CANCARE RESEARCH
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A Robust Educational Initiative for EMS Clinicians Focusing on Pit-Crew CPR Improves Neurologically Intact Survival.
Clinical takeaway The training initiative was associated with gradually improving neurologically intact survival, but not improved overall discharge survival. The observational design does not establish that training caused these changes.
Summary & abstract
Study summary
A retrospective before-and-after study evaluated pit-crew CPR training across 27 EMS agencies in 1,917 adults with non-traumatic out-of-hospital cardiac arrest. In interrupted time series analysis, survival to discharge with good neurological function increased gradually after implementation (adjusted odds ratio 1.20 per four-month interval; 95% confidence interval 1.01–1.44). Sustained return of spontaneous circulation increased at intervention onset (adjusted odds ratio 1.41; 95% confidence interval 1.1–1.81). Overall survival to hospital discharge showed no change before, at, or after implementation, distinguishing the neurological outcome association from the absence of an observed overall survival improvement.
Study limitation: The retrospective before-and-after design remains vulnerable to confounding and concurrent changes in resuscitation care despite statistical adjustment.
Published abstract
OBJECTIVES: To evaluate whether the implementation of a region-wide pit-crew cardiopulmonary resuscitation (CPR) initiative was associated with improved survival to hospital discharge with good neurological function among adults with non-traumatic out-of-hospital cardiac arrest (OHCA) in a heterogenous, multi-agency emergency medical services (EMS) system in south-central Connecticut. METHODS: We conducted a retrospective, before-and-after observational study using the Cardiac Arrest Registry to Enhance Survival (CARES). The pit-crew CPR intervention, comprising structured didactic and hands-on simulation-based training was delivered across 27 EMS agencies from September 28, 2021 through August 2, 2022. The primary outcome was survival to hospital discharge with good neurological function (Cerebral Performance Category 1-2). Secondary outcomes included survival to hospital discharge and sustained return of spontaneous circulation (ROSC). We performed an interrupted time series analysis using the beginning of our intervention (September 28, 2021) as the interruption to model. Multivariable logistic regression models were adjusted for age, sex, race, shockable initial rhythm, witnessed arrest, arrest location, and bystander CPR. RESULTS: A total of 1917 adult non-traumatic OHCA patients (922 pre-intervention; 995 post-intervention) were resuscitated by EMS clinicians in the study period. In progression since intervention, there was a significant increase in neurologically intact survival per 4-month interval (adjusted odds ratio [OR] 1.20; 95% confidence interval [CI], 1.01-1.44), suggesting a gradual improvement in outcomes over time after protocol implementation. At intervention start, there was a significant increase in ROSC (aOR 1.41; 95% CI, 1.1-1.81). There was no change in survival to hospital discharge prior to the intervention, at the time of the intervention, or following the intervention. CONCLUSIONS: Implementation of a pit-crew CPR model across a heterogenous, multi-agency EMS system was associated with a significant gradual increase in neurologically intact survival in the post-intervention period, as well as a significant immediate improvement in ROSC at the time of protocol implementation. These findings support structured, team-based resuscitation as a feasible and effective strategy to improve cardiac arrest outcomes within existing EMS systems.
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Immunonutritional status and survival after cardiac arrest: prognostic value of the prognostic nutritional index, the cholesterol-modified prognostic nutritional index, and the controlling nutritional status score in post-cardiopulmonary resuscitation intensive care patients.
Clinical takeaway These routine laboratory-derived indices were associated with ICU mortality after cardiac arrest, but their modest discrimination and retrospective evaluation leave their clinical prognostic utility uncertain.
Summary & abstract
Study summary
This single-center retrospective study evaluated immunonutritional indices measured within 24 hours of ICU admission in 444 adults after return of spontaneous circulation following out-of-hospital cardiac arrest. Non-survivors had lower Prognostic Nutritional Index (PNI), higher cholesterol-modified PNI (CPNI), and higher Controlling Nutritional Status (CONUT) scores than survivors. In separate adjusted models, mortality odds ratios were 0.64 per 10-point PNI increase, 1.25 per 10-point CPNI increase, and 1.24 per one-point CONUT increase. Discrimination for ICU mortality was modest, with AUCs of 0.689 for PNI, 0.631 for CPNI, and 0.681 for CONUT.
Study limitation: The single-center retrospective design limits generalizability; the abstract reports no confidence intervals for adjusted associations.
