Bibliographie sur l'arrêt cardiaque

Study objective: Cardiopulmonary resuscitation (CPR) is critical for out-of-hospital cardiac arrest patients but is prone to rapid changes and errors. Effective teamwork and leadership are essential for high-quality CPR. We aimed to introduce the Airway-Circulation-Leadership-Support (A-C-L-S) teamwork model in the emergency department (ED) to address these challenges.

Methods: The study comprised 2 phases. The development phase involved reviewing CPR videos, categorizing problems, and formulating strategies using the Systems Engineering Initiative for Patient Safety model. Resuscitation tasks were organized into A-C-L-S domains using hierarchical task analysis. Equipment and environmental deficits were optimized ergonomically with a pit-crew style arrangement. Mnemonics enhanced teamwork and leadership. The evaluation phase assessed postimplementation ED resuscitation team performance, focusing on adherence, timeliness, and quality of A-C-L-S tasks.

Results: The development phase produced a structured teamwork model, assigning tasks, tools, mnemonics, and positions based on A-C-L-S domains. The A-team manages the airway and optimizes end-tidal CO levels; the C-team focuses on high-quality chest compressions and defibrillation. Leadership coordinates resuscitation efforts using goal-directed mnemonics (DABCDE), whereas the S-team handles medications, timekeeping, and recording. The evaluation phase showed improvements in adherence and timeliness of A-C-L-S tasks, with sustained increases in chest compression fraction before mechanical CPR, from 67.2% preimplementation to 83.0% postimplementation, 89.1% after 1 year, and 86.1% after 2 years. Overall, chest compression fraction also improved from 81.7% to 88.6%, peaking at 92.2% after 1 year and maintaining 90.8% after 2 years.

Conclusion: The A-C-L-S teamwork model is feasible, applicable, and effective. Further research is needed to assess its influence on patient outcomes.

Objective: Targeted temperature management (TTM), through its physiological effects on intracranial pressure, may impede the progression to brain death (BD) in severe anoxic brain injury post-cardiac arrest (CA). We examined the potential association between the use of TTM and the occurrence of BD after CA.

Design: Monocentric, retrospective study.

Setting: Intensive care unit, Versailles Hospital, France.

Participants: Comatose survivors of CA who died from BD or postanoxic encephalopathy (PAE) after 24 hours.

Main outcome measures: PAE deaths corresponded to withdrawal of life-sustaining therapy (WLST) due to irreversible postanoxic coma or vegetative state according to prognostication guidelines. BD corresponded to the cessation of cerebral vascularisation secondary to intracranial hypertension. The diagnosis of BD was definite by clinical diagnosis of deep coma according to the Glasgow Coma Scale 3, loss of all brainstem reflexes and the demonstration of apnoea during a hypercapnia test. A cerebral omputed tomography (CT) scan or two isoelectric and unreactive electroencephalograms were used to confirm BD. To identify the independent association between TTM and BD, we conducted a multivariable logistic regression analysis.

Results: Out of 256 patients included between 2005 and 2021, 54.3% received TTM for at least 24 hours, and 56 patients (21.9%) died from BD. In the multivariable analysis, TTM for 24 hours or more was not associated with a decrease in BD (Odds Ratio 1.08, 95% CI 0.51 to 2.32). Factors associated with BD included a total duration of no-flow plus low-flow exceeding 30 min, CA due to neurological causes or hanging and a high arterial partial pressure of carbon dioxide between days 1 and 2 after admission.

Conclusions: This exploratory analysis of post-CA patients with severe anoxic brain injury did not find an association between TTM ≥24 hours and a reduction in BD. Further studies are needed to identify specific subgroups of post-CA patients for whom TTM may be especially futile or even harmful.

Background: Out-of-hospital cardiac arrest (OHCA) is a global health issue, for which rapid public access defibrillation (PAD) increases survival.

Objectives: The purpose of this study was to evaluate international legislation relating to PAD and develop legal recommendations to improve PAD in OHCA.

