiac Arrest During Chest Compression Using NIRS: A Pilot Study Tsukasa Yagi, Ken Nagao, Tsuyoshi Kawamorita, Taketomo Soga, Mitsuru Ishii, Nobutaka Chiba,
More informationOut-of-hospital Cardiac Arrest. Franz R. Eberli MD, FESC, FAHA Cardiology Triemli Hospital Zurich, Switzerland
Out-of-hospital Cardiac Arrest Franz R. Eberli MD, FESC, FAHA Cardiology Triemli Hospital Zurich, Switzerland Conflict of Interest I have no conflict of interest to disclose regarding this presentation.
More informationProtocol. This trial protocol has been provided by the authors to give readers additional information about their work.
Protocol This trial protocol has been provided by the authors to give readers additional information about their work. Protocol for: Hasselqvist-Ax I, Riva G, Herlitz J, et al. Early cardiopulmonary resuscitation
More informationStayin Alive: Pediatric Advanced Life Support (PALS) Updated Guidelines
Stayin Alive: Pediatric Advanced Life Support (PALS) Updated Guidelines Margaret Oates, PharmD, BCPPS Pediatric Critical Care Specialist GSHP Summer Meeting July 16, 2016 Disclosures I have nothing to
More informationOutcomes of Therapeutic Hypothermia in Cardiac Arrest. Saad Mohammed Shariff, MBBS Aravind Herle, MD, FACC
Outcomes of Therapeutic Hypothermia in Cardiac Arrest Saad Mohammed Shariff, MBBS Aravind Herle, MD, FACC https://my.americanheart.org/idc/groups/ahamah-public/@wcm/@sop/@scon/documents/downloadable/ucm_427331.pdf
More informationHypothermia: The Science and Recommendations (In-hospital and Out)
Hypothermia: The Science and Recommendations (In-hospital and Out) L. Kristin Newby, MD, MHS Professor of Medicine Duke University Medical Center Chair, Council on Clinical Cardiology, AHA President, Society
More informationTomohide Komatsu, Kosaku Kinoshita, Atsushi Sakurai, Takashi Moriya, Junko Yamaguchi, Atsunori Sugita, Rikimaru Kogawa, Katsuhisa Tanjoh
Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan Correspondence to Dr Atsushi Sakurai, Division of Emergency
More informationOutcomes from out-of-hospital cardiac arrest in Detroit
Resuscitation (2007) 72, 59 65 CLINICAL PAPER Outcomes from out-of-hospital cardiac arrest in Detroit Robert B. Dunne a,, Scott Compton a,b,c,d, R.J. Zalenski b, Robert Swor c, Robert Welch d, Brooks F.
More informationScience Behind Resuscitation. Vic Parwani, MD ED Medical Director CarolinaEast Health System August 6 th, 2013
Science Behind Resuscitation Vic Parwani, MD ED Medical Director CarolinaEast Health System August 6 th, 2013 Conflict of Interest No Financial or Industrial Conflicts Slides: Drs. Nelson, Cole and Larabee
More informationOutcomes of Cardiopulmonary Resuscitation Performed in Emergency Department, Hospital Universiti Sains Malaysia
ORIGINAL ARTICLE Outcomes of Cardiopulmonary Resuscitation Performed in Emergency Department, Hospital Universiti Sains Malaysia K S Chew*, Z M Idzwan*, N A R Hisamuddin*, J Kamaruddin**, W A Wan Aasim**
More information2015 Interim Training Materials
2015 Interim Training Materials ACLS Manual and ACLS EP Manual Comparison Chart Assessment sequence Manual, Part 2: The Systematic Approach, and Part BLS Changes The HCP should check for response while
More informationResuscitation Science : Advancing Care for the Sickest Patients
Resuscitation Science : Advancing Care for the Sickest Patients William Hallinan University of Rochester What is resuscitation science? Simply the science of resuscitation : Pre arrest Arrest care Medical
More informationWORKSHEET for Evidence-Based Review of Science for Veterinary CPCR
RECOVER 2011 1 of 6 WORKSHEET for Evidence-Based Review of Science for Veterinary CPCR 1. Basic Demographics Worksheet author(s) James Barr Mailing address: 4474 TAMU Texas A&M University College Station,
More informationObjectives. Trends in Resuscitation POST-CARDIAC ARREST CARE: WHAT S THE EVIDENCE?