Published abstract
BACKGROUND: Patients achieving return of spontaneous circulation (ROSC) after cardiac arrest experience marked systemic inflammation, metabolic stress, and nutritional impairment, all of which contribute to high mortality. Practical prognostic indices reflecting immunonutritional status may facilitate early risk stratification in this population. AIM: To evaluate the prognostic value of immunonutritional indices for predicting mortality in patients with ROSC after out-of-hospital cardiac arrest. METHODS: This single-center, retrospective cohort study included adult patients admitted to the intensive care unit after ROSC following out-of-hospital cardiac arrest between January 2015 and January 2025. Prognostic Nutritional Index (PNI), cholesterol-modified Prognostic Nutritional Index (CPNI), and Controlling Nutritional Status (CONUT) scores were calculated from laboratory parameters obtained within the first 24 h of ICU admission. Patients were classified as survivors or non-survivors based on ICU outcome. Associations with mortality were evaluated using univariate and multivariate logistic regression analyses, and discriminatory performance was assessed using receiver operating characteristic curve analysis. RESULTS: Among 444 post-ROSC patients, non-survivors had lower PNI (43.66 ± 15.47 vs. 55.06 ± 17.21) and higher CPNI (81.10 ± 13.70 vs. 66.90 ± 18.25) and CONUT scores (4.27 ± 3.04 vs. 2.43 ± 2.43; all p < 0.001). In separate stepwise multivariable models, PNI (aOR 0.64 per 10-point increase), CPNI (aOR 1.25 per 10-point increase), and CONUT (aOR 1.24 per 1-point increase) remained independently associated with mortality. AUCs were 0.689, 0.631, and 0.681, respectively; PNI showed the highest sensitivity (86.3%) at a cut-off of ≤ 59.90. CONCLUSION: PNI, CPNI, and CONUT were significantly associated with ICU mortality after out-of-hospital cardiac arrest. These indices may reflect systemic inflammation, immune dysfunction, metabolic stress, and nutritional reserve rather than nutritional status alone. Their availability from routine laboratory parameters may support early risk stratification. Further prospective studies are needed to confirm their prognostic value and clinical applicability.
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Early post-ROSC laboratory phenotypes and clinical outcomes after out-of-hospital cardiac arrest: a 10-year national cohort study.
Clinical takeaway Early laboratory phenotypes were associated with neurological and mortality outcomes after resuscitated cardiac arrest. These exploratory associations warrant external validation before any phenotype-guided clinical application.
Summary & abstract
Study summary
This retrospective Singapore cohort classified 1,514 adults resuscitated after presumed cardiac out-of-hospital arrest using 14 laboratory variables within six hours of ROSC. Three phenotypes emerged: multi-organ dysfunction, homeostatic, and immune-dysregulated. Compared with multi-organ dysfunction, adjusted odds of poor neurological recovery at discharge were lower for homeostatic (0.50, 95% CI 0.30–0.78) and immune-dysregulated phenotypes (0.46, 0.26–0.78). Adjusted 30-day mortality hazard ratios were 0.71 (95% CI 0.61–0.83) and 0.78 (0.64–0.94), respectively; lower mortality hazards also persisted at three years.
Study limitation: Retrospective associations adjusted only for age, sex and initial rhythm remain vulnerable to residual confounding; validation was internal.
