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From February 21 through April 1, 2019, a total of 229 cases of out-of-hospital cardiac arrest were reported in four provinces of Lombardy, Italy. During the same period in 2020 (the first 40 days of the Covid-19 epidemic), 362 cases were reported — a 58% increase. Of the additional 133 cases in 2020, a total of 103 involved suspected or diagnosed Covid-19.

PurposeThe aim of this study was to assess the neurologic outcome following extracorporeal cardiopulmonary resuscitation (ECPR) in five European centers.MethodsRetrospective database analysis of prospective observational cohorts of patients undergoing ECPR (January 2012–December 2016) was performed. The primary outcome was 3-month favorable neurologic outcome (FO), defined as the cerebral performance categories of 1–2. Survival to ICU discharge and the number of patients undergoing organ donation were secondary outcomes. A subgroup of patients with stringent selection criteria (i.e., age ≤ 65 years, witnessed bystander CPR, no major co-morbidity and ECMO implemented within 1 h from arrest) was also analyzed.ResultsA total of 423 patients treated with ECPR were included (median age 57 [48–65] years; male gender 78%); ECPR was initiated for OHCA in 258 (61%) patients. Time from arrest to ECMO implementation was 65 [48–84] min. Eighty patients (19%) had favorable neurological outcome. ICU survival was 24% (n = 102); 23 (5%) non-survivors underwent organ donation procedures. Favorable neurological outcome rate was lower (9% vs. 34%, p < 0.01) in out-of-hospital than in-hospital cardiac arrest and was significantly associated with shorter time from collapse to ECMO. The application of stringent ECPR criteria (n = 105) resulted in 38% of patients with favorable neurologic outcome.ConclusionsECPR was associated with intact neurological recovery in 19% of unselected cardiac arrest victims, with 38% favorable outcome if stringent selection criteria would have been applied.

An increase in the incidence of OHCA during the COVID-19 pandemic has been recently demonstrated. However, there are no data about how the COVID-19 epidemic influenced the treatment of OHCA victims. We performed an analysis of the Lombardia Cardiac Arrest Registry comparing all the OHCAs occurred in the Provinces of Lodi, Cremona, Pavia and Mantua (northern Italy) in the first 100 days of the epidemic with those occurred in the same period in 2019. The OHCAs occurred were 694 in 2020 and 520 in 2019. Bystander cardiopulmonary resuscitation (CPR) rate was lower in 2020 (20% vs 31%, p<0.001), whilst the rate of bystander automated external defibrillator (AED) use was similar (2% vs 4%, p = 0.11). Resuscitation was attempted by EMS in 64.5% of patients in 2020 and in 72% in 2019, whereof 45% in 2020 and 64% in 2019 received ALS. At univariable analysis, the presence of suspected/confirmed COVID-19 was not a predictor of resuscitation attempt. Age, unwitnessed status, non-shockable presenting rhythm, absence of bystander CPR and EMS arrival time were independent predictors of ALS attempt. No difference regarding resuscitation duration, epinephrine and amiodarone administration, and mechanical compression device use were highlighted. The return of spontaneous circulation (ROSC) rate at hospital admission was lower in the general population in 2020 [11% vs 20%, p = 0.001], but was similar in patients with ALS initiated [19% vs 26%, p = 0.15]. Suspected/confirmed COVID-19 was not a predictor of ROSC at hospital admission. Compared to 2019, during the 2020 COVID-19 outbreak we observed a lower attitude of laypeople to start CPR, while resuscitation attempts by BLS and ALS staff were not influenced by suspected/confirmed infection, even at univariable analysis.

Pollution has been suggested as a precipitating factor for cardiovascular diseases. However, data about the link between air pollution and the risk of out-of-hospital cardiac arrest (OHCA) are limited and controversial. By collecting data both in the OHCA registry and in the database of the regional agency for environmental protection (ARPA) of the Lombardy region, all medical OHCAs and the mean daily concentration of pollutants including fine particulate matter (PM10, PM2.5), benzene (C6H6), carbon monoxide (CO), nitrogen dioxide (NO2), sulphur dioxide (SO2), and ozone (O3) were considered from January 1st to December 31st, 2019 in the southern part of the Lombardy region (provinces of Pavia, Lodi, Cremona and Mantua; 7863 km2; about 1550000 inhabitants). Days were divided into high or low incidence of OHCA according to the median value. A Probit dose-response analysis and both uni- and multivariable logistic regression models were provided for each pollutant. The concentrations of all the pollutants were significantly higher in days with high incidence of OHCA except for O3, which showed a significant countertrend. After correcting for temperature, a significant dose-response relationship was demonstrated for all the pollutants examined. All the pollutants were also strongly associated with high incidence of OHCA in multivariable analysis with correction for temperature, humidity, and day-to-day concentration changes. Our results clarify the link between pollutants and the acute risk of cardiac arrest suggesting the need of both improving the air quality and integrating pollution data in future models for the organization of emergency medical services.