POST-CARDIAC ARREST CARE: WHAT S THE EVIDENCE? Nicole Kupchik RN, MN, CCNS, CCRN, PCCN, CMC Objectives Discuss the 2015 AHA Guideline Updates for Post- Arrest Care Discuss oxygenation & hemodynamic taregts
More informationJohnson County Emergency Medical Services Page 23
Non-resuscitation Situations: Resuscitation should not be initiated in the following situations: Prolonged arrest as evidenced by lividity in dependent parts, rigor mortis, tissue decomposition, or generalized
More informationIn-hospital Care of the Post-Cardiac Arrest Patient. David A. Pearson, MD, FACEP, FAAEM Associate Program Director Department of Emergency Medicine
In-hospital Care of the Post-Cardiac Arrest Patient David A. Pearson, MD, FACEP, FAAEM Associate Program Director Department of Emergency Medicine Disclosures I have no financial interest, arrangement,
More informationIntroduction. Original Article
Acute and Critical Care 2018 May 33(2):83-88 / ISSN 2586-6052 (Print) ㆍ ISSN 2586-6060 (Online) Original Article APACHE II Score Immediately after Cardiac Arrest as a Predictor of Good Neurological Outcome
More informationPost Cardiac Arrest Care 2015 American Heart Association Guideline Update for CPR and Emergency Cardiovascular Care
Post Cardiac Arrest Care 2015 American Heart Association Guideline Update for CPR and Emergency Cardiovascular Care รศ.ดร.พญ.ต นหยง พ พานเมฆาภรณ ภาคว ชาว ส ญญ ว ทยา คณะแพทยศาสตร มหาว ทยาล ยเช ยงใหม System
More informationDisclosures. Extra-Corporeal Membrane Oxygenation During Cardio- Pulmonary Resuscitation ECPR April 22, 2016 ECG. Case. Case. Case Summary 4/22/2016
Extra-Corporeal Membrane Oxygenation During Cardio- Pulmonary Resuscitation ECPR April 22, 2016 Nothing to disclose. Disclosures Ivan J Chavez MD Case ECG History 60 y/o male No prior history of CAD In
More informationCardiopulmonary Resuscitation in Adults
Cardiopulmonary Resuscitation in Adults Fatma Özdemir, MD Emergency Deparment of Uludag University Faculty of Medicine OVERVIEW Introduction Pathophysiology BLS algorithm ALS algorithm Post resuscitation
More informationVictorian Ambulance Cardiac Arrest Registry (VACAR)
Victorian Ambulance Cardiac Arrest Registry (VACAR) Dr Karen Smith (PhD) VACAR Chair Manager Research and Evaluation Ambulance Victoria Smith K, Bray J, Barnes V, Lodder M, Cameron P, Bernard S and Currell
More informationAdvanced Resuscitation - Child
C02C Resuscitation 2017-03-23 1 up to 10 years Office of the Medical Director Advanced Resuscitation - Child Intermediate Advanced Critical From PRIMARY ASSESSMENT Known or suspected hypothermia Algorithm
More informationChanging Demographics in Death After Devastating Brain Injury
Changing Demographics in Death After Devastating Brain Injury Andreas H. Kramer MD MSc FRCPC Departments of Critical Care Medicine & Clinical Neurosciences Foothills Medical Center, University of Calgary
More informationAdvanced Resuscitation - Adult
C02A Resuscitation 2017-03-23 17 years & older Office of the Medical Director Advanced Resuscitation - Adult Intermediate Advanced Critical From PRIMARY ASSESSMENT Known or suspected hypothermia Algorithm
More informationSerum neutrophil gelatinase-associated lipocalin levels predict the neurological outcomes of out-of-hospital cardiac arrest victims
Kaneko et al. BMC Cardiovascular Disorders (2017) 17:111 DOI 10.1186/s12872-017-0545-y RESEARCH ARTICLE Open Access Serum neutrophil gelatinase-associated lipocalin levels predict the neurological outcomes
More informationOver the last 3 decades, advances in the understanding of
Temporal Trends in Sudden Cardiac Arrest A 25-Year Emergency Medical Services Perspective Thomas D. Rea, MD, MPH; Mickey S. Eisenberg, MD, PhD; Linda J. Becker, MA; John A. Murray, MD; Thomas Hearne, PhD
More informationA mong patients who have an out-of-hospital cardiac