Published abstract
BACKGROUND: Prior phenotyping in out-of-hospital cardiac arrest (OHCA) relied predominantly on prehospital indicators, which neither describe nor grade the underlying ischemia-reperfusion injury. We aimed to derive laboratory-based phenotypes and describe their clinical characteristics and outcome associations. METHODS: We conducted a retrospective cohort study of adult resuscitated OHCA patients of presumed cardiac etiology between 01/02/2011 and 01/01/2022, linking Singapore's national OHCA and cardiovascular databases. Unsupervised latent class analysis (LCA) was applied to 14 laboratory variables within six hours post-return of spontaneous circulation (ROSC). Stability was confirmed through split-sample validation. Logistic regression and Cox proportional hazards model, adjusted for age, sex and initial cardiac rhythm, assessed poor neurological recovery at hospital discharge, 30-day and 3-year mortality. RESULTS: Among 1514 eligible patients (median age 65.0 years, 73.6% males), LCA identified three distinct phenotypes: multi-organ dysfunction (MOD, N = 286), homeostatic (HOM, N = 967), and immune-dysregulated (IMD, N = 261), independently reproduced in derivation (entropy = 0.817) and replication (entropy = 0.892) subsamples. The most discriminative variables were creatinine, eosinophil and lymphocyte. Compared to MOD, both HOM (aOR: 0.50, 95% CI 0.30-0.78, p = 0.004) and IMD (aOR: 0.46, 95% CI 0.26-0.78, p = 0.005) phenotypes had significantly lower odds of poor neurological recovery. This pattern was consistent for 30-day mortality (HOM aHR: 0.71, 95% CI 0.61-0.83; IMD aHR: 0.78, 95% CI 0.64-0.94) and 3-year mortality (HOM aHR: 0.70, 95% CI 0.60-0.82; IMD aHR: 0.74, 95% CI 0.62-0.90), all p ≤ 0.01. CONCLUSION: Early post-ROSC laboratory data identified three prognostically distinct phenotypes among resuscitated OHCA patients. These exploratory findings support external validation and investigation of phenotype-guided therapies.
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Early-Phase Computed Tomography Bowel Diameter and Neurological Outcomes Post-Extracorporeal Cardiopulmonary Resuscitation.
Clinical takeaway Early CT bowel diameter showed weak overall discrimination for unfavorable neurological outcomes after ECPR. Higher subgroup estimates remain exploratory and do not establish clinical prognostic utility.
Summary & abstract
Study summary
This single-centre observational study examined early abdominal CT bowel diameter in 181 patients undergoing ECPR for out-of-hospital cardiac arrest. The primary endpoint was unfavorable neurological outcome at one month, defined as Cerebral Performance Category 3–5. Overall discrimination was weak: AUC 0.58 (95% confidence interval, 0.47–0.70). Exploratory subgroup AUCs were higher in patients aged 65 years or older (0.83; 95% confidence interval, 0.69–0.96) and those with initial nonshockable rhythms (0.69; 95% confidence interval, 0.47–0.91). Bowel diameter was measured by an investigator blinded to outcomes.
Study limitation: The single-centre observational design and exploratory subgroup findings limit generalizability and confidence in prognostic performance.
Published abstract
AIM: We aimed to conduct an exploratory investigation on the association between bowel diameter on early-phase abdominal computed tomography (CT) and neurological outcomes in patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA). METHODS: This observational study included patients who underwent ECPR for OHCA and abdominal CT before intensive care unit admission between January 2015 and December 2021 at a tertiary emergency medical center. Maximum bowel diameter was measured with a picture archiving and communication system by an investigator blinded to outcomes. The primary endpoint was unfavorable neurological outcomes at 1 month, defined as Cerebral Performance Category 3-5. The discriminatory ability of bowel diameter was assessed using the area under the receiver operating characteristic curve (AUC). RESULTS: Data from 181 patients were analyzed (median age, 57 years; 84.5% male). Bowel diameter demonstrated a weak ability to predict unfavorable neurological outcomes, with an AUC of 0.58 (95% confidence interval [CI], 0.47-0.70). However, higher discriminatory performance was observed in subgroups of patients aged ≥ 65 years (AUC, 0.83; 95% CI, 0.69-0.96) and those with initial nonshockable rhythms (AUC, 0.69; 95% CI, 0.47-0.91). CONCLUSION: The results of this exploratory investigation suggest that bowel diameter may represent a potential adjunctive marker associated with functional outcomes post-ECPR for OHCA.
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Outcomes Following Impedance Threshold Device Use During Out-of-Hospital Cardiac Arrest.
Clinical takeaway ITD use was associated with better early resuscitation outcomes but lower survival to discharge. These observational findings do not establish benefit or harm, particularly given incomplete disposition data.
Summary & abstract
Study summary
This observational study included 97,439 adult non-traumatic out-of-hospital cardiac arrest records, comparing ITD alone, ITD with active compression-decompression, and neither device. ITD alone was associated with higher return of spontaneous circulation than neither device (26.7% versus 23.8%; adjusted odds ratio 1.09 [1.04, 1.14]). However, survival to discharge was lower with ITD alone (23.9% versus 32.0%; adjusted odds ratio 0.68 [0.61, 0.76]). Discharge home, used as the favorable neurologic outcome, showed a similar adverse association. Disposition outcomes were available for only 13,026 patients, limiting interpretation of longer-term associations.
