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Resuscitation 84 (2013) 129136

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Resuscitation

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Editorial

Resuscitation highlights in 2012

We are delighted to report that the number and quality of manuscripts submitted to Resuscitation continues to rise. We havesummarised below some of the keypapers across the full spectrumof cardiopulmonary resuscitation (CPR).

1. Epidemiology

An analysis of a nationwide registry in South Korea showed thatpoisonings were responsible for 4.4% of 20, 536 out-of-hospitalcardiac arrest (OHCA) cases of non-cardiac aetiology. 1 Poisonsincluded insecticides (15.5%); herbicides (13.2%); unknown pesti-cides (19.9%); non-pesticide drugs (16.8%); and unknown poisons(6%). The survival to admission rate was 22.5% for insecticides,3.2% for herbicides, 16.2% for unknown pesticides, 16.7% for non-pesticides and11.3% forthe unknown poisoningcases.The survivalto dischargerates was9.9%for insecticides, 0.0%for herbicides, 2.1%for unknown pesticides, 3.3% for non-pesticides and 3.2% for theunknown group.

Cardiac arrest from a non-shockable rhythm or non-cardiac

cause comprises a substantial proportion of those who survive tohospital discharge. In a study of 1001 OHCA patients who wereresuscitated and discharged alive, 313/1001 (31%) had presentedwith a non-shockable rhythm and 210/1001 (21%) with non-cardiac aetiology .2 Five-year survival was 43% for non-shockablerhythms compared to 73% for shockable rhythms, and 45% fornon-cardiac aetiology compared to 69% for cardiac aetiology( p < 0.001).

It is unclear how often resuscitation is futile when applied toindividuals who experience OHCA in nursing homes. Of 2350 car-diac arrests in such facilities in Melbourne, Australia from 2000 to2009, bystander CPR had been performed in 66% and a shockablerhythm was present in 7.6% of patients on arrival of paramedics. 3

Survival was less than survival in those aged >70 years of age who

had an OHCA in their own homes (1.8% vs. 4.7%, p = 0.001). Theauthors concluded that survival might be improved by basic lifesupport (BLS) training of nursing home staff and availability of automated external debrillators (AEDs).

Based on thetheoreticalprotectiveeffect of sexhormones, thereis considerable interest in whether age and/or female gender areassociated with survival after OHCA. An analysis of data from 29cities in the U.S. that participate in the Cardiac Arrest Registry toEnhance Survival (CARES) program showed that although femalesof all ages were less likely to have a cardiac arrest in public, or onethat was witnessed or treatablewith debrillation, odds of survivalwere higher in younger females. 4

2. Prevention

Resuscitation continues to be a leading journal for publicationsrelated to rapid response teams (RRTs) and systems and identi-cation of the deteriorating patient. After expansion of the medicalemergency systemto include a mentalhealth facility, it was shownthat the rate of Medical Emergency Team (MET) calls to this facilitywassimilar to that of a tertiary hospital;the staff needed to manageneurological and cardiovascular problems in particular. 5

The ANZICS-CORE MET dose Investigators studied team com-position, resourcing and details of activation criteria from 39Australian hospitals. 6 They showed signicant variation in RRTcomposition, staffskills and activationcriteria.They recommendedimproved resourcing of RRTs, training of the team members, andimproved standardisation of calling criteria. The National EarlyWarning System (NEWS) was introduced into the United Kingdom(UK) in 2012.An abbreviatedversion of theUK-basedVitalPACEWS(ViEWS) scoring system, which is very similar to NEWS, has beenvalidatedin a Canadian hospital. 7 The abbreviated ViEWS score had

comparable discrimination to the original score and had reason-able goodness of t for most patients except for those requiringintensive care.

A retrospective study of the stafng of a RRS documentedthat resident-led RRS may have similar outcomes to attendingintensivist-led events, prompting the suggestion of prospectivestudies to determine ideal team composition. 8 Optimising thedifferent components of the RRS is critical before conclusionscan be made about the efcacy of this intervention. Determin-ing who should lead the team is one component in this. 9 It wasdemonstrated that medication errors are very common duringmedical emergencies and education and systematic changes areneededduringmedicalemergenciesto avoidharm. 10 Otherauthorsfound that observation chart design has a substantial impact on

the decision accuracy and response times of health professionalsand novices in recognising abnormal patient observations. 11 Withincreasing use of electronic systems this may become less of anissue.