Keywords: Cardiac arrest, Cardiopulmonary resuscitation, Chest compressions

BackgroundPrognostication after an out-of-hospital cardiac arrest (OHCA) remains a challenge. The peripheral-derived perfusion index (PI) is a simple and non-invasive way to assess perfusion. We sought to assess whether the PI was able to discriminate the prognosis of patients resuscitated from an OHCA.MethodsAll the reports generated by the manual monitor/defibrillator (Corpuls 3 by GS Elektromedizinische Geräte G. Stemple GmbH, Germany) used for all the OHCAs who achieved ROSC treated by our Emergency Medical Service from January 2015 to December 2018 were reviewed. The mean PI value of each minute after ROSC was automatically provided by the device and the mean value of 30 min of monitoring (MPI30) was calculated. Pre-hospital data were collected according to the Utstein 2014 recommendations.ResultsAmong 1,909 resuscitation attempts, ROSC was achieved in 346 and it was possible to calculate an MPI30 in 164. MPI30 was higher in the patients who survived at 30 days [1.6 (95% CI 1.2–2.1) vs 1 (95% CI 0.8–1.3), p = 0.0017]. At the multivariable Cox regression model, after correction for shockable rhythm, witnessed status, bystander CPR, age, and blood pressure, MPI30 was found to be an independent predictor of both 30-day mortality [RR 0.83 (95% CI 0.69–0.99), p = 0.036] and 30-day mortality or poor neurologic outcome [RR 0.85 (95% CI 0.72–0.99), p = 0.04]. Overall 30-day survival with good neurologic outcome was significantly different in the three tertiles [T1: 0.1–0.8; T2: 0.9–1.8 and T3: 1.82–7.8, log-rank p = 0.007].ConclusionThe post-ROSC peripheral perfusion index was found to be an independent predictor of 30-day mortality or poor neurologic outcome. It could help prognostication in OHCA patients.

The relationship between COVID-19 and out-of-hospital cardiac arrests (OHCAs) has been shown during different phases of the first pandemic wave, but little is known about how to predict where cardiac arrests will increase in case of a third peak. To seek for a correlation between the OHCAs and COVID-19 daily incidence both during the two pandemic waves at a provincial level. We considered all the OHCAs occurred in the provinces of Pavia, Lodi, Cremona, Mantua and Varese, in Lombardy Region (Italy), from 21/02/2020 to 31/12/2020. We divided the study period into period 1, the first 157 days after the outbreak and including the first pandemic wave and period 2, the second 158 days including the second pandemic wave. We calculated the cumulative and daily incidence of OHCA and COVID-19 for the whole territory and for each province for both periods. A significant correlation between the daily incidence of COVID-19 and the daily incidence of OHCAs was observed both during the first and the second pandemic period in the whole territory (R = 0.4, p<0.001 for period 1 and 2) and only in those provinces with higher COVID-19 cumulative incidence (period 1: Cremona R = 0.3, p = 0.001; Lodi R = 0.4, p<0.001; Pavia R = 0.3; p = 0.01; period 2: Varese R = 0.4, p<0.001). Our results suggest that strictly monitoring the pandemic trend may help in predict which territories will be more likely to experience an OHCAs' increase. That may also serve as a guide to re-allocate properly health resources in case of further pandemic waves.