Study limitation: Incomplete disposition follow-up and potential residual confounding limit causal interpretation; discharge home was the proxy for favorable neurologic outcome.
Published abstract
BACKGROUND: Existing work is equivocal regarding the benefit of impedance threshold device (ITD) use among patients experiencing out-of-hospital cardiac arrest (OHCA). We examined the association of ITD use with prehospital outcomes and longer-term dispositions in a nationally representative sample of OHCA patients. METHODS: We included adult, non-traumatic, OHCA scene runs from the 2024 ESO Data Collaborative. We compared patients treated with (a) ITD only; (b) ITD and active compression-decompression device (ITD+ACD); and (c) neither device (no ITD). Prehospital outcomes included return of spontaneous circulation (ROSC) and survival to hospital arrival (SHA); disposition outcomes included survival to hospital discharge and favorable neurologic outcome (i.e., discharge to home). We used multivariate logistic regression to examine the association of treatment group with outcomes, adjusting for demographics and several potential confounders. RESULTS: We included 97,439 patient records (85.3% no ITD; 13.1% ITD only; 1.6% ITD+ACD). Disposition outcomes were available for 13,026 patients (23.3%). ROSC was higher for patients treated with ITD only (26.7%) than those treated with no ITD (23.8%; aOR=1.09 [1.04, 1.14]); a similar pattern emerged for SHA. Conversely, survival to discharge was lower for patients treated with ITD only (23.9%) than those treated with no ITD (32.0%; aOR=0.68, [.61, .76]); a similar pattern emerged for favorable neurologic outcome. The ITD+ACD group showed more extreme versions of the trends observed for ITD only. CONCLUSIONS: ITD use was associated with improved prehospital outcomes but worsened dispositional outcomes among patients experiencing OHCA, suggesting this device may prove beneficial early in resuscitation of OHCA patients.
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Spectral characteristics and parameters of pulse oximetry waveforms for assessing resuscitation status.
Clinical takeaway Pulse oximetry waveform analysis may help recognize ROSC during ongoing compressions, but these retrospective diagnostic findings do not establish improved resuscitation outcomes.
Summary & abstract
Study summary
This retrospective study evaluated pulse oximetry plethysmography in 451 adults with cardiac arrest across 497 CPR episodes at 14 Chinese tertiary hospitals. A hybrid spectral pattern during ongoing compressions with spontaneous circulation identified clinically documented return of spontaneous circulation (ROSC) with 100% specificity and positive predictive value of 1.000. During compression-only periods, waveform area was higher in stable than unstable ROSC groups (3232.2 versus 2769.6 PVPG; P=0.007). Disappearance of the plethysmography waveform despite a concurrent ECG signal identified pulseless electrical activity with 100% specificity.
Study limitation: The abstract reports no sensitivity estimates or confidence intervals for diagnostic performance, limiting interpretation of the reported perfect specificity.
Published abstract
BACKGROUND: Real-time assessment of physiological resuscitation status is critical for guiding personalised cardiopulmonary resuscitation (CPR) and avoiding unnecessary harm from prolonged chest compressions. Non-invasive, objectively trackable tools for this purpose remain limited. METHODS: This multicentre retrospective study (2013-2018) included 451 adult patients with cardiac arrest (497 CPR episodes) from 14 Chinese tertiary hospitals, comprising 158 Out-of-Hospital Cardiac Arrest (OHCA) episodes with prehospital SpO2/ECG monitoring continued upon ED arrival and full pulse oximetry plethysmography (POP)/ECG/end-tidal carbon dioxide (ETCO2) monitoring established in the ED, and 339 In-Hospital Cardiac Arrest (IHCA) episodes occurring in the ED. We analysed POP waveforms across four statuses: compression-only (CC), chest compression with return of spontaneous circulation (CC + ROSC, spontaneous circulation during ongoing compressions), non-compression without ROSC, and spontaneous circulation-only (SC). Time-domain (area under the POP curve [POPAUC]) and frequency-domain spectral features were evaluated against clinically documented ROSC. RESULTS: A frequency-domain "hybrid" pattern during the CC + ROSC identified ROSC with 100% specificity (PPV 1.000). In CC status, POPAUC was higher in stable-ROSC than unstable-ROSC (3232.2 ± 1008.2 vs. 2769.6 ± 1013.0 PVPG, P = 0.007). The POPAUC was lower in CC + ROSC status than in SC status for stable-ROSC (2768.2 ± 997.8 vs. 3335.8 ± 842.4 PVPG, P = 0.001), but the reverse was observed for unstable-ROSC (2697.5 ± 941.0 vs. 1338.1 ± 952.6 PVPG, P < 0.001). POP waveforms disappearance with concurrent ECG presence identified pulseless electrical activity with 100% specificity. CONCLUSION: Pulse oximetry plethysmography waveform analysis-using signals already available on standard monitors-may provide a non-invasive, real-time approach that may help identify ROSC during ongoing compressions and distinguish between stable and unstable circulation.