The prognostic valueof point-of-care measurement of biomark-ers related to dyspnoea (brain natriuretic peptide (BNP), d -dimer,myoglobin, creatine kinase MB isoenzyme, and troponin I) wasevaluated in patients receiving a medical emergency team (MET)review. 12 Although, BNP and d -dimer were poor discriminants of ICU admission and hospital mortality, normal BNP and d -dimerlevels practically exclude subsequent need for ICU admission andhospital mortality.

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130 Editorial / Resuscitation 84 (2013) 129136

The British Thoracic Society (BTS) has published guidance foroxygen administration and recommends a target SpO 2 of 9498%for most adult patients. Using a large dataset of routinely collectedvital signs from four hospitals, SpO 2 values and mortality wereanalysed among37,593 acutegeneral medical inpatientsbreathingroom air. 13 Mortality (95% CI) for patients with initial SpO 2 valuesof 97%, 96% and 95%was 3.65% (3.224.13); 4.47% (3.995.00); and5.67% (5.036.38),respectively.SpO 2 rangedfrom70% to100%witha median (IQR) of 97% (9598%). These important ndings informreview of further BTS guidelines, and consideration of denitionsof normal oxygen saturation, and encourage study of the impact of oxygenation on outcome. The authors have suggested that the BTSshould consider changing its target saturation for actively treatedpatients not at risk of hypercapnic respiratory failure to 9698%.

Applying what has been learnt from in-hospital identicationof critical illness to the pre-hospital environment, it was shownthat clinical judgement alone has a low sensitivity for critical ill-ness pre-hospital, and the addition of a Modied Early WarningScore (MEWS) improved detection but at the expense of reducedspecicity. 14 An optimal scoring system for identifying critical ill-ness prehospital is awaited.

3. Debrillation

The value of a brief period of CPR before debrillation contin-ues to be studied. Whether a brief period of CPR during prolongedventricular brillation (VF) restores high energy phosphates inthe myocardium was studied using a rat model. 15 After 4 min of untreatedVF, just 2 min of CPRrestoredATP levelsto that of controlrats not in cardiac arrest.

Using a porcine prolonged (8min) VF model, the effect on oxy-gen metabolism and resuscitation outcomes of a shock-rst versusstrategywas comparedwitha CPR-rst approach. 16 The shock-rststrategy resulted in better oxygen metabolism and haemodynamicstatus, although there was no difference in the rates of ROSC or24-h survival. These results are similar to the clinical outcomes

reported in the Resuscitation Outcomes Consortium (ROC) ran-domised clinical trial showing no difference in survival betweengroupsof OHCA patients treated with an early versus a late analysisof cardiac rhythm. 17

4. Resuscitation teams

There has been a steady growth in the number of studiesexamining the evaluation/auditing of resuscitation team per-formance. Investigators have used a variety of methods todocument performance ranging from direct observation 10,18 andchart review 19 downloads from CPR feedback/prompt devices, 20,21

audio recording, 22 video recording, 23,24 analysis of transthoracicimpedance, 25,26 ECG signals 27 and capnography. 28 Whilst most

studies that have used these datafor post eventdebrieng have pro-duced encouraging results, other authors recommend that giventhe cost of implementation, institutions should carefully con-sider implementation as part of a broader quality improvementprogramme. 29

In addition to evaluating technical skill performance, there isgrowing recognition of the importance of non-technical skills suchas team work, leadership, communication, co-ordination, situa-tional awareness, leadership and decision-making. 30,31 A numberof different tools have emerged that can be used to measuredifferent domains of non-technical skills. The performance char-acteristics of two of the more promising tools were compared:the Observational Skill-based Clinical Assessment tool for Resus-citation (OSCAR) and the Team Emergency Assessment Measure

(TEAM) both performed well with high levels of inter-observer

and intra-observer agreement. 32 The TEAM score is a short, simpleto use tool that measures the performance of the entire resusci-tation team over 12 domains. 33 The tool is suggested as usefulwhen a quickglobal perspectiveof resuscitation teamperformanceis required. The OSCAR score measures individual performance inteams covering 48 assessment areas .34 The tool is longer and morecomplex to use but provides information about individual teammembers performance and may have a role in identifying future

trainingneeds.The Simulation TeamAssessment Tool(STAT) evalu-ates both technical and non-technical domains. 35 Evaluationof thistools performance characteristics found similarly good for resultsfor overall performance, basic skills, circulation and human fac-tors, although performed less well in the assessment of airway andbreathingskills.However, asthe tool hasover90 elementsto assess,its use is likely to be limited to the simulation and experimentalsettings.

