UNASSIGNED: An uncommon cause of reflex syncope is carotid sinus syndrome (CSS). In rare cases, this can be caused by compression of the carotid sinus by a progressive or invasive tumour.
UNASSIGNED: A 57-year-old female was presented at the emergency department with recurrent syncope in the morning. After initial observation, no heart rhythm abnormalities or syncope were observed. The day after discharge, she was presented again with a syncope. Hypotension and bradycardia were observed this time. Furthermore, a mass in the neck area was found near the carotid artery. She was admitted to the cardiology department with suspected carotid sinus syndrome for telemetric observation. Diagnostics by biopsy and PET-CT showed a metastasized squamous cell carcinoma of the tongue. Initial treatment of dexamethasone was started after which the recurrence of the syncope decreased. However, during admission, an in-hospital cardiac arrest occurred due to persistent vagal stimulation. As a result, the patient was started on neoadjuvant chemotherapy and midodrine, after which she experienced multiple complications and died.
UNASSIGNED: To the best of our knowledge, this is the first case report that shows an IHCA due to severe hypotension related to a carotid sinus syndrome.

Prosthetic valvular infolding during transcatheter aortic valve implantation (TAVI) is an under-recognized yet significant complication that can occur. Here, we describe the case of a 61-year-old male with a history of heart failure with reduced ejection fraction (HFrEF) and low-flow, low-gradient severe aortic valve stenosis of a bicuspid aortic valve who presented to undergo TAVI. During the procedure, repositioning of the valve resulted in prosthetic valvular infolding and resultant severe aortic regurgitation (AR), culminating in cardiac arrest. Swift balloon valvuloplasty corrected the valve geometry and eliminated any AR, allowing hemodynamic recovery and completion of the procedure. Our case and review highlight methods, both angiographic and echocardiographic, to recognize prosthetic valvular infolding the moment it presents, as well as strategies to correct the infolding with minimal detriment to the patient.

The recreational and medicinal uses of cannabis are increasing worldwide. Given the recent legalization of marijuana in some regions of the United States, the use of edible formulations has become increasingly popular, especially among the elderly. These new formulations can be up to 10 times more potent than previously available preparations and have been associated with a variety of cardiovascular adverse effects. Here, we present a case of an elderly male who presented with dizziness and altered mental status. He was found to be severely bradycardic and emergently required atropine. Further investigation revealed that he accidentally ingested large amounts of oral cannabis. An extensive cardiac workup revealed no other etiology for his arrhythmia. Cannabidiol (CBD) and tetrahydrocannabinol (THC) are the most commonly studied cannabis compounds. With the increased access to and popularity of edible cannabis formulations, this case demonstrates the need for further research regarding the safety of oral cannabis.

We aimed to describe and evaluate the National Early Warning Score (NEWS) in the 24 hours preceding an in-hospital cardiac arrest among general somatic ward patients.The 24 hours preceding the in-hospital cardiac arrest were divided into four timespans and analysed by a medical record review of 127:254 matched case-control patients. The median NEWS ranged from 3 (2-6) to 6 (3-9) points for cases vs 1 (0-3) to 1 (0-3) point for controls. The proportion of cases ranged from 23-45% at high risk vs 3-6% for controls. The NEWS high-risk category was associated with an increase of 3.17 (95% confidence interval (CI) 1.66-6.04) to 4.43 (95% CI 2.56-7.67) in odds of in-hospital cardiac arrest compared to the low-risk category.NEWS, with its intuitive and for healthcare staff easy to interpret risk classification, is suitable for discriminating deteriorating patients with major deviating vital signs scoring high risk on NEWS.

High quality cardiopulmonary resuscitation (CPR) is critical to improve survival from cardiac arrest. While low dose- high frequency case-based training enhances CPR skill retention, it is unclear if this training method is feasible in a clinical environment and if it yields improved clinical CPR quality during in-hospital cardiac arrest. We evaluated the implementation of a novel platform providing low dose- high frequency psychomotor CPR training and its impact upon CPR quality.
The described training platform was launched on two nursing units (60 beds) in a university teaching hospital. Quarterly utilization of the platform was integrated into normal clinical duties of hospital staff. Simulated CPR performance and staff compliance were evaluated pre- and post-intervention. In addition, clinical CPR performance was evaluated for periods of six months before and after four quarters of implementation (median, IQR).
The low dose, high frequency CPR training led to retention of simulated CPR skills (compression rate, depth and fraction) during each quarter exceeding high-quality guideline thresholds. Clinical CPR quality, measured by compression fraction (Pre: 83% (73, 95) and Post: 93% (88, 98), p < 0.001) and rate (Pre: 109 (96, 126) and Post: 120 (108, 130), p = 0.008) increased significantly following platform implementation. Over the intervention period, program compliance was greater than 97%.
Low dose-high frequency case based psychomotor CPR training is feasible in a clinical setting with high compliance. In two nursing units, this method of training resulted in enhanced CPR skill retention and improved in-hospital clinical CPR quality.