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Prehospital prognostication after out-of-hospital cardiac arrest in tertiary care centers: the R-EDByUS score in the JAAM-OHCA registry.
Clinical takeaway The score showed strong overall discrimination for one-month neurological outcomes in tertiary-center OHCA patients. These findings support risk stratification, not certainty about an individual patient’s outcome.
Summary & abstract
Study summary
This external validation included 29,345 adults with presumed cardiogenic OHCA transported to tertiary care centers, predicting unfavorable neurological outcome at one month. R-EDByUS discrimination was good in prehospital ROSC and ongoing CPR cohorts, with areas under the curve of 0.906 and 0.913, respectively. Calibration was good in the prehospital ROSC cohort, but discrimination was lower among ongoing CPR patients receiving PCI, TTM, or ECMO. Among patients with predicted risk ≥99%, unfavorable outcomes occurred in 112/112 with prehospital ROSC and 20,560/20,588 with ongoing CPR.
Study limitation: Performance varied across intervention subgroups, and good calibration was reported only for the prehospital ROSC cohort.
Published abstract
AIM: The R-EDByUS score predicts unfavorable neurological outcomes after out-of-hospital cardiac arrest (OHCA) using prehospital variables alone, with separate models based on return of spontaneous circulation (ROSC) status at hospital arrival. However, whether the score remains valid in patients transported to tertiary care centers is uncertain. We therefore aimed to validate it externally in this setting. METHODS: Using the JAAM-OHCA Registry, we analyzed adult patients with presumed cardiogenic OHCA transported to tertiary care centers. The regression-based R-EDByUS score was applied to predict unfavorable neurological outcome (Cerebral Performance Category 3-5) at 1 month in the prehospital ROSC and ongoing cardiopulmonary resuscitation (CPR) cohorts. Discrimination and calibration were assessed, and score performance was examined across in-hospital intervention subgroups (percutaneous coronary intervention, targeted temperature management, and extracorporeal membrane oxygenation). We also assessed the proportion of patients with unfavorable outcomes among those with a predicted probability ≥99%. RESULTS: Of 29,345 patients, 3305 were classified into the prehospital ROSC cohort and 26,040 into the ongoing CPR cohort. The score showed good discrimination, with areas under the curve of 0.906 and 0.913, and good calibration in the prehospital ROSC cohort. Discrimination was lower among patients who received PCI, TTM, or ECMO in the ongoing CPR cohort. Among patients with a predicted probability ≥99%, 100% (112/112; prehospital ROSC) and 99.9% (20,560/20,588; ongoing CPR) had unfavorable outcomes. CONCLUSION: The R-EDByUS score showed good discrimination in the JAAM-OHCA Registry, supporting its use for early risk stratification in cardiogenic OHCA even in tertiary care centers.
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Automated external defibrillators for in-hospital cardiac arrest: a systematic review.
Clinical takeaway The review does not establish a patient-centred outcome benefit from routine ward-level AED deployment. Heterogeneous observational evidence leaves the balance between earlier defibrillation and possible compression interruptions uncertain.
Summary & abstract
Study summary
This systematic review compared AED use with manual defibrillation for in-hospital cardiac arrest outside specialized areas, synthesizing six reports from five observational cohorts descriptively. Neurologically favorable survival findings were inconsistent, with improvement reported after a combined AED-and-training intervention in one study. The largest multicentre cohort found no significant difference in neurological disability among survivors (adjusted relative risk 1.01, 95% CI 0.93–1.09). ROSC and survival to discharge were not consistently improved. Evidence was insufficient to determine whether routine ward-level AED deployment improves outcomes.
