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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EFor people who experience an out-of-hospital cardiac arrest (OHCA), prehospital body cooling has been linked to improved survival rates. The benefits of therapeutic hypothermia after an OHCA were discussed by a panel of experts, including background information on the epidemiology and prognostic importance of pre-hospital factors on survival outcomes, whether all patients should be cooled after experiencing an OHCA, and issues involved in percutaneous coronary intervention during cardiopulmonary resuscitation.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EMyocardial Infarction\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECritical Care\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EMyocardial Infarction\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECritical Care\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EFor people who experience an out-of-hospital cardiac arrest (OHCA), prehospital body cooling has been linked to improved survival rates. The benefits of therapeutic hypothermia after an OHCA were discussed by a panel of experts, including background information on the epidemiology and prognostic importance of prehospital factors on survival outcomes, whether all patients should be cooled after experiencing an OHCA, and issues involved in percutaneous coronary intervention (PCI) during cardiopulmonary resuscitation (CPR).\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EPROVIDING CONTEXT\u003C\/h2\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EChristian Hassager, MD, Rigshospitalet, Copenhagen, Denmark, set the context for the discussion by providing epidemiologic data and the prognostic importance of prehospital factors on outcomes in people who experience OHCA. Citing statistics from Denmark, he said that OHCAs occur in about 60 per 100 000 person-years. When looking at prehospital prognostic factors, he said significant factors related to survival included\u003C\/p\u003E\n         \u003Cul class=\u0022list-unord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n               \u003Cp id=\u0022p-4\u0022\u003Emale sex\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n               \u003Cp id=\u0022p-5\u0022\u003Eage \u0026lt; 80 years\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n               \u003Cp id=\u0022p-6\u0022\u003Elack of comorbidities where the arrest is in a public place\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n               \u003Cp id=\u0022p-7\u0022\u003Epresence of a bystander witness\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\n               \u003Cp id=\u0022p-8\u0022\u003Ebystander CPR performed\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-6\u0022\u003E\n               \u003Cp id=\u0022p-9\u0022\u003Earrest of presumed cardiac etiology\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-7\u0022\u003E\n               \u003Cp id=\u0022p-10\u0022\u003Ea shockable primary rhythm\u003C\/p\u003E\n            \u003C\/li\u003E\u003C\/ul\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EAfter multivariate adjustment, bystander witness and CPR, presumed cardiac etiology, and ventricular tachycardia (VT) and ventricular fibrillation (VF) as primary rhythm remained independent positive prognostic factors. Negative prognostic factors included increased age, longer time to emergency medical services care, and a cardiac arrest at night.\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EData from a Danish cohort of nearly 20 000 patients who experienced OHCA between 2001 and 2010 showed that survival at arrival at the hospital has increased, as has the percentage of bystanders administering CPR (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Wissenberg M et al. \u003Cem\u003EJAMA\u003C\/em\u003E. 2013].\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/42\/33\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Trends Over Time in Patients With Out-of-Hospital Cardiac Arrest in Denmark\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-534254413\u0022 data-figure-caption=\u0022Trends Over Time in Patients With Out-of-Hospital Cardiac Arrest in Denmark\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/42\/33\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/42\/33\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/42\/33\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15367\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-13\u0022 class=\u0022first-child\u0022\u003ETrends Over Time in Patients With Out-of-Hospital Cardiac Arrest in Denmark\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003ECPR, cardiopulmonary resuscitation.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EAdapted from Wissenberg M et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. \u003Cem\u003EJAMA\u003C\/em\u003E. 2013;310:1377\u20131384. Copyright \u00a9 (2013) American Medical Association. All rights reserved.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EIn conclusion, Dr Hassager emphasized that bystander CPR is increasing and currently \u0026gt; 50% of OHCAs in Denmark have a bystander who administers CPR. Along with bystander CPR, the other most important prehospital prognostic factors include having someone witness the cardiac arrest, having VT\/VF as the primary rhythm, time to EMS care, and time to return of spontaneous circulation (ROSC).\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EDO ALL PATIENTS BENEFIT?\u003C\/h2\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EJacob E. M\u00f8ller, MD, Odense University Hospital, Odense, Denmark, discussed 4 main questions regarding the benefit of therapeutic hypothermia in patients experiencing an OHCA. Namely, should all OHCAs be cooled? Which temperature should be the target temperature to cool patients in this setting to confer a survival benefit? When should cooling take place? How long should a patient be cooled?\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EIn answering all of these questions, Prof M\u00f8ller reviewed several key studies that overall showed no clear survival advantage of therapeutic hypothermia in unselected patients, which questions the current thinking on the temperature needed to benefit patients in this situation as well as when and for how long cooling should be done.