Bologna 2018 Retrospective

The 2018 ERC Congress in Bologna in Italy saw many interesting workshops and speakers. We gladly share the summaries of the presentations with you.

Day 1: Thursday 20 September 2018

Day 2: Friday 21 September 2018

Day 3: Saturday 22 September 2018

Day 1: Thursday 20 September 2018

New technological strategies to save lives

Latest Resuscitation Trials 1: Implications for Practice

New technological strategies to save lives

Cardiac arrest recognition

Speaker - Marcus Ong

Based on a Pre-hospital Emergency Care National Blueprint and a system with geolocalisation of cell-phones, AED location and volunteers, total survivors increased from 48 to 125, bystander CPR rate from 22% to 54% and AED use from 1.8% to 4.1%. Younger patients (<65) are 2.6 times more likely to survive than older patients (>65).

 

Enhanced Community response

Speaker – Mattias Ringh

-        Early recognition and call for help => use modern techniques

-        Early bystander CPR: questions about true bystander CPR, quality of CPR and quality of CPR feedback devices

-        Early defibrillation: AED challenge because low use of AEDs (2-3%) and most (70%) OHCAs occur at home.

-        CPR smartphone “apps” may be used for learning and retention of CPR skills.

  • Unclear if it improves CPR during “real life” resuscitation
  • Better than nothing but not superior to traditional training

 

Flying AEDs

Speaker – Andreas Claesson

-        30 days survoival with the use of an onsite AED: Stockholm 2006-2012: 70% -- Westcoast Swedenb 2008-2015: 68%

-        Timesaving benefits in OHCA: urban areas 1.5 minutes timesaving – rural areas: 19 minutes

-        Potentialm in UAV-technolofgy (Unmanned Aerila Vehocles) for other conditiop,ns

-        Optimal lmocations / safety / feasibility / costs and bystabnder-drone-EMCC interaction needs further evaluation

-        EASA lesgislation soon to comeµ

-        Clinical study to be lauched

 

Beyond CPR feedback

Speaker - Giuseppe Ristagno

-        Modern defibrillators could guide resuscitation and defibrillate of course

-        CPR prior to defibrillation: if response time < 5 min survival is same but if > 5 minutes first CPR is the most important (p=0.006)

-        VF waveform lowers without and improves with CPR over time

-        CPR depth is important for  success of defibrillation

 

Latest Resuscitation Trials 1: Implications for Practice

 

The Adrenaline trial

Speaker– Gavin Perkins

-        ROSC with adrenaline (A group): 36.3% versus 11.7% with placebo (P-group)

-        Admitted to hospital: 23.8% in A group vs. 8.0% in P-group

-        Survival to 30 days: 3.2% in A group vs 2.4% in P-group

-        Favourable neurologic outcome at discharge : 2.2% in A group vs 1.9% in P-group (no significant difference)

-        Poor neurological outcome: 31.0% in A group vs 17.8% in P-group (more severe brain damage in A group)

-        3 months outcome: no statistical difference

-        Conclusion: Adrenaline can restart the heart nut it‘s not good for the brain

 

Airways

Speaker – Jonathan Benger

-        Comparing tracheal intubation (ETI) to supraglottic airway (SGA)

  • Overall patient outcomes are the same
  • SGA is associated with higher use and greater ventilation success
  • Rates of aspiration and regurgitation are the same
  • Further studies needed for evidence that advanced airway management (AAM) improves outcomes in OHCA

 

Pragmatic Airway Resuscitation Trial

Speaker - Henry Wang

-        Laryngeal tube (LT) versus endotracheal intubation (ETI) in Adult OHCA: what is best

-        Initial LT associated with better outcomes than initial ETI

-        EMS providers may consider initial LT in adult OHCA

 

CAAM Study: Effect of Bag-Mask Ventilation vs Endotracheal intubation during Cardiopulmonary Resuscitation

Speaker - Stefano Malinverni

-        Inconclusive trial: non-inferiority of BMV compared to ETI was not demonstrated

-        Significant higher ROSC for ETI

-        Significant lower airway difficulty, failure and regurgitation for ETI

-        ETI does not increase Chest Compression Fraction

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Day 2: Friday 21 September 2018

Technology-enhanced learning

Technologies to save children

New developments in research

Year in review

Neonates

Latest resuscitation trials 2

Technology to support pre-hospital care

Technology-enhanced learning

Social media to engage the population

Speaker – Andy Lockey

-        Social media has the ability to instantly reach a massive audience

-        Useful top get key messages out

-        Great for campaigning

-        There are some limitations however

-        Take home message – use the “mother” test. Are you posting something she would disapprove of??? If so, Stop!

Virtual reality for CPR training

Speaker - Federico Semeraro

-        Chest compression depth and rate are better with virtual learning than with conventional training (resp. 3.7 mm and 1.4 compressions

-        Further studies needed

 

Let’s get CoSY: what’s next

Speaker - Patrick Van de Voorde

 

Resuscitation apps: what’s out there?