Study limitation: Included studies were observational and heterogeneous, with incomplete characterization of CPR quality and training.
Published abstract
BACKGROUND: Automated external defibrillators (AEDs) improve survival after out-of-hospital cardiac arrest, but their role in in-hospital cardiac arrest (IHCA) remains uncertain. This systematic review evaluates whether ward-accessible AED capability prior to code blue team arrival improves survival and neurologic outcomes compared with standard resuscitation systems. METHODS: Six databases were searched. Eligible studies compared AED use to manual defibrillation in IHCA outside specialized areas. Primary outcome was survival with favorable neurological status (CPC 1-2, mRS 0-3, or no deterioration from baseline). Secondary outcomes included ROSC, survival at 24 h, survival to discharge, 30-day survival, CPR quality, and timing metrics. Three independent reviewers performed study selection, data extraction, and risk-of-bias assessment. Due to substantial heterogeneity, results were synthesized descriptively. RESULTS: Six reports from five unique study cohorts met inclusion criteria (total screened = 5510). Neurologically favorable survival was inconsistent. One study reported improved outcomes following a combined AED-and-training intervention, whereas the largest multicentre cohort found no significant difference in neurological disability among survivors (adjusted relative risk 1.01, 95% CI 0.93-1.09). ROSC and survival to discharge were not consistently improved. Only one study directly quantified AED-associated compression pauses, and effects on time to defibrillation varied by setting. CONCLUSION: Available evidence is insufficient to determine whether routine ward-level AED deployment improves IHCA outcomes. Included studies were observational and heterogeneous and CPR quality and training were incompletely characterized. Potential benefit from earlier defibrillation in shockable rhythms must be weighed against possible compression interruptions. Contemporary comparative studies are needed.
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Amiodarone after conversion from a non-shockable to a shockable rhythm in out-of-hospital cardiac arrest: A propensity score-matched analysis from the German resuscitation registry.
Clinical takeaway Amiodarone use was associated with greater discharge survival in this rhythm-conversion population, but a neurologically favourable survival benefit remains uncertain. The observational findings do not establish causality.
Summary & abstract
Study summary
This retrospective German registry study compared amiodarone with no amiodarone during resuscitation in adults with non-traumatic out-of-hospital cardiac arrest, an initially non-shockable rhythm, and at least two subsequent defibrillations. Among 1,843 propensity-matched pairs, amiodarone was associated with higher survival to hospital discharge (6.5% versus 4.2%; OR 1.58, 95% CI 1.18–2.12). Favourable neurological outcome at discharge was not significantly different (3.7% versus 2.9%; OR 1.31, 95% CI 0.91–1.89), leaving uncertainty about whether the observed survival association extends to neurologically favourable survival.
Study limitation: Retrospective propensity matching cannot exclude residual confounding, and the neurological outcome estimate remains imprecise.
Published abstract
BACKGROUND: Amiodarone should be administered after three shocks according the current ERC ALS guidelines. However, its effect in out-of-hospital cardiac arrest (OHCA) patients with an initial non-shockable rhythm who subsequently convert to a shockable rhythm is not established. METHODS: We performed a retrospective observational cohort study using data from the German Resuscitation Registry. Adult patients with non-traumatic OHCA, having an initial non-shockable rhythm and subsequently received at least two defibrillations were included. Propensity-score-matched patient pairs (1:1) were analysed to compare outcomes between patients who received amiodarone during resuscitation and those who did not. The primary outcome was survival to hospital discharge. Secondary outcomes included hospital admission with return of spontaneous circulation (ROSC), 24-h survival, survival to hospital discharge, and favourable neurological outcome at hospital discharge. RESULTS: Of 5535 patients included 3181 received amiodarone and 2354 did not. After propensity-score matching, 1843 patients remained in each group. Amiodarone administration was associated with higher rates of hospital admission with ROSC (26.7% vs. 23.0%; OR 1.22, 95% confidence interval 1.05-1.42), 24-h survival (21.4% vs. 14.7%; OR 1.58, 95% CI 1.33-1.87), and survival to hospital discharge (6.5% vs. 4.2%; OR 1.58, 95% CI 1.18-2.12). Favourable neurological outcome at hospital discharge was not statistically significant (3.7% vs. 2.9%; OR 1.31, 95% CI 0.91-1.89). CONCLUSIONS: In OHCA patients with an initial non-shockable rhythm who subsequently converted to a shockable rhythm, amiodarone administration was associated with improved short-term and long-term survival, but not with a statistically significant improved favourable neurological outcome. Future controlled studies might define the proper (earlier) time of amiodarone administration.
