Pulmonary embolism (PE) is a life-threatening condition resulting from the obstruction of pulmonary arteries by blood clots, usually originating from deep veins. Symptoms of PE might vary from nothing to sudden death. Clinically, individuals may present very differently. When a diagnosis of PE is suspected, any possible life-saving intervention must be implemented because survival from cardiac arrest following PE is often quite low. Although there are not many randomized controlled trials that provide guidelines for treating suspected PE in cardiac arrest victims, the few published case reports and other minor studies suggest that thrombolysis and other therapies are associated with good outcomes. We report a patient with PE who presented in cardiac arrest with its clinical, electrographic, and radiologic findings, along with the appropriate therapy chosen based on hemodynamic stability. It is important to intervene early to prevent severe complications and improve the patient\'s outcomes.

OBJECTIVE: Evaluate the association between early naloxone use and outcomes after out-of-hospital cardiac arrest (OHCA) with initial non-shockable rhythms.
METHODS: This study was a secondary analysis of data collected in the Portland Cardiac Arrest Epidemiologic Registry, a database containing details of emergency medical services (EMS)-treated OHCA cases in the Portland, Oregon metropolitan region. Eligible patients had non-traumatic OHCA with an initial non-shockable rhythm and received naloxone by EMS or law enforcement prior to IV/IO access (exposure group). The primary outcome was ROSC at emergency department (ED) arrival. Secondary outcomes included survival to admission, survival to hospital discharge, and cerebral performance category score ≤2 at discharge (good neurologic outcome). We performed multivariable logistic regressions adjusting for age, sex, arrest location, witness status, bystander interventions, dispatch to EMS arrival time, initial rhythm, and county of arrest.
RESULTS: There were 1807 OHCA cases from 2018 to 2021 meeting eligibility criteria, with 57 receiving naloxone before vascular access. Patients receiving naloxone prior to vascular access attempts had higher adjusted odds (aOR [95% CI]) of ROSC at any time (2.14 [1.20-3.81]), ROSC at ED arrival (2.14 [1.18-3.88]), survival to admission (2.86 [1.60-5.09]), survival to discharge (4.41 [1.78-10.97]), and good neurologic outcome (4.61 [1.74-12.19]).
CONCLUSIONS: Patients with initial non-shockable OHCA who received law enforcement or EMS naloxone prior to IV/IO access attempts had higher adjusted odds of ROSC at any time, ROSC at ED arrival, survival to admission, survival to discharge, and good neurologic outcome.

UNASSIGNED: Recent studies have shown inconsistent results regarding the association between QRS characteristics and survival outcomes in patients with cardiac arrest and pulseless electrical activity (PEA) rhythms. This meta-analysis aimed to identify the usefulness of QRS width and frequency as prognostic tools for outcomes in patients with cardiac arrest and PEA rhythm.
UNASSIGNED: Extensive searches were conducted using Medline, Embase, and the Cochrane Library to find articles published from database inception to 4 June 2023. Studies that assessed the association between the QRS characteristics of cardiac arrest patients with PEA rhythm and survival outcomes were included. The Newcastle-Ottawa Scale was used to assess the methodological quality of the included studies.
UNASSIGNED: A total of 9727 patients from seven observational studies were included in this systematic review and meta-analysis. The wide QRS group (QRS ≥ 120 ms) was associated with significantly higher odds of mortality than the narrow QRS group (QRS < 120 ms) (odds ratio (OR) = 1.86, 95% confidence interval (CI) = 1.11-3.11, I2 = 58%). The pooled OR for mortality was significantly higher in patients with a QRS frequency of < 60/min than in those with a QRS frequency of ≥ 60/min (OR = 1.90, 95% CI = 1.19-3.02, I2 = 65%).
UNASSIGNED: Wide QRS width or low QRS frequency is associated with increased odds of mortality in patients with PEA cardiac arrest. These findings may be beneficial to guide the disposition of cardiac arrest patients with PEA during resuscitation.

UNASSIGNED: Blood-based biomarkers play a central role in the diagnosis and treatment of critically ill patients, yet none are routinely measured during the intra-arrest phase of out-of-hospital cardiac arrest (OHCA). Our objective was to describe methodological aspects, sources of evidence, and gaps in research surrounding intra-arrest blood-based biomarkers for OHCA.
UNASSIGNED: We used scoping review methodology to summarize existing literature. The protocol was designed a priori following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews. Inclusion criteria were peer-reviewed scientific studies on OHCA patients with at least one blood draw intra-arrest. We excluded in-hospital cardiac arrest and animal studies. There were no language, date, or study design exclusions. We conducted an electronic literature search using PubMed and Embase and hand-searched secondary literature. Data charting/synthesis were performed in duplicate using standardized data extraction templates.
UNASSIGNED: The search strategy identified 11,834 records, with 118 studies evaluating 105 blood-based biomarkers included. Only eight studies (7%) had complete reporting. The median number of studies per biomarker was 2 (interquartile range 1-4). Most studies were conducted in Asia (63 studies, 53%).  Only 22 studies (19%) had blood samples collected in the prehospital setting, and only six studies (5%) had samples collected by paramedics. Pediatric patients were included in only three studies (3%). Out of eight predefined biomarker categories of use, only two were routinely assessed: prognostic (97/105, 92%) and diagnostic (61/105, 58%).
UNASSIGNED: Despite a large body of literature on intra-arrest blood-based biomarkers for OHCA, gaps in methodology and knowledge are widespread.