5. Quality of CPR

Important data on the quality of CPR and its relationship withoutcome emerged during 2012. In a series of large, observationalstudies, new insights into optimal chest compression character-

istics were identied. A relationship between chest compressionrate and depth was identied rst in a simulation study fasterchest compression rates compromised the ability to maintain ade-quate compression depth. 36 These ndings have been veried insubsequent human studies. Among 133 patients receiving CPR forOHCA according to the European Resuscitation Council (ERC) 2005guidelines, chest compression rates exceeding 120 min 1 wereassociated with a lower compression depth (4.5 (SE 0.06) vs. 4.1(SE 0.06), p < 0.001). 37 Taken together with data from the ROCstudy, which recruited 3098 patients in OHCA and found ROSCrates peaked at a compression rate of 125 min 1 ,38 these data rein-force the ERC basic life support guidelines that compression ratefor adults should be between 100120min 1 .39,40

6. Advanced life support

6.1. Airway

The role of advanced airway techniques during CPR is contro-versial. Observational data from the North American ROC epistrycompared tracheal intubation with one of the three supraglotticairway (SGA) devices: laryngeal tube (LT), Combitube, or laryn-geal mask airway (LMA) for 10,455 OHCAs recruited to the ROCPRIMED trial. 41 Survival to hospitaldischargewithmodiedRankinscore 3 was: intubation 4.7%, SGA 3.9%. Successful tracheal intu-bation was associatedwith increased survival to hospital discharge(adjusted OR 1.40; 95% CI 1.04, 1.89), ROSC (adjusted OR 1.78;95% CI 1.54, 2.04) and 24h survival (adjusted OR 1.74; 95% CI

1.49, 2.04) whencomparedwith successfulSGAinsertion.Althoughthese results need to be interpreted with caution, they provide animpetus for a denitive study.

A study of patients in the Korean OHCA database used propen-sity matching to compare outcomes in patients who had trachealintubation, bag mask ventilation or LMA insertion. 42 Overallsurvival to admission was 20.2% and discharge 6.9%. Adjustedoutcomes using propensity-matched samples showed survival toadmission and discharge were similar for tracheal intubation andbag mask. Adjusted survival to admission was similar for LMA andbagmask, butsurvivalto discharge was signicantly lowerfor LMAcompared with bag mask.

A further question mark over the use of SGAs during CPR iswhether they affect carotid blood ow. Insertion of a SGA (LTS-

D, LMA

Flexible, Combitube) during experimental CPR in pigs was


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Editorial / Resuscitation 84 (2013) 129136 131

associated with a decrease in carotid artery blood ow when com-pared with tracheal intubation. 43 AnMRI of an anesthetised patientsuggested that the AirQ SGA did not distort the carotid arteries. 44

Skills for tracheal intubation are not available in all settings andSGAs may be a useful alternative. Intermediate level emergencymedical technicians (EMTs) working in a rural prehospital settinghad a 77% insertion success rate with the LTS-D. 45 In a report fromthe in-hospital setting, the i-gel SGA was inserted successfully bynurses and junior doctors with an 82% rst attempt insertion suc-cess rate and 99% overall success rate. 46 The simplicity of i-geluse compared to other SGAs is leading to its increased use forin-hospital resuscitation whilst awaiting the arrival of an airwayexpert. 47

The Japanese Emergency Airway Network recorded 1486 (502with cardiac arrest) emergency department tracheal intubationswith success rates between hospitals for rst attempts of 4083%,and with up to 3 attempts of 74100%. 48 The overall adverse eventrate was 11% and unrecognised oesophageal intubation (lapse of time and clinical deterioration such as oxygen saturation


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access was much quicker to achieve then central venous accessin patients in whom peripheral venous access was not possible. 73

In a pig cardiac arrest model, intraosseous access by both tibialand sternal routes was effective, although adrenaline bioavailabil-ity was greater with sternal access. 74 Intravenous access and drugscan cause tissue necrosis. The same complication was describedtwo days after adrenaline and thrombolysis given by the tibialintraosseous route during cardiac arrest despite early removal of the intraosseous needle. 75,76 Animal data indicate that electrolytemeasurements of blood taken via intraosseous needles are simi-lar to arterial blood values measured with a handheld cartridgeanalyser. 77