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External Validation of a Post-Cardiac Arrest Risk Score (SLANT) for In-Hospital Mortality in Patients Receiving Targeted Temperature Management.
Clinical takeaway SLANT showed reasonable mortality discrimination in this external cohort. These findings support further evaluation for contextual risk stratification, not its use as a standalone determinant of individual prognosis or care decisions.
Summary & abstract
Study summary
This retrospective cohort externally validated SLANT for predicting in-hospital mortality in 451 comatose adult out-of-hospital cardiac arrest survivors receiving targeted temperature management at three Taiwanese tertiary hospitals during 2016–2023. Overall, 300 patients (66.5%) died during hospitalisation. The score had an area under the receiver operating characteristic curve of 0.746 (95% confidence interval 0.696–0.796), with acceptable calibration, particularly at moderate to high risk. At a score threshold of ≥14, sensitivity was 65.7%, specificity 78.2%, and positive predictive value 85.7%.
Study limitation: Retrospective validation in three Taiwanese tertiary hospitals limits generalisability beyond similar patients and care settings.
Published abstract
BACKGROUND: Despite improvements in cardiopulmonary resuscitation and post-cardiac arrest care, in-hospital mortality among survivors of out-of-hospital cardiac arrest (OHCA) remains high, particularly in Asia. The SLANT score was developed to predict outcomes in patients with comatose OHCA receiving targeted temperature management (TTM), but its performance outside the original derivation cohort remains uncertain. We aimed to externally validate the SLANT score for predicting in-hospital mortality in an East Asian population. METHOD: We conducted a multicentre retrospective cohort study across three tertiary hospitals in Taiwan between 2016 and 2023. Adult patients with OHCA who achieved sustained return of spontaneous circulation, remained comatose, and received TTM were included. The SLANT score-comprising initial non-shockable rhythm, post-TTM leukocyte abnormality, total adrenaline dose ≥5 mg, absence of bystander cardiopulmonary resuscitation, and resuscitation duration ≥20 minutes-was calculated using original definitions. The outcome was in-hospital mortality. Discrimination was assessed using the area under the receiver operating characteristic curve (AUC), and calibration was evaluated with calibration plots. RESULTS: Among 451 eligible patients, 300 (66.5%) died during hospitalisation. The SLANT score demonstrated good discrimination for in-hospital mortality (AUC 0.746; 95% confidence interval 0.696-0.796), with acceptable calibration, particularly in moderate- to high-risk ranges. A score threshold ≥14 provided the optimal balance between sensitivity (65.7%) and specificity (78.2%), with a positive predictive value of 85.7%. CONCLUSIONS: In this East Asian cohort, the SLANT score showed reasonable discrimination and calibration for predicting in-hospital mortality. These findings support its potential role in post-cardiac arrest risk stratification, while underscoring the need for contextual clinical judgment.
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Automated Derivation of Cerebral Performance Category at Hospital Discharge After Cardiac Arrest Using Natural Language Processing and Machine Learning.
Clinical takeaway Automated discharge CPC classification showed promising holdout performance, but these results do not establish reliable early prognostication independent of clinician documentation or withdrawal-of-life-sustaining-therapy decisions.
Summary & abstract
Study summary
This retrospective study across three US academic hospitals evaluated automated discharge CPC classification in adults comatose after cardiac arrest. Good outcomes were defined as CPC 1–3 and poor outcomes as CPC 4–5. An NLP logistic regression model trained on 249 patients was evaluated in 108 holdout patients. Using hospitalization-wide notes, accuracy was 81% and AUROC 0.90; using first-24-hour notes, these fell to 74% and 0.83. Precision for poor outcomes was higher, particularly among patients undergoing withdrawal of life-sustaining therapy, highlighting the importance of documentation context.
Study limitation: Performance was evaluated in a 108-patient holdout set, and early documentation may reflect prognostic framing as well as patient biology.