Utstein-style reporting templates provide a structured framework with which to compare systems of care for cardiac arrest. The 2004 Utstein reporting template encompassed both out-of-hospital and in-hospital cardiac arrest. A 2015 update of the Utstein template focused on out-of-hospital cardiac arrest, which makes this update of the in-hospital template timely. Representatives of the International Liaison Committee on Resuscitation developed an updated in-hospital Utstein reporting template iteratively by meeting face-to-face, by teleconference, and by online surveys between 2013 and 2018. Data elements were grouped by hospital factors, patient variables, pre-event factors, cardiac arrest and postresuscitation processes, and outcomes. Elements were classified as core or supplemental by use of a modified Delphi process. Variables were described as core if they were considered essential. Core variables should enable reasonable comparisons between systems and are considered essential for quality improvement programs. Together with core variables, supplementary variables are considered useful for research.

Utstein-style reporting templates provide a structured framework with which to compare systems of care for cardiac arrest. The 2004 Utstein reporting template encompassed both out-of-hospital and in-hospital cardiac arrest. A 2015 update of the Utstein template focused on out-of-hospital cardiac arrest, which makes this update of the in-hospital template timely. Representatives of the International Liaison Committee on Resuscitation developed an updated in-hospital Utstein reporting template iteratively by meeting face-to-face, by teleconference, and by online surveys between 2013 and 2018. Data elements were grouped by hospital factors, patient variables, pre-event factors, cardiac arrest and postresuscitation processes, and outcomes. Elements were classified as core or supplemental by use of a modified Delphi process. Variables were described as core if they were considered essential. Core variables should enable reasonable comparisons between systems and are considered essential for quality improvement programs. Together with core variables, supplementary variables are considered useful for research.

This study describes the predictors of in-hospital cardiac arrest (IHCA) within 24 h of ED triage and evaluates their ability to predict patients at risk of IHCA.
A case-control study was conducted in the ED. \'Cases\' are herein defined as hospitalised patients who experienced IHCA within 24 h after ED triage. The exclusion criteria were those younger than 16 years old, cases of traumatic arrest, or had do-not-resuscitate orders. The controls were adults, non-traumatic cases, who did not experience IHCA within 24 h of ED triage. A multivariable regression model was used to identify significant predictors of IHCA. The ability to discriminate was quantified by utilising an area under receiver operating characteristic (AuROC) curve.
Two hundred and fifty IHCAs were compared with 1000 controls. Five predictors emerged that were: higher National Early Warning Score (NEWS) at triage, equal or increase of NEWS after ED management, coronary artery disease as a comorbid disease, the use of a vasoactive agent, and initial serum bicarbonate level lower than 23.5 mmoL/L, independently associated with IHCA. The AuROC of the final model from all predictors was 0.91 (95% CI 0.89-0.93) higher than NEWS alone model (AuROC at 0.78, 95% CI 0.74-0.81).
We conclude that a combination of NEWS and four independent predictors identify patients at risk of IHCA more effectively than NEWS alone.

Study the incidence and reasons behind in-hospital cardiac arrests (IHCAs) after rapid response team (RRT) reviews.
We conducted a matched case-control study at Tampere University Hospital, Finland. Data on adult patients who were triaged to remain on general ward after first (index) RRT review without treatment limitations but who suffered an IHCA within the following 48 h were prospectively collected for 5.3 years. These cases were matched (age ±3 years, sex, surgical/medical ward, admission year) at a 1:4 ratio to controls (no ICHA after RRT review).
Of 2653 index RRT reviews, 17 patients suffered an IHCA on general ward within the 48 h after review. Their 30-day mortality rate was 88%. The incidence was 6.3/1000 index RRT reviews or 4.6/100,000 hospital admissions. Patients who suffered an IHCA within 48 h after RRT review were more likely to have a preceding ICU admission, and their median national early warning scores (NEWSs) at the end of the index RRT reviews (=last NEWSs) were higher than those of the controls. Higher last NEWS was the only factor associated with ICHA after RRT review (OR 1.22, 95% CI 1.00-1.49, p = 0.048) in a conditional multivariable regression model.
IHCA within 48 h after an index RRT review on general ward is a rare event with poor prognosis. It is independently associated with higher NEWS at the end of the index RRT review. Careful consideration is stressed, when patients with high NEWS are left on ward after RRT reviews.