6.7. Trauma

Resuscitation withhaemoglobin-based oxygen carriers (HBOCs)is appealing but safety and effectiveness are still to be demon-strated. The current status of products under development andthosethat have completedphase threeclinical trials werereviewedrecently .78 Transfusionpracticesare inconsistent andit is unknownif some practices improve survival. The PRospective ObservationalMulticenter MajorTrauma Transfusion (PROMMTT) studyenrolled1245 trauma patients admitted to ten Level 1 trauma centres inthe US; 297 received massive transfusions. 79 The collaborationhas demonstrated the feasibilityof prospective trauma transfusionstudies and the observational datacollectedare a valuable resourcefor research in trauma to guide future randomised trials.

Two studies from Melbourne, Australia documented the epi-demiology and outcome from traumatic cardiac arrest in adultsandchildren. 80,81 R esuscitation for traumaticOHCAis oftenconsid-eredfutile and,disappointingly, theirdatafor children support thatconclusion. For adults in this paramedic-based EMS system, resus-citation resulted in a survival of 5% butthe quality of survival needsmore study. While the role of resuscitative thoracotomy is estab-lishedin adult traumaticcardiac arrest, itsrole in paediatric traumais unclear. In one study, the authors concluded that emergent tho-racotomy is a potentially life-saving procedure (10% survived tohospital discharge) for children following traumatic cardiac arrestfrom penetrating trauma to the heart; no blunt trauma patientssurvived. 82

A systolic blood pressure (SBP) of 90mmHg is often used asthe threshold for prioritising penetrating trauma patients, but datafrom the Trauma Audit and Research Network (TARN) between2000 and 2009 indicated that a SBP of


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Editorial / Resuscitation 84 (2013) 129136 133

cardiac arrest patients, the patients who needed active rewarmingdid not have a worse outcome. 100 Neither the speed of rewarmingnor the development of fever had an effect on outcome.

Accurate temperature control during cooling is essential to pre-vent cooling-related side effects. The optimal site of temperaturemeasurement during TH remains controversial. In a prospectiveobservational study of 12 patients assessed during intravascularcooling following cardiac arrest, both nasopharyngeal and urinarybladder temperature measurements were similar to blood temper-atures measured using a pulmonary artery catheter. 101

The mechanism by which TH improves neurological outcomecontinues to be investigated. A study using a rat cardiac arrestmodel showed that post cardiac arrest TH protects selectively vul-nerable cerebellar Purkinje cells even when initiation of coolingwas delayed to 8h. 102

Although most research on TH focuses on its neurologicaleffects, it also has signicant effects on the cardiovascular sys-tem. Other than the bradycardia that usually accompanies TH,and which is probably benecial, there are no additional risks of arrhythmias. 103 In a pig model of VF cardiac arrest, TH attenuatedhistological myocardial injury. 104 In a pig myocardial infarctionmodel, TH did not potentiate diastolic LV failure, but stabilisedhaemodynamics and improved systemic oxygen supply/demandimbalanceby reducing demand. 105 In contrast,in a sheepmodel, THwas associatedwith decreasedventricular function,oxygen extrac-tion and microvascular ow compared to normothermia; 106 thesechanges were associated with increased blood lactate values. Theauthors suggest that TH may impair tissue oxygen delivery throughmaldistribution of capillary ow.

The 2008 International Liaison Committee on Resuscitation(ILCOR)/American Heart Association (AHA) Consensus Statementfor the treatment of PCAS suggests that goal-directed therapy, tar-geting meanarterialpressure(MAP),centralvenous pressure (CVP),and central venous oxygen saturation (ScvO 2 ), should be usedto optimise oxygen delivery. 107 A review of 44 implementationstudies showed that only one-third specied at least one haemo-dynamic goal. The authors conclude that an explicit description of haemodynamic goals should be provided in future studies. 108

7.3. Hyperoxia

The effect of hyperoxia following cardiac arrest remains uncer-tain.In a meta-analysis ofsix animalstudies( n = 95),treatmentwith100% oxygen resulted in a signicantly worse neurological decitscore than oxygen administered at lower concentrations, with astandardised mean difference of 0.64 (95% CI 1.06 to 0.22). 109