1114 CARDIOVASCULAR MEDICINE Can we define patients with no chance of survival after outof-hospital cardiac arrest? J Herlitz, J Engdahl, L Svensson, M Young, K-A Ängquist, S Holmberg... See end of article
More informationEpinephrine Cardiovascular Emergencies Symposium 2018
Epinephrine Cardiovascular Emergencies Symposium 218 Corey M. Slovis, M.D. Vanderbilt University Medical Center Metro Nashville Fire Department Nashville International Airport Nashville, TN High Quality
More informationPost-Resuscitation Care. Prof. Wilhelm Behringer Center of Emergency Medicine University of Jena
Post-Resuscitation Care Prof. Wilhelm Behringer Center of Emergency Medicine University of Jena Conflict of interest Emcools Shareholder and founder, honoraria Zoll: honoraria Bard: honoraria, nephew works
More informationKey statistics from the National Cardiac Arrest Audit: Paediatric arrests April 2012 to March 2017
Key statistics from the National Cardiac Arrest Audit: Paediatric arrests April 12 to March 17 Supported by Resuscitation Council (UK) and Intensive Care National Audit & Research Centre (ICNARC) Data
More informationDECLARATION OF CONFLICT OF INTEREST. Research grants: Sanofi-Aventis
DECLARATION OF CONFLICT OF INTEREST Research grants: Sanofi-Aventis Invasive management after cardiac arrest Nikolaos I Nikolaou FESC, FERC Athens, Greece Survival (%) Survival from Out of Hospital Cardiac
More information2016 Top Papers in Critical Care
2016 Top Papers in Critical Care Briana Witherspoon DNP, APRN, ACNP-BC Assistant Director of Advanced Practice, Neuroscience Assistant in Division of Critical Care, Department of Anesthesiology Neuroscience
More informationNo social problems noted No past med hx Mother had spontaneous rupture of fetal membranes SB born on Needed to be resuscitated at birth
No social problems noted No past med hx Mother had spontaneous rupture of fetal membranes SB born on 9-16-2011 Needed to be resuscitated at birth (included assisted vent) Had generalized edema and possible
More informationDevelopments in Cardiopulmonary Resuscitation Guidelines
Developments in Cardiopulmonary Resuscitation Guidelines Bernd W. Böttiger Seite 1 To preserve human life by making high quality resuscitation available to all Outcome after CPR in Germany ROSC ( Return
More informationAfter this review our system decided to implement guidelines which allowed EMS personnel to
How far is too far? A review of the evidence for Prehospital Termination of Resuscitation after Cardiac Arrest Shalu S. Patel, MD Christine Van Dillen MD University of Florida-Gainesville Out-of-hospital
More informationManagement of Cardiac Arrest Based on : 2010 American Heart Association Guidelines
Management of Cardiac Arrest Based on : 2010 American Heart Association Guidelines www.circ.ahajournals.org Elham Pishbin. M.D Assistant Professor of Emergency Medicine MUMS C H E S Advanced Life Support
More informationPOTENTIAL UTILITY OF NEAR-INFRARED SPECTROSCOPY IN OUT-OF-HOSPITAL CARDIAC ARREST: AN ILLUSTRATIVE CASE SERIES
POTENTIAL UTILITY OF NEAR-INFRARED SPECTROSCOPY IN OUT-OF-HOSPITAL CARDIAC ARREST: AN ILLUSTRATIVE CASE SERIES Adam Frisch, MD, Brian P. Suffoletto, MD, MS, Rachel Frank, EMT, Christian Martin-Gill, MD,
More informationMichigan Pediatric Cardiac Protocols. Date: November 15, 2012 Page 1 of 1 TABLE OF CONTENTS
Date: November 15, 2012 Page 1 of 1 TABLE OF CONTENTS Pediatric Asystole Section 4-1 Pediatric Bradycardia Section 4-2 Pediatric Cardiac Arrest General Section 4-3 Pediatric Narrow Complex Tachycardia
More information2015 AHA Guidelines: Pediatric Updates
2015 AHA Guidelines: Pediatric Updates Advances in Pediatric Emergency Medicine December 9, 2016 Karen O Connell, MD, MEd Associate Professor of Pediatrics and Emergency Medicine Emergency Medicine and