Published abstract
BACKGROUND: Clinical notes in the electronic health record (EHR) contain rich information that may be leveraged for automated prognostication using natural language processing (NLP) and machine learning. We evaluated the performance and potential biases of an NLP-based machine learning model for deriving cerebral performance category (CPC) for comatose patients following cardiac arrest using EHR clinical notes. METHODS: We conducted a retrospective cohort study of adult patients who were comatose after in-hospital or out-of-hospital cardiac arrest across three academic hospitals in the USA. Neurological outcomes were assessed at hospital discharge, with CPC scores of 1-3 indicating good outcomes and 4-5 indicating poor outcomes. An NLP-based logistic regression model was trained on 249 patients using all clinical notes throughout hospitalization. Model performance was evaluated on a holdout set of 108 patients. Performance was also evaluated on the holdout set using only notes documented within the first 24 h of hospitalization. RESULTS: Using all clinical notes, the model achieved an overall accuracy of 81%, with an area under the receiver operating characteristic curve (AUROC) of 0.90 and an area under the precision-recall curve (AUPRC) of 0.89. When restricted to notes documented within the first 24 h of hospitalization, model accuracy decreased to 74%, with AUROC of 0.83 and AUPRC of 0.83. The model demonstrated higher precision in predicting poor neurological outcomes, particularly among patients who underwent withdrawal of life-sustaining therapy. CONCLUSIONS: An NLP-based machine learning model demonstrated high accuracy in deriving CPC for comatose patients after cardiac arrest using EHR clinical notes. Clinical documentation within 24 h after cardiac arrest contained substantial prognostic signals about neurological outcomes, reflecting a combination of patient biology, clinician assessment, and potentially early prognostic framing. Future research should incorporate multimodal data and employ interpretable advanced language models to increase accuracy toward fully automatable CPC derivation.
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Prehospital predictors of clinical outcomes in out-of-hospital cardiac arrest with pulseless electrical activity: a JCS-ReSS report.
Clinical takeaway Prehospital information may support risk stratification after arrest with initial pulseless electrical activity, but its prognostic meaning varies by presumed aetiology. These observational associations do not establish individual prognosis.
Summary & abstract
Study summary
This nationwide Japanese cohort included 442,630 adults with out-of-hospital cardiac arrest and initial pulseless electrical activity; the primary outcome was favourable neurological outcome at one month. Witnessed arrest predicted a favourable outcome (RR 1.65), while longer response time predicted a worse outcome (RR 0.66; 10 versus 5 minutes). Prehospital return of spontaneous circulation was the strongest predictor at hospital arrival (RR 23.31). Conversion to a shockable rhythm had opposite associations by presumed aetiology: favourable in cardiac arrest (RR 1.37), but worse in non-cardiac arrest (RR 0.73).
Study limitation: The abstract reports no confidence intervals or absolute neurological outcome rates, limiting assessment of precision and clinical magnitude.
Published abstract
BACKGROUND: Out-of-hospital cardiac arrest (OHCA) with pulseless electrical activity (PEA) has a poor prognosis and is aetiologically heterogeneous. We aimed to identify prehospital predictors of a favourable outcome, overall and by presumed aetiology. METHODS: This nationwide cohort study analysed 442,630 adults with OHCA and an initial rhythm of PEA from the All-Japan Utstein Registry between 2005 and 2024. The primary outcome was a favourable neurological outcome at 1 month. Two models were fitted, at the scene and at hospital arrival, each also within each aetiology. Epinephrine and advanced airway management (AAM) were assessed by time-dependent propensity score sequential matching. RESULTS: At the scene, a witnessed arrest (risk ratio [RR], 1.65) predicted a favourable neurological outcome, and a longer response time predicted a worse one (RR, 0.66; 10 versus 5 min). The gradient with age was steeper in cardiac than non-cardiac PEA (RR, 0.38 versus 0.78). At hospital arrival, prehospital return of spontaneous circulation (RR, 23.31) was the strongest predictor, but conversion to a shockable rhythm predicted a favourable outcome only in cardiac PEA and a worse outcome in non-cardiac PEA (RR, 1.37 versus 0.73). Standardised to a common covariate distribution, 1-month survival was higher in non-cardiac PEA, whereas a favourable neurological outcome was more likely in cardiac PEA. After time-dependent adjustment, the apparent harm from epinephrine and AAM was attenuated. CONCLUSIONS: Prehospital information available before hospital arrival predicted a favourable neurological outcome, but its prognostic meaning depended on the presumed aetiology. These independent prehospital predictors could inform future risk stratification.
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