However, the authors conclude that the poor generalisability of animal models to human cardiac arrest makes the clinical appli-cability of these data uncertain. In study of 223 children who hadbeen resuscitated after in-hospital cardiac arrest, hyperoxaemiaafter ROSC or24 h laterwas notassociatedwithmortality;however,

hypercapnia andhypocapniawere associatedwith highermortalitythan normocapnia. 110

7.4. Cerebral oxygenation

Cerebral oxygenation measured using near infrared spec-troscopy (NIRS) is being evaluated by several investigators duringandafter cardiacarrest.Regionalcerebral oximetry(rSO 2 )waseval-uated during CPR in 19 patients; the 5 patients achieving ROSChadsignicantlyhighermean rSO 2 values than those not achievingROSC.111 Cerebral oximetry may have a role in predicting ROSC incardiac arrest andis undergoingfurtherevaluation. Thistechnologycould provide real-timefeedback on the quality of CPR betterCPR should result in higher rSO 2 values. This hypothesis was investi-

gatedin 9 patientswith in-hospital cardiac arrest butunfortunately

high quality CPR was not reected signicantly by an increase inrSO2 values. 112 In another study, rSO 2 values were measured in 92patients admitted to hospital in Japan after OHCA and were corre-latedwith outcome. 113 Sixty-one patients with rSO 2 25% showedpoor neurological outcome in the receiver operating curve analy-sis (optimal cut-off point 25%; sensitivity 0.772; specicity 1.000;positive predictive value 1.000; area under the curve (AUC) 0.919; p < 0.0001).

7.5. Coronary revascularisation

Acute coronary angiography with percutaneous coronary inter-vention (PCI) is becoming a standard of care for patients with ROSCafter OHCA and who do not have an obvious non-cardiac cause fortheir cardiac arrest. A systematic review of acute coronary angiog-raphyin patients resuscitated fromOHCA identiedno randomisedcontrolled trials, 10 non-randomised cohort studies and 22 caseseries without controls. 114 The 10 comparison studies demon-strated a pooled unadjusted odds ratio for survival of 2.78 (95%CI 1.894.10) favouring acute coronary angiography. However, afurther small study ( n =70) from Australia did not show a sur-vival advantage for out-of-hospital VF/pVT cardiac arrest patients

undergoing immediate coronary angiography +/ PCI comparedwith those admitted directly to the ICU. 115 The PROCAT (ParisianRegion Out of Hospital Cardiac Arrest) investigators have shownthat among 896 OHCA patients, the use of an early diagnosis proto-col with immediate coronaryangiography and/or CT scanidentiedthe cause of cardiac arrest in nearly two-third of cases. 116

8. Prognostication

Prognostication in the comatose cardiac arrest survivor con-tinues to be challenging and has been made potentially moredifcult following widespread implementation of TH. A reviewof the history of prognostication in anoxicischaemic coma 117

provides valuable background and sets the scene for eagerly antic-ipated revised guidelines.

In a retrospective analysis of 38 comatose PCAS patients treatedwith TH and continuous EEG monitoring (cEEG), 9 (23%) hadelectrographic seizures and 17 (48%) had evidence of epilepti-form activity (electrographic seizures or interictal epileptiformdischarges). 118 Most seizures started before rewarming andevolved from prior interictal epileptiform activity. Ninety-fourpercent (16/17) of patients with epileptiform activity had poorneurological outcome or death at discharge. Early myoclonus incomatose survivors of cardiac arrest is considered a sign of severeglobal brain ischaemia and has been associated with high rates of mortality and poor neurological outcomes. In contrast, is a reporton three cardiac arrest patients treated with TH who had goodneurological outcomes (two patients with a CPC score = 1 and one

patient with a CPC score = 2), despite showing massive myoclonuswithin the rst 4h after ROSC. 119 The authors conclude that earlymyoclonus may not imply a uniformly poor prognosis in patientstreated with TH.

Prediction of the ultimate outcome of individual patients earlyafter ROSC would be very valuable but is currently consideredtoo unreliable. Investigators from Japan have proposed a seven-point score (5-R score: arrest-to-rst CPR interval 5 min, VF/pVT,absence of re-arrest before leaving the emergency department,time to ROSC 30min andrecoveryof pupillarylightreex), whichcan be used in the emergency department to predict ultimateoutcome in patients undergoing TH. 120 A score of 5 predictedgood neurological outcome with a sensitivity of 82.5% (95% con-dence interval [CI], 67.292.7%) and specicity of 92.3% (95% CI,

74.999.1%).