More informationThe ARREST Trial: Amiodarone for Resuscitation After Out-of-Hospital Cardiac Arrest Due to Ventricular Fibrillation
The ARREST Trial: Amiodarone for Resuscitation After Out-of-Hospital Cardiac Arrest Due to Ventricular Fibrillation Introduction The ARREST (Amiodarone in out-of-hospital Resuscitation of REfractory Sustained
More informationResearch Article Identifying Prognostic Criteria for Survival after Resuscitation Assisted by Extracorporeal Membrane Oxygenation
Critical Care Research and Practice Volume 2016, Article ID 9521091, 5 pages http://dx.doi.org/10.1155/2016/9521091 Research Article Identifying Prognostic Criteria for Survival after Resuscitation Assisted
More informationScience Behind CPR Update from Darrell Nelson, MD, FACEP Emergency Medicine Wake Forest University Health Sciences
Science Behind CPR Update from 2010 Darrell Nelson, MD, FACEP Emergency Medicine Wake Forest University Health Sciences FRAMING THE DISCUSSION NO ONE SURVIVES CARDIAC ARREST, EXCEPT ON TV Conflicts of
More informationDon t let your patients turn blue! Isn t it about time you used etco 2?
Don t let your patients turn blue! Isn t it about time you used etco 2? American Association of Critical Care Nurses National Teaching Institute Expo Ed 2013 Susan Thibeault MS, CRNA, APRN, CCRN, EMT-P
More informationWORKSHEET for Evidence-Based Review of Science for Veterinary CPCR
RECOVER 2011 1 of 7 WORKSHEET for Evidence-Based Review of Science for Veterinary CPCR 1. Basic Demographics Worksheet author(s) Ann Peruski Date Submitted for review: 18 Apr 2011 Mailing address: 6995
More informationCardiac Arrest January 2017 CPR /3/ Day to Survival Propensity Matched
Cardiac Arrest January 217 Corey M. Slovis, M.D. Vanderbilt University Medical Center Metro Nashville Fire Department Nashville International Airport Nashville, TN CPR 217 Used data based on protocol that
More informationAdvanced Resuscitation - Adolescent
C02B Resuscitation 2017-03-23 10 up to 17 years Office of the Medical Director Advanced Resuscitation - Adolescent Intermediate Advanced Critical From PRIMARY ASSESSMENT Known or suspected hypothermia
More informationi-stat Alinity v Utilization Guide
istat Alinity v Utilization Guide The istat Alinity v delivers blood gas, acidbase, electrolyte, chemistry, and hematology measurements in a completely portable, handheld package. Accuracy is ensured by
More informationPost-Resuscitation Care: Optimizing & Improving Outcomes after Cardiac Arrest. Objectives: U.S. stats
Post-Resuscitation Care: Optimizing & Improving Outcomes after Cardiac Arrest Nicole L. Kupchik RN, MN, CCNS CCRN-CMC Clinical Nurse Specialist Harborview Medical Center Seattle, WA Objectives: At the
More informationECLS: A new frontier for refractory V.Fib and pulseless VT
ECLS: A new frontier for refractory V.Fib and pulseless VT Ernest L. Mazzaferri, Jr. MD, FACC September 15, 2017 Cardiovascular Emergencies: An exploration into the expansion of time-critical diagnosis
More informationin Cardiac Arrest Management Sean Kivlehan, MD, MPH May 2014
in Cardiac Arrest Management Sean Kivlehan, MD, MPH May 2014 1. Capnography 2. Compressions 3. CPR Devices 4. Hypothermia 5. Access 6. Medications Outline Capnography & Termination Significantly Associated
More informationPost-Arrest Care: Beyond Hypothermia
Post-Arrest Care: Beyond Hypothermia Damon Scales MD PhD Department of Critical Care Medicine Sunnybrook Health Sciences Centre University of Toronto Disclosures CIHR Physicians Services Incorporated Main
More informationUniversity of Washington. From the SelectedWorks of Kent M Koprowicz
University of Washington From the SelectedWorks of Kent M Koprowicz 2007 Site variation in EMS Treatment, Transport and Survival in relation to Restoration of Spontaneous Circulation (ROSC) for Adult Out-of-Hospital