Speaker - Jasmeet Soar

-        A lot of apps – but are they medical devices?

-        Face to face training is similar to Lifesaver

-        Lifesaver + face to face is best

Technologies to save children

Digital systems for monitoring vital signs

Speaker - Meera Joshi

-        To optimise the identification of acute deterioration and sepsis through wearable sensors and digital alerting systems

-        Continuous monitoring by wearable patches reduce ICU length of stay (0.9 days)

-        Mortality reduction 25.5%

-        Patients found it comfortable and easy to use

 

What can an oxygen saturation probe tell you

Speaker – Ian Maconochie

-        Different factors can affect readings for pulse oximetry

-        There are transmission modes (most used) or reflective modes (for feet, forehead, chest, wrists)

 

The value of point of care tests (POCT) in paediatric emergencies

Speaker - Patrick Van de Voorde

 

Does cardiac screening save athletes lives?

Speaker - Laurie J. Morrison

-        Incidence of athlete induced OHCA much less than maternal OHCA

-        Pre-screening is unnecessary in 2-45 year old athletes pre sports

-        Maternal screening needs more investigation before implementation

-        Survival rates are high in both athlete, mom and neonate

-        OHCA aetiology is a mixed bag

New developments in research

EurecaTwo:

Speaker – Jan-Thorsten Gräsner

-        Cardiac Arrest suspected          38 585

-        Cardiac Arrest confirmed          37 054 (96%)

  • CPR started                              25 171 (67.9%)
    • Overall Survival            8 231 (32.7%)
    • CPR not started            11 854 (32%)

 

Escape-Net

Speaker – Marieke Blom

-        SCA is lethal within minutes

-        OHCA SCA = ~50% of cardoiac deaths and ~20% of natural deaths

 

Bayesian Approches

Speaker – Lars W. Andersen

-        Bayesian methods are an alternative/complement to frequentist methods

-        Prior information (subjective or objective) is needed

-        Mathematically complex (simulations)

-        More flexible in the context of adaptive designs

-        Easy to interpret results – intuitive probabilities

 

Efficient Trial Designs

Speaker – Michael W. Donnino

-        We need better “preparation” before large clinical trials to be more efficient during trials – animal studies etc

-        Choose endpoints carefully and recognise the limitations of the ‘ideal” versus “actual” population

-        Control groups need to be carefully chosen

-        Carefully chose a control group and often consider “usual care” arm (even that is controversial)

-        Patients in clinical trials must be protected despite

 

Year in review

EMS dispatch

Speaker – Maaret Castrén

-        Every 30 seconds delay in detection CA reduces good survival with 3%

-        Telephone CPR increased survival and was as effective as Bystander CPR

-        Video-instructed method of instructing bystander: more delay in chest compression but better results in compression rate and correct hand position than audio instruction

-        Bystander CPR + fast response = better survival

-        Recognition of CA: 45.8% identified

 

Cardiac arrest treatment: the Gaps

Speaker – Janet Bray

-        Airway:

  • Type and duration of training required for performing advanced airway management during CPR
  • Intubates versus laryngeal tube: lower survival to 72 h, lower rates of ROSC and lower survival to hospital discharge
  • RCTs: how you maintain an airway is less important that that it is done
  • Hyperventilation by professionals whatever the interface used (>70%)

-        Oxygen:

  • Intra-arrest hyperoxia associated with lower mortality
  • Post-arrest hyperoxia associated with higher mortality

-        Drugs: Adrenaline: higher ROSC but higher proportion of poor neurological outcome at discharge

-        Target Temperature Management: no difference in outcome if 24 or 48 h TTM

 

Surviving cardiac arrest

Speaker - Kirstie Haywood

-        What do we know: cognitive impairment, emotional well-being, physical and functional impact, social participation and family network

-        Central goal is community reintegration and return to work

-        What is required? CA has life-changing consequences and need long-term support, patient and public involvement.

Neonates

Delayed cord clamping low tech the way ahead?

Speaker – Jonathan Wyllie

-        Natural is to delay cord clamping for at least 1 minute and perhaps until respiration is established

-        Recording time of cord clamping and time to respiration in all deliveries: mandatory

-        Develop techniques to the needs of the baby

  • Easy in term babies who do not need assistance
  • Harder in Caesarian Section and those who need resuscitation
  • Hardest in compromised babies: more trials needed

-        We do not know:         

  • The effect on babies not breathing at birth
  • How long the delay should be
  • Combined maternal/neonatal outcomes for those deliveries

 

Technology needed to resuscitate babies next to their mothers

Speaker - Joe Fawke

-        Life start <-> Caesarian section <-> Resuscitaire®

=> Practical problems: length of cord, thermal care, initial HR/breathing, position, …

-        Most babies require stabilisation rather than resuscitation

=> Most babies can be managed at the bedside

-        Some babies require resuscitation

=> Follow guidelines, just slightly closer to the mother

“Just take a couple of steps from where you would usually stand and turn towards mum’s bed. Then do what you normally do.