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94. Testori C, Sterz F, Holzer M, et al. The benecial effect of mild therapeutichypothermiadependson thetime of completecirculatorystandstill in patientswith cardiac arrest. Resuscitation 2012;83:596601.

95. Bellomo R, KellumJA, Ronco C. Acute kidneyinjury. Lancet 2012;380:75666.96. Chua HR, Glassford N, Bellomo R. Acute kidney injury after cardiac arrest.

Resuscitation 2012;83:7217.97. Susantitaphong P, Alfayez M, Cohen-Bucay A, Balk EM, Jaber BL. Therapeu-

tic hypothermia and prevention of acute kidney injury: a meta-analysis of randomized controlled trials. Resuscitation 2012;83:15967.

98. Kim YM, Yim HW, Jeong SH, Klem ML, Callaway CW. Does therapeu-tic hypothermia benet adult cardiac arrest patients presenting with

non-shockable initial rhythms?A systematic review and meta-analysisof ran-domized and non-randomized studies. Resuscitation 2012;83:18896.

99. Lundbye JB, Rai M, Ramu B, et al. Therapeutic hypothermia is associated withimproved neurologic outcome and survival in cardiac arrest survivors of non-shockable rhythms. Resuscitation 2012;83:2027.

100. Bouwes A, Robillard LB, Binnekade JM, et al. The inuence of rewarmingafter therapeutic hypothermia on outcome after cardiac arrest. Resuscitation2012;83:9961000.

101. Knapik P, Rychlik W, Duda D, Golyszny R, Borowik D, Ciesla D. Relation-ship between blood, nasopharyngeal and urinary bladder temperature duringintravascular cooling for therapeutic hypothermia after cardiac arrest. Resus-citation 2012;83:20812.

102. Paine MG, Che D, Li L, Neumar RW. Cerebellar Purkinje cell neurodegener-ation after cardiac arrest: effect of therapeutic hypothermia. Resuscitation2012;83:15116.

103. Lebiedz P, Meiners J, Samol A, et al. Electrocardiographic changes during ther-apeutic hypothermia. Resuscitation 2012;83:6026.

104. Lee JH, Suh GJ, KwonWY, et al. Protective effects of therapeutic hypothermiain post-resuscitation myocardium. Resuscitation 2012;83:6339.

105. Schwarzl M, Huber S, Maechler H, et al. Left ventricular diastolic dysfunctionduring acute myocardial infarction: effect of mild hypothermia. Resuscitation2012;83:150310.

106. He X, Su F, Taccone FS, Maciel LK, Vincent JL. Cardiovascular and microvas-cular responses to mild hypothermia in an ovine model . Resusci tation2012;83:7606.

107. NolanJP, Neumar RW, AdrieC, et al. Post-cardiac arrest syndrome: epidemiol-ogy, pathophysiology, treatment, and prognostication. A Scientic Statementfrom the International Liaison Committee on Resuscitation; the AmericanHeart Association Emergency Cardiovascular Care Committee; the Council onCardiovascular Surgeryand Anesthesia;the Councilon Cardiopulmonary,Peri-operative, and Critical Care; the Council on Clinical Cardiology; the Council onStroke. Resuscitation 2008;79:35079.

108. Gaieski DF,NeumarRW, Fuchs B, et al. Haemodynamic management strategiesare not explicitly dened in the majority of therapeutic hypothermia imple-mentation studies. Resuscitation 2012;83:8359.

109. Pilcher J, Weatherall M, Shirtcliffe P, Bellomo R, Young P, Beasley R. The effectof hyperoxiafollowing cardiac arrest a systematic review and meta-analysis

of

animal trials. Resuscitation 2012;83:41722.110. Del Castillo J, Lopez-Herce J, Matamoros M, et al. Hyperoxia, hypocapnia andhypercapnia as outcome factors after cardiac arrest in children. Resuscitation2012;83:145661.

111. Parnia S, Nasir A, ShahC, Patel R, Mani A, Richman P. A feasibility studyevaluat-ingthe roleof cerebraloximetryin predicting returnof spontaneouscirculationin cardiac arrest. Resuscitation 2012;83:9825.

112. Kamarainen A, Sainio M, Olkkola KT,Huhtala H, Tenhunen J, Hoppu S. Qualitycontrolled manual chest compressions and cerebral oxygenation during in-hospital cardiac arrest. Resuscitation 2012;83:13842.