More informationContinuation of cardiopulmonary resuscitation in a Chinese hospital after unsuccessful EMS resuscitation
142 Journal of Geriatric Cardiology September 2009 Vol 6 No 3 Clinical Research Continuation of cardiopulmonary resuscitation in a Chinese hospital after unsuccessful EMS resuscitation Xiao-Bo Yang 1,
More informationMinnesota Resuscitation Consortium
Minnesota Resuscitation Consortium Dedicated to reducing deaths due to cardiac arrest in all of Minnesota How will we benchmark our success? What means will we pursue to reach this goal? American Heart
More informationResuscitation 81 (2010) Contents lists available at ScienceDirect. Resuscitation. journal homepage:
Resuscitation 81 (2010) 410 417 Contents lists available at ScienceDirect Resuscitation journal homepage: www.elsevier.com/locate/resuscitation Clinical paper Post-resuscitative clinical features in the
More informationCardiac arrest Cardiac arrest (CA) occurs when the heart ceases to produce an effective pulse and circulate blood It includes four conditions:
Basic Life Support: Cardiopulmonary Resuscitation (CPR). 2017 Lecture prepared by, Amer A. Hasanien RN, CNS, PhD Cardiac arrest Cardiac arrest (CA) occurs when the heart ceases to produce an effective
More informationMichigan Pediatric Cardiac Protocols. Date: November 15, 2012 Page 1 of 1 TABLE OF CONTENTS
Date: November 15, 2012 Page 1 of 1 TABLE OF CONTENTS Pediatric Asystole Section 4-1 Pediatric Bradycardia Section 4-2 Pediatric Cardiac Arrest General Section 4-3 Pediatric Narrow Complex Tachycardia
More informationi-stat Alinity v Utilization Guide
istat Alinity v Utilization Guide The istat Alinity v delivers blood gas, acidbase, electrolyte, chemistry, and hematology results in a completely portable, handheld package. Accuracy is ensured by extensive
More informationWORKSHEET for Evidence-Based Review of Science for Veterinary CPCR
RECOVER 2011 1 of 9 WORKSHEET for Evidence-Based Review of Science for Veterinary CPCR 1. Basic Demographics Worksheet author(s) Nathan Peterson Date Submitted for review: 7/19/11 Mailing address: 1818
More informationVanderbiltEM.com. Prehospital STEMIs. EMS Today 2018 Research That Should Be On Your Radar Screen 3/1/2018
EMS Today 2018 Research That Should Be On Your Radar Screen Corey M. Slovis, M.D. Vanderbilt University Medical Center Metro Nashville Fire Department Nashville International Airport Nashville, TN VanderbiltEM.com
More informationDisclosure. Co-investigators 1/23/2015
The impact of chest compression fraction on clinical outcomes from shockable out-of-hospital cardiac arrest during the ROC PRIMED trial Sheldon Cheskes, MD CCFP(EM) FCFP Medical Director, Sunnybrook Centre
More informationFirst Documented Rhythm and Clinical Outcome From In-Hospital Cardiac Arrest Among Children and Adults
ORIGINAL CONTRIBUTION First Documented Rhythm and Clinical Outcome From In-Hospital Among Children and s Vinay M. Nadkarni, MD Gregory Luke Larkin, MD Mary Ann Peberdy, MD Scott M. Carey William Kaye,
More informationChemistry Reference Ranges and Critical Values
Alanine Aminotransferase (ALT, SGPT) 3-9 years 9-18 years 1-9 years 9-18 years 10-25 U/L 10-35 U/L 10-30 U/L 10-25 U/L 10-30 U/L 10-35 U/L 10-25 U/L 10-35 U/L 10-25 U/L 10-20 U/L 10-35 U/L Albumin 0-6
More informationChemistry Reference Ranges and Critical Values
Alanine Aminotransferase (ALT, SGPT) 3-9 years 9-18 years 1-9 years 9-18 years 10-30 U/L 10-30 U/L 10-20 U/L Albumin 0-6 days 6 days - 37 months 37 months - 7 years 7-20 years 2.6-3.6 g/dl 3.4-4.2 g/dl
More informationAny man s death diminishes me, because I am involved in mankind. - John Donne
Any man s death diminishes me, because I am involved in mankind - John Donne Cardiac Arrest in 2011 Where are we? Or where should we be? Michael W. Dailey, MD FACEP Associate Professor of Emergency Medicine