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OBJECTIVE: To report the prevalence of initial shockable cardiac arrest rhythms (I-SHKR), incidence of subsequent shockable cardiac arrest rhythms (S-SHKR), and factors associated with I-SHKRs and S-SHKRs and explore their association with return of spontaneous circulation (ROSC) rates in dogs and cats undergoing CPR.
METHODS: Multi-institutional prospective case series from 2016 to 2021, retrospectively analyzed.
METHODS: Eight university and eight private practice veterinary hospitals.
METHODS: A total of 457 dogs and 170 cats with recorded cardiac arrest rhythm and event outcome reported in the Reassessment Campaign on Veterinary Resuscitation CPR registry.
RESULTS: Logistic regression was used to evaluate association of animal, hospital, and arrest variables with I-SHKRs and S-SHKRs and with patient outcomes. Odds ratios (ORs) were generated, and significance was set at P < 0.05. Of 627 animals included, 28 (4%) had I-SHKRs. Odds for I-SHKRs were significantly higher in animals with a metabolic cause of arrest (OR 7.61) and that received lidocaine (OR 17.50) or amiodarone (OR 21.22) and significantly lower in animals experiencing arrest during daytime hours (OR 0.22), in the ICU (OR 0.27), in the emergency room (OR 0.13), and out of hospital (OR 0.18) and that received epinephrine (OR 0.19). Of 599 initial nonshockable rhythms, 74 (12%) developed S-SHKRs. Odds for S-SHKRs were significantly higher in animals with higher body weight (OR 1.03), hemorrhage (OR 2.85), or intracranial cause of arrest (OR 3.73) and that received epinephrine (OR 11.36) or lidocaine (OR 18.72) and significantly decreased in those arresting in ICU (OR 0.27), emergency room (OR 0.29), and out of hospital (OR 0.38). Overall, 171 (27%) animals achieved ROSC, 81 (13%) achieved sustained ROSC, and 15 (2%) survived. Neither I-SHKRs nor S-SHKRs were significantly associated with ROSC.
CONCLUSIONS: I-SHKRs and S-SHKRs occur infrequently in dogs and cats undergoing CPR and are not associated with increased ROSC rates.

Pulseless electrical activity (PEA) is considered an enigmatic phenomenon in resuscitation research and practice. Finding individuals with no consciousness or pulse but with continued electrocardiographic (EKG) complexes obviously raises the question of how they got there. The development of monitors that can display the underlying rhythm has allowed us to differentiate between VF, asystole, and PEA. Lack of clear understanding of the emergence of PEA has limited the research and development of interventions that might improve the low rates of survival typically associated with PEA. Over 30 years of studying and practicing resuscitation have allowed the authors to see a substantial rise in PEA with variable survival rates, based on the patients\' illness spectrum and intensity of monitoring. This paper presents a small case series of individuals with brain death whose family members consented to the echocardiographic observation of the dying process after disconnection from life support. The observation from these cases confirms that PEA is a late phase in the clinical dying process. Echocardiographic images delineate the stages of pseudo-PEA with ineffective contractions, PEA, and then asystole. The process is contiuous with none of the sudden phase shifts seen in dysrhythmic events such as VF, VT or SVT. The implications of these findings are that PEA is a common manifestation of tissue hypoxia and metabolic substrate depletion. Our findings offer prospects for studies of the development of interventions to improve PEA survival.

A patient with trauma presents a unique and/or complex challenge to the ethical foundation that guides nursing care. Patients with trauma, by the very nature of the suddenness of their injury, are unable to predetermine or express their wishes in the event of a catastrophic injury. The providers who care for patients with trauma do not have an established patient relationship to aid them in decision-making based on what they think the patient would wish or based on past conversations. Yet, they provide expert care and use ethical principles to direct their professional responsibility to these patients.

The proportion of sudden cardiac arrests (SCA) manifesting with pulseless electrical activity (PEA) has increased significantly, and the survival rate remains lower than ventricular fibrillation (VF). However, a subgroup of PEA-SCA cases does survive and may yield key predictors of improved outcomes when compared to non-survivors. We aimed to identify key predictors of survival from PEA-SCA.
Our study sample is drawn from two ongoing community-based, prospective studies of out-of-hospital SCA: Oregon SUDS from the Portland, OR metro area (Pop. approx. 1 million; 2002-2017) and Ventura PRESTO from Ventura County, CA (Pop. approx. 850,000, 2015-2021). For the present sub-study, we included SCA cases with PEA as the presenting rhythm where emergency medical services (EMS) personnel attempted resuscitation.
We identified 1,704 PEA-SCA cases, of which 173 (10.2%) were survivors and 1,531 (89.8%) non-survivors. Patients whose PEA-SCA occurred in a healthcare unit (16.9%) or public location (18.1%) had higher survival than those whose PEA-SCA occurred at home (9.3%) or in a care facility (5.7%). Young age, witness status, PEA-SCA location and pre-existing COPD/asthma were independent predictors of survival. Among witnessed cases the survival rate was 10% even if EMS response time was >10 minutes.
Key determinants for survival from PEA-SCA were young age, witnessed status, public location and pre-existing COPD/asthma. Survival outcomes in witnessed PEA cases were better than expected, even with delayed EMS response.

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