113. ItoN, NantoS, NagaoK, Hatanaka T,Nishiyama K, KaiT. Regional cerebraloxy-gen saturation on hospital arrival is a potential novel predictorof neurologicaloutcomes at hospital dischargein patientswith out-of-hospital cardiac arrest.Resuscitation 2012;83:4650.

114. Larsen JM, Ravkilde J. Acute coronary angiography in patients resuscitatedfrom out-of-hospital cardiac arrest a systematic review and meta-analysis.Resuscitation 2012;83:142733.

115. Nanjayya VB, Nayyar V. Immediate coronary angiogram in comatose sur-vivors of out-of-hospital cardiac arrest an Australian study. Resuscitation

2012;83:699704.116. Chelly J, Mongardon N, Dumas F,et al.Benet of anearlyand systematic imag-

ing procedure after cardiac arrest: insights from the PROCAT (Parisian RegionOut of Hospital Cardiac Arrest) registry. Resuscitation 2012;83:144450.

117. Wijdicks EF. From clinical judgment to odds: a history of prognostication inanoxicischemic coma. Resuscitation 2012;83:9405.

118. Mani R, Schmitt SE, Mazer M, Putt ME, Gaieski DF. The frequency and tim-ing of epileptiform activity on continuous electroencephalogram in comatosepost-cardiac arrest syndrome patients treated with therapeutic hypothermia.Resuscitation 2012;83:8407.

119. Lucas JM, Cocchi MN, Salciccioli J, et al. Neurologic recovery after therapeu-tic hypothermia in patientswith post-cardiac arrest myoclonus. Resuscitation2012;83:2659.

120. Okada K,Ohde S, Otani N,et al.Prediction protocolfor neurologicaloutcomeforsurvivors of out-of-hospital cardiac arrest treated with targeted temperaturemanagement. Resuscitation 2012;83:7349.

121. Oda Y, Tsuruta R, Fujita M, et al. Prediction of the neurological outcome with

intrathecal high mobility group box 1 and S100B in cardiac arrest victims: apilot study. Resuscitation 2012;83:100612.

122. Sugimori H, Kanna T, Yamashita K, et al. Early ndings on brain computedtomography and the prognosisof post-cardiac arrest syndrome: application of the score for stroke patients. Resuscitation 2012;83:84854.

123. Skrifvars MB, Varghese B, Parr MJ. Survival and outcome prediction using theApache III and the out-of-hospital cardiac arrest (OHCA) score in patientstreated in the intensive care unit (ICU) following out-of-hospital, in-hospitalor ICU cardiac arrest. Resuscitation 2012;83:72833.

124. Cha WC, Lee SC, Shin SD, Song KJ, Sung AJ, Hwang SS. Regional isat ion of out-of-hospital cardiac arrest care for patients without prehospital return of spontaneous circulation. Resuscitation 2012;83:133842.

125. Ro YS,ShinSD, Song KJ,et al.A comparison of outcomes of out-of-hospital car-diac arrest with non-cardiac etiology between emergency departments withlow- and high-resuscitation case volume. Resuscitation 2012;83:85561.

126. CudnikMT, Sasson C, ReaTD, et al.Increasing hospitalvolumeis not associatedwith improved survival in out of hospital cardiac arrest of cardiac etiology.Resuscitation 2012;83:8628.

Jerry P. Nolan

Anaesthesia and Intensive Care Medicine,Royal United Hospital, Bath, UK

Joe P. OrnatoDepartment of Emergency Medicine, Virginia

Commonwealth University, Richmond, VA, USA

Michael J.A. Parr a , b , c , da Intensive Care, Liverpool and Macquarie University

Hospitals, Sydney, Australiab University of New South Wales, Sydney, Australia

c University of Western Sydney, Sydney, Australiad Macquarie University, Sydney, Australia

Gavin D. PerkinsCritical Care Medicine, University of Warwick,

Warwick Medical School and Heart of England NHS Foundation Trust, Coventry CV4 7AL, UK

Jasmeet Soar Anaesthesia and Intensive Care Medicine,

Southmead Hospital, North Bristol NHS Trust,Bristol BS10 5NB, UK

Corresponding author. Tel.: +44 7768595911.E-mail addresses: [email protected] (J.P. Nolan),

[email protected] (J.P. Ornato), [email protected](M.J.A. Parr), [email protected] (G.D.

Perkins), [email protected] (J. Soar)

2 January 2013
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]

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