More informationSupplementary Appendix
Supplementary Appendix This appendix has been provided by the authors to give readers additional information about their work. Supplement to: Chan PS, Nallamothu BK, Krumholz HM, et al. Long-term outcomes
More informationPost-Cardiac Arrest Syndrome. MICU Lecture Series
Post-Cardiac Arrest Syndrome MICU Lecture Series Case 58 y/o female collapses at home, family attempts CPR, EMS arrives and notes VF, defibrillation x 3 with return of spontaneous circulation, brought
More informationUrea Cycle Defects. Dr Mick Henderson. Biochemical Genetics Leeds Teaching Hospitals Trust. MetBioNet IEM Introductory Training
Urea Cycle Defects Dr Mick Henderson Biochemical Genetics Leeds Teaching Hospitals Trust The Urea Cycle The urea cycle enables toxic ammonia molecules to be converted to the readily excreted and non toxic
More informationFluid Resuscitation in Critically Ill Patients with Acute Kidney Injury (AKI)
Fluid Resuscitation in Critically Ill Patients with Acute Kidney Injury (AKI) Robert W. Schrier, MD University of Colorado School of Medicine Denver, Colorado USA Prevalence of acute renal failure in Intensive
More informationECG Changes in Patients Treated with Mild Hypothermia after Cardio-pulmonary Resuscitation for Out-of-hospital Cardiac Arrest
ECG Changes in Patients Treated with Mild Hypothermia after Cardio-pulmonary Resuscitation for Out-of-hospital Cardiac Arrest R. Schneider, S. Zimmermann, W.G. Daniel, S. Achenbach Department of Internal
More informationResuscitation Guidelines update. Dr. Luis García-Castrillo Riesgo EuSEM Vice president
Resuscitation Guidelines update Dr. Luis García-Castrillo Riesgo EuSEM Vice president There are no COIs to disclose in this presentation. CPR Mile Stones 1958 -William Kouwenhoven, cardiac massage. 1967
More informationAdvanced airway placement (ETT vs SGA)
Advanced airway placement (ETT vs SGA) Among adults who are in cardiac arrest in any setting (P), does tracheal tube insertion as first advanced airway (I), compared with insertion of a supraglottic airway
More informationAdvanced Cardiac Life Support (ACLS) Science Update 2015
1 2 3 4 5 6 7 8 9 Advanced Cardiac Life Support (ACLS) Science Update 2015 What s New in ACLS for 2015? Adult CPR CPR remains (Compressions, Airway, Breathing Chest compressions has priority over all other
More informationMetabolism of proteins and amino acids
BIOQUÍMICA E BIOLOGIA CELULAR António Ascensão, José Magalhães Metabolism of proteins and amino acids Faculdade de Desporto, Universidade do Porto, 1º Ciclo, 1º Ano 202_2013 Humans degradation of ingested
More informationPOST-CARDIAC ARREST CARE: WHAT HAPPENS AFTER ROSC MATTERS! Emergency Nurses Association
POST-CARDIAC ARREST CARE: WHAT HAPPENS AFTER ROSC MATTERS! Emergency Nurses Association - 2016 Nicole Kupchik MN, RN, CCNS, CCRN, PCCN, CMC Objectives Discuss the 2015 AHA Guideline Updates for Post- Arrest
More informationObjectives. Design: Setting &Patients: Patients. Measurements and Main Results: Common. Adverse events VS Mortality
ADVERSE EVENTS AND THEIR RELATION TO MORTALITY IN OUT-OF-HOSPITAL CARDIAC ARREST PATIENTS TREATED WITH THERAPEUTIC HYPOTHERMIA Reporter R1 吳志華 Supervisor VS 王瑞芳 100.04.02 Niklas Nielsen, MD, PhD; Kjetil
More informationAutomated external defibrillators and survival after in-hospital cardiac arrest: early experience at an Australian teaching hospital
Automated external defibrillators and survival after in-hospital cardiac arrest: early experience at an Australian teaching hospital Roger J Smith, Bernadette B Hickey and John D Santamaria Early defibrillation
More informationBut unfortunately, the first sign of cardiovascular disease is often the last. Chest-Compression-Only Resuscitation Gordon A.