\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EBased on the current evidence, which is largely observational, he said that there are no data to support cooling patients who, after OHCA, are in a nonshockable rhythm, those who revert to shockable rhythm, or those in cardiogenic shock [Mader TJ et al. \u003Cem\u003ETher Hypothermia Temp Manag\u003C\/em\u003E. 2014; Thomas AJ et al. \u003Cem\u003EResuscitation\u003C\/em\u003E. 2013]. Although he said that evidence does not currently support the benefit of therapeutic hypothermia for patients with a nonshockable rhythm, he also said that no data demonstrate any harm either.\u003C\/p\u003E\n         \u003Cp id=\u0022p-18\u0022\u003EIn terms of goal temperature, he cited data from a recent well-designed study that showed little rationale for targeting the currently recommended 33\u00b0C to improve survival. The study evaluated all-cause mortality in 939 unconscious adults randomized to targeted temperature of either 33\u00b0C or 36\u00b0C after OHCA and found no difference between the 2 temperature cohorts (50% vs 48%; HR, 1.06; 95% CI, 0.89 to 1.28; \u003Cem\u003EP\u003C\/em\u003E = .51) [Nielsen N et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2013]. Again, Prof M\u00f8ller emphasized that although the data do not support a target temperature of 33\u00b0C, the data indicate no additional harm either.\u003C\/p\u003E\n         \u003Cp id=\u0022p-19\u0022\u003EFor determining when to cool patients, there is also a lack of evidence supporting initiation of therapeutic hypothermia in the ambulance outside of the hospital [Kim F et al. \u003Cem\u003EJAMA\u003C\/em\u003E. 2014; Bernard SA et al. \u003Cem\u003ECirculation\u003C\/em\u003E. 2010] and recommended that cooling should not be done prior to hospitalization, though Prof M\u00f8ller suggested the results may be confounded by an imbalance in baseline risk between the 2 intervention groups.\u003C\/p\u003E\n         \u003Cp id=\u0022p-20\u0022\u003EIn terms of the duration of hypothermia, he noted that while 24 hours is the current recommendation, the evidence to support this duration is lacking. He emphasized that the answer to this question remains to be determined and is currently under investigation.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EPCI DURING CPR\u003C\/h2\u003E\n         \u003Cp id=\u0022p-21\u0022\u003EMarko Noc, MD, University Medical Center, Ljubljana, Slovenia, addressed what can be done in patients with refractory cardiac arrest needing ongoing chest compression during PCI for ROSC.\u003C\/p\u003E\n         \u003Cp id=\u0022p-22\u0022\u003EEmphasizing that PCI can be challenging or impossible if the lesion is complex and distal, Prof Noc said that a bigger issue in his experience in managing these patients is that even with an open artery, ROSC is often not established, patients often have recurrent cardiac arrest, or patients end up with profound cardiogenic shock despite successful PCI.\u003C\/p\u003E\n         \u003Cp id=\u0022p-23\u0022\u003ETo better manage these patients, he proposed coupling hemodynamic support with PCI. He proposed first doing a venoarterial extracorporeal membrane oxygenation (ECMO) insertion during ongoing automated chest compression, stopping chest compression to perform a coronary angiography and PCI, and then keeping ECMO after PCI to reverse perfusion failure, inducing hypothermia and to buy time for the \u201cstunned\u201d myocardium.\u003C\/p\u003E\n         \u003Cp id=\u0022p-24\u0022\u003EHe highlighted the importance of early induction of ECMO by citing a European study of 51 patients with refractory cardiac arrest in whom automated chest compression was started out of the hospital and followed by ECMO implantation upon hospital arrival at a median delay from collapse to ECMO of 120 minutes [Le Guen M et al. \u003Cem\u003ECritical Care\u003C\/em\u003E. 2011]. Of the 51 patients, only 2 (4%) survived and were in good neurologic condition at 28 days, arguing for an aggressive central neurologic system protective strategy with therapeutic hypothermia.\u003C\/p\u003E\n         \u003Cp id=\u0022p-25\u0022\u003EProf Noc shared a schema that may provide a method of more effectively managing patients with refractory cardiac arrest based on early use of ECMO (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/42\/33\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Future Schema on Treating Patients With Refractory Cardiac Arrest\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-534254413\u0022 data-figure-caption=\u0022Future Schema on Treating Patients With Refractory Cardiac Arrest\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/42\/33\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/42\/33\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/42\/33\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15368\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-26\u0022 class=\u0022first-child\u0022\u003EFuture Schema on Treating Patients With Refractory Cardiac Arrest\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003ECA, cardiac arrest; CABG, coronary artery bypass grafting; CAG, coronary angiography; cath lab, catheter laboratory; CICU, cardiac intensive care unit; ECMO, extracorporeal membrane oxygenation; ER, emergency room; IC, intensive care; ICU, intensive care unit; PCI, percutaneous coronary intervention.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-4\u0022\u003EReproduced with permission from M Noc, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-27\u0022\u003EFinally, Prof Noc emphasized the need for developing adequate multidisciplinary prehospital and in hospital systems to better support the critical need to not delay the time between cardiac arrest and performing ECMO and PCI.\u003C\/p\u003E\n         \u003Cp id=\u0022p-28\u0022\u003EIn conclusion, many important questions and exciting developments continue to evolve in the area OHCA, prognostic risk stratification, therapeutic hypothermia, and other interventions to improve patient outcomes.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/42\/33.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzokn1\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzokn1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}