Methods: Searches covering 5 domains (automated external defibrillator [AED] provision, funding, identification, maintenance, lay responder training) were conducted in 99 jurisdictions worldwide: United States (50) and Canada (13) analyzed at state/province level; 36 other countries analyzed at national level. Forty-nine legislation sources were searched from September 27, 2021, to May 5, 2022. Legislative data were classified: Enabling Legislation (facilitating PAD) or Disabling Legislation (hindering PAD). Based on retrieved data, recommendations for international AED laws were developed.

Results: Searches identified 419,248 legal records. Enabling Legislation regarding AED provision in public areas was present in 60% U.S. States, 8% Canadian provinces, and 22% of nations studied from the rest of world. Disabling Legislation regarding registration of AEDs, that could potentially discourage AED ownership, was found in 37 North American jurisdictions. Enabling Legislation regarding AED signage was found in 66% U.S. States and 39% of all jurisdictions worldwide. Overall, 48% of worldwide jurisdictions studied had legislative requirements for AED maintenance, including 80% of all U.S. States. Internationally, 49.5% of jurisdictions studied had Enabling Legislation mandating AED training, and 66% United States had this for schools. Only 4 jurisdictions worldwide gave implicit authorization to laypersons for AED use in emergencies.

Conclusions: There is significant variability in international legislation relating to PAD. All countries should consider Enabling Legislation that could decrease delays to PAD. Similarly, Disabling Legislation potentially hindering prompt PAD during OHCA should be withdrawn.

Purpose: Hyperoxemia is common in patients resuscitated after out-of-hospital cardiac arrest (OHCA) admitted to the intensive care unit (ICU) and may increase the risk of mortality. However, the effect of hyperoxemia on functional outcome, specifically related to the timing of exposure to hyperoxemia, remains unclear.

Methods: The secondary analysis of the Target Temperature Management 2 (TTM-2) randomized trial. The primary aim was to identify the best cut-off of partial arterial pressure of oxygen (PaO) to predict poor functional outcome within the first 24 h from admission, with this period further separated into 'very early' (0-4 h), 'early' (8-24 h), and 'late' (28-72 h) periods. Hyperoxemia was defined as the highest PaO recorded during each period. Poor functional outcome was defined as a 6 months modified Rankin Score (mRS) of 4 to 6.

Results: A total of 1,631 patients were analysed for the 'very early' and 'early' periods, and 1,591 in the 'late period'. In a multivariate logistic regression model, a PaO above 245 mmHg during the very early phase was independently associated with a higher probability of poor functional outcome (Odds Ratio, OR = 1.63, 95 % Confidence Interval, CI 1.08-2.44, p = 0.019). No significant associations were found for the later periods.

Conclusions: Very early hyperoxemia after ICU admission is associated with higher risk of poor functional outcome after OHCA. Avoiding hyperoxia in the initial hours after resuscitation should be considered.

Editorial: The use of automated external defibrillators (AEDs) in a timely manner is critical for improving survival rates in out-of-hospital cardiac arrest (OHCA) cases. However, in developing countries, logistical and infrastructural challenges often result in delays, particularly in suburban areas. This study evaluates the feasibility and safety of using drones to deliver AEDs in suburban OHCA scenarios. A series of ninety test flights were conducted using a DJI Matrice 600 drone (DJI, China) to deliver a Philips HeartStart AED (Philips, Netherlands) across varying payloads. Bystanders in simulated OHCA situations identified their location via mobile applications, enabling the drone operator to dispatch the drone beyond the pilot's line of sight. The results showed a 97.7% success rate in AED delivery, with a median flight distance of 4042 m and a median response time of 7 min and 39 s. Despite payload variations, the drone maintained adequate speed and landing accuracy, with a mean speed of 9.17 m per second and a median landing error of 122 centimeters. The findings suggest that drones have significant potential for improving emergency medical responses in suburban areas of developing countries. Integration into emergency services could address current delays, though further research is necessary to optimize performance under varying conditions.