THE UNIVERSITY OF ARIZONA Sarver Heart Center 1 THE UNIVERSITY OF ARIZONA Sarver Heart Center 2 But unfortunately, the first sign of cardiovascular disease is often the last 3 4 1 5 6 7 8 2 Risk of Cardiac
More informationConsensus Paper on Out-of-Hospital Cardiac Arrest in England
Consensus Paper on Out-of-Hospital Cardiac Arrest in England Date: 16 th October 2014 Revision Date: 16 th October 2015 Introduction The purpose of this paper is to bring some clarity to the analysis of
More informationIpotermia terapeutica controversie e TTM 2 Trial Iole Brunetti
Ipotermia terapeutica controversie e TTM 2 Trial Iole Brunetti U.O.C Anestesia e Terapia Intensiva Policlinico San Martino - GENOVA Natural Course of Neurological Recovery Following Cardiac Arrest Cardiac
More informationDepartment of Surgery, Division of Cardiothoracic Surgery
Review of In-Hospital and Out-of-Hospital Cardiac Arrests at a Tertiary Community Hospital for Potential ECPR Rescue Amanda Broderick 1, Jordan Williams 1, Alexandra Maryashina 1, & James Wu, MD 1 1 Department
More informationWORKSHEET for Evidence-Based Review of Science for Veterinary CPCR
RECOVER 2011 1 of 7 WORKSHEET for Evidence-Based Review of Science for Veterinary CPCR 1. Basic Demographics Worksheet author(s) Kate Hopper Mailing address: Dept Vet Surgical & Radiological Sciences Room
More informationRepeated Pneumonia Severity Index Measurement After Admission Increases its Predictive Value for Mortality in Severe Community-acquired Pneumonia
ORIGINAL ARTICLE Repeated Pneumonia Severity Index Measurement After Admission Increases its Predictive Value for Mortality in Severe Community-acquired Pneumonia Chiung-Zuei Chen, 1 Po-Sheng Fan, 2 Chien-Chung
More informationPost-resuscitation care for adults. Jerry Nolan Royal United Hospital Bath
Post-resuscitation care for adults Jerry Nolan Royal United Hospital Bath Post-resuscitation care for adults Titration of inspired oxygen concentration after ROSC Urgent coronary catheterisation and percutaneous
More informationCLINICAL RESEARCH STUDY
CLINICAL RESEARCH STUDY The Effects of Sex on Out-of-Hospital Cardiac Arrest Outcomes Manabu Akahane, MD, PhD, a Toshio Ogawa, MSc, a Soichi Koike, MD, PhD, b Seizan Tanabe, MD, c Hiromasa Horiguchi, PhD,
More informationTargeted temperature management after post-anoxic brain insult: where do we stand?
Targeted temperature management after post-anoxic brain insult: where do we stand? Alain Cariou Intensive Care Unit Cochin University Hospital Paris Descartes University INSERM U970 (France) COI Disclosure
More informationJUST SAY NO? THE LATEST LOOK AT ACLS MEDICATIONS BRIDGETTE SVANCAREK, MD
JUST SAY NO? THE LATEST LOOK AT ACLS MEDICATIONS BRIDGETTE SVANCAREK, MD OBJECTIVES Review the progression of the American Heart Association s ACLS cardiac arrest medication guidelines Identify the latest
More information