Background Despite the importance of Ultrasound-guided Regional Anaesthesia (UGRA) in Emergency Medicine (EM), there is significant variability in UGRA training among emergency physicians. We recently developed a one-day (8 h), simulation-based UGRA course, specifically tailored to help emergency physicians to integrate these skills into their clinical practice. Methods In this pre/post intervention study, emergency physicians attended a course consisting of a 4-hour teaching on background knowledge and a practical part structured as follows: a scanning session on a healthy individual; a needling station with an ex-vivo model (turkey thighs); a simulation-based learning experience on local anaesthetic toxicity (LAST); a session on the UGRA simulator BlockSim™. Participants rated their level of knowledge across several domains of UGRA practice; for this purpose, we used a 5-points Likert scale (from 0 to 4). Participants also rated the perceived utility of the practical sessions. We extrapolated baseline characteristics of participants, and we paired the answers of pre- and post-course questionnaires using Wilcoxon signed-rank test. Results Seventy-four emergency physicians across ten Italian regions and Switzerland completed the pre-and post- course questionnaire. Most of them were EM residents (75.68%) who had never performed UGRA. Median self-reported knowledge significantly improved from 1 to 3 in the following domains of UGRA indications: Knowledge of contraindications and UGRA techniques [pre-course 1 (IQR 1–2), post-course 3 (IQR 2–3)]; Equipment and drugs [pre-course 1(IQR 1–1), post-course 3 (IQR2-3)]; LAST recognition [pre-course 1 (IQR 1–2), post-course 3 (IQR 2–4)]; LAST management [pre-course 1 (IQR 1–1,75), post-course 3 (IQR 2–3)] ( p  < 0.001). A smaller improvement was observed in the domain Knowledge of “sonoanatomy” (from 1 to 2; p < 0.001); this might be due to the fact that a one-hour scanning session on a single healthy volunteer may be insufficient for learners to gain confidence with the relevant sonoanatomy. Most participants rated positively the utility of practical stations (100% for the scanning session; 100% for the ex-vivo station with turkey thigh; 91.8% for the BlockSim™). Limitations The main limitation of this study is that measurements are limited to learners’ reaction to learning and self-assessment outcomes. We did not measure the impact of our course on participants’ performance in simulated settings, or on their behavior in the clinical setting, or on patient outcomes. The sample size of participants was relatively small, although larger than most published similar studies. Conclusions This one-day simulation-based, UGRA course tailored for emergency physicians led to improved participants’ self-reported knowledge across several domains of UGRA practice. The course represents an effective educational strategy and can be replicated in other settings for the initial training of emergency physicians in UGRA.

Chest compressions depth and complete chest recoil are both important for high-quality Cardio-Pulmonary Resuscitation (CPR). It has been demonstrated that anthropometric variables affect chest compression depth, but there are no data about they could influence chest recoil. The aim of this study was to verify whether physical attributes influences chest recoil in lay rescuers. We evaluated 1 minute of compression-only CPR performed by 333 laypersons immediately after a Basic Life Support and Automated External Defibrillation (BLS/AED) course. The primary endpoint was to verify whether anthropometric variables influence the achievement a complete chest recoil. Secondary endpoint was to verify the influence of anthropometric variables on chest compression depth. We found a statistically significant association between weight and percentage of compressions with correct release (p≤0.001) and this association was found also for height, BMI and sex. People who are heavier, who are taller, who have a greater BMI and who are male are less likely to achieve a complete chest recoil. Regarding chest compressions depth, we confirm that the more a person weighs, the more likely the correct depth of chest compressions will be reached. Anthropometric variables affect not only chest compression depth, but also complete chest recoil. CPR instructors should tailor their attention during training on different aspect of chest compression depending on the physical characteristics of the attendee.

The association between the level of physical activity and quality of cardio-pulmonary resuscitation (CPR) performed by laypeople is unclear. The aim of this study was to evaluate the associations between physical activity level and laypeople performance during an eight-minute scenario of CPR. This study was a secondary analysis of the MANI-CPR Trial. The entire cohort of participants was grouped based on the level of physical activity assessed using the International Physical Activity Questionnaire (IPAQ) into a “low-moderate” level group and a “high” level group. Descriptive statistics were used for unadjusted analysis and multivariate logistic and linear regression models were also performed. A total of 492 participants who reached the score of “Advanced CPR performer” at the 1-min final test monitored by Laerdal Resusci Anne QCPR were included in this analysis; 224 with a low-moderate level and 268 with a high level of physical activity. A statistically significant difference was found for the outcome of percentage of compressions with adequate depth (low-moderate group: 87.8% [41·4%-99·3%], high group: 97% [63·2%–100%]; P = 0·003). No associations remained significant after controlling for biometric characteristics of the participants, compression protocols and sex. Adequate quality CPR may not need high baseline level of physical activity to be performed by a lay rescuer. •Associations between physical activity and quality of cardio-pulmonary resuscitation are unclear.•Biometric characteristics may affect the quality of cardio-pulmonary resuscitation.•Adequate quality CPR may not need high level of physical activity to be performed by laypeople.