 

Neonatal respiratory function monitors: ready for prime time neonatal resuscitation

Speaker - Arjan te Pas

-        Why?   Vulnerable moment for breathing and chest rise

-        How?   With an all-in one monitor. And a weekly audit.

-        What?  Improve mask technique and monitor

 

Keeping babies warm during resuscitation – how does technology help?

Speaker – Daniele Trevisanuto

-        Incidence of hypothermia remains high in very preterm infants in high and low-resource settings

-        Hypothermia at NICU admission is a strong indicator of mortality and morbidity

-        What can we do to avoid hypothermia?

Staff education and QI interventions are mandatory to improve thermal management during neonatal resuscitation

Latest resuscitation trials 2

Out-of-hospital cardiac arrest and amiodarone, lidocaine

Speaker – Peter J. Kudenchuk

-        Unwitnessed arrest => “no gain, no pain”

-        Witnessed arrest => 5% absolute survival

-        Net effect => ~3% absolute survival

 

Therapeutic Hyopthermia after Paediatric Cardiac Arrest (THAPCA)

Speaker – Vinay Nadkarni

-        Out-of-hospital THAPCA: Among comatose children who survived OHCA, THAPCA as compared with therapeutic normothermia did not confer a significant benefit in survival with good neurological outcome at 1 year

-        In-hospital THAPCA: idem as in OHCA THAPCA

 

Large Randomized Trial of Continuous vs. Interrupted Chest Compressions in OHCA

Speaker – Henry Wang

-        Largest cardiac arrest randomized trial

-        No improvement of survival or neurologic status with CCC vs. ICC

Technology to support pre-hospital care

How technology can support major incidents?

Speaker – Pierre Carli

-        There is no limit in technology development

-        EMS use: adapted to the needs of major casulat incidence / disaster

-        Scientific analysis of the results: many examples of the use of new technologies published, but rarely with an objective assessment of imaopct on care of vitims

 

Advances in control of life-threatening bleeding

Speaker – Eunice N Singletary

-        Pressure stops bleeding

-        Indirect/circumferential pressure via tourniquets effective and new technology being incorporated to improve successful application

-        Development of haemostatic agents treated dressings and application devices to promote clotting

-        New devices such as junctional tourniquets and wound clamps in locations that are less easily compressed

-        New syringe-type applicators allow FA use of untreated expanding mini sponges

-        Course/Classes lead to better success with learning TQ application but audio/visual assistance may aid

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Day 3: Saturday 22 September 2018

Technologies to monitor and prevent deterioration

Technology to enhance recovery after cardiac arrest

Closing ceremony

Technologies to monitor and prevent deterioration

Monitoring hospital-level performance

Speaker – Jerry Nolan

-        In-hospital CA registries can provide valuable date on hospital performance

-        Risk adjustment is vitally important

-        Hospital with more guideline-recommended practices have better outcomes

-        Divergent data on hospital characteristics and outcome after OHCA

Technology to enhance recovery after cardiac arrest

Technology to enhance recovery after cardiac arrest

Speaker - Ruud Koster

-        Immediate recognition of a collapse is the key decision for immediate action

-        Bystander actions in the first 10 minutes are more important than actions in the weeks that follows

-        Long term outcome and recovery after CA are determined in the first minutes after collapse

-        Automate recognition of collapse and pulselessness may be possible by new technology

 

Cognitive rehabilitation

Speaker - Gisela Lilja

-        Cognitive impairment common after CA and associated to poorer health and social participation

-        Follow-up including cognitive screening recommended for all CA survivors to provide further support

-        For patients in risk, further evaluation should be provided by someone experienced in brain injury problems

-        Cognitive rehab good evidence to increase participation in society, especially compensatory techniques

-        Novel techniques are an important part of cognitive rehabilitation, but have to be trained and teached.

 

Physical rehabilitation after OHCA

Speaker - Paulien H. Goossens

-        Cardiac rehabilitation for everyone

-        Screen (and treat) cognitive impairments

-        Don’t forget the caregivers

 

Technology to support patients and relatives

Speaker - Thomas R. Keeble

-        Allows to interact with patient group

-        Patient directed healthcare pathways

-        Access to education, outcome tools and therapy

Closing ceremony

Will this patient recover consciousness after cardiac arrest?

Speaker - Claudio Sandroni

-        Most resuscitated patients die of HIBI (hypo-ischaemic brain injury)

-        Prognostication should assess the severity of HIBI

-        It is a time-dependent process

-        The neural correlates of consciousness are incompletely understood

-        The correlation between HIBI, unconsciousness and prognostic indices are incompletely understood

-        Standardisation is now available for important predictors such as Pupillary Light Reflex and EEG

-        Subacute/chronic phase of HIBI deserves investigation (white matter most involved)

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