Sheldon Cheskes

INTRODUCTIONOut-of-hospital cardiac arrest (OHCA) survival remains near 10%, and researchers continue to investigate new methods to improve survival (1). From 2010 to 2015, Japanese investigators i...

In Canada, an estimated 60,000 out-of-hospital cardiac arrests (OHCA) occur annually, with mortality rates upwards of 90% (1). High quality cardiopulmonary resuscitation (CPR) is one of the most im...

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging intervention to control hemorrhage and to improve perfusion to vital organs. It is commonly used in patients with he...

Background: The incidence of opioid-associated out-of-hospital cardiac arrest (OA-OHCA) remains high; however, it can often be challenging for paramedics to identify opioid use as the cause of OHCA upon arrival at the scene and during resuscitation. We examined characteristics of occult OA-OHCAs and derived a score to help guide paramedic identification of these arrests. Methods: We conducted a retrospective study of OHCA patients in southern Ontario from 2020 to 2022. Descriptive statistics were used to summarize characteristics by etiology, and multivariable logistic regression was conducted to examine the association between variables and OA-OHCA. Results: Of 5634 treated patients with no obvious cause based on paramedic judgement, 1302 patients had full coroner investigations. There were 199 (15%) cardiac arrests related to drug overdose, of which 153 (77%) were due to opioids and 46 (23%) due to non-opioid drugs. Several variables were associated with occult OA-OHCA (p<0.05), including male sex, younger age, unwitnessed status, bystander naloxone administration, history of drug use, paraphernalia on the scene, and evidence of drug use in our regression models. A model was derived using a set of these variables and was able to discriminate strongly between opioid-associated and non-opioid-associated arrests (AUC = 0.9). Conclusion: We derived a simple predictive score to help EMS improve the identification of occult OA-OHCA patients. Future studies will include validation and prospective clinical trials to evaluate the score and selective treatments for OA-OHCA.

Objective: As opioid-related fatalities continue to climb, it is imperative to advance our understanding of the management of life-threatening opioid emergencies, including cardiac arrest. Emergency medical services (EMS) administered naloxone reverses critical respiratory depression within minutes; however, the role of naloxone in cases of opioid-associated cardiac arrest (OA-OHCA) is unknown. This systematic review sought to summarize patient outcomes following EMS-administered naloxone in OA-OHCA cases. Methods: Following PRISMA guidelines, a systematic search was conducted in OVID Medline, Embase, and Cochrane from database inception to December 2024. Original, peer-reviewed studies examining patients with OA-OHCA who were given naloxone by EMS were included. Two independent reviewers screened titles/abstracts and full-texts in Covidence based on predetermined inclusion criteria. Relevant data points were extracted, and a risk of bias assessment was conducted for included studies. No meta-analysis was performed due to heterogeneity across the included studies. Results: The literature search yielded 4814 articles, of which 8 studies met eligibility and were included. Seven of the included studies were retrospective cohort studies conducted in the United States. The eighth included study was a prospective cohort study conducted in Denmark. The total sample size for drug-related OHCA patients was 1294 (range 16–471) from all the included studies. Risk of bias was assessed to be low to moderate in seven studies and serious in one study. A minority of patients achieved return of spontaneous circulation (ROSC), with ROSC ranging from 4.3% to 50%. Survival to hospital admission ranged from 11.1% to 55%, while survival to hospital discharge ranged from 0% to 20.4%. Conclusions: There are a limited number of studies assessing the use of naloxone in patients who present in opioid-associated out-of-hospital cardiac arrest (OA-OHCA). Further research is needed to evaluate the effectiveness of naloxone in this patient population.

BACKGROUND: Sudden cardiac death (SCD) can be caused by heritable cardiac conditions, as such, up to 50% of family members may be at risk. Coroners are responsible for communicating this risk, in addition to investigating the cause of death. The purpose of this study was to explore how family members of SCD victims experience the type, timing, and suitability of communication with coroners about the cause of death and their own risk for SCD. METHODS: We conducted an explanatory sequential mixed methods study. Eligible family members of SCD victims aged 2 to 70 years, who died in 2021 from a potentially heritable cardiac condition and were investigated by the Office of the Chief Coroner of Ontario (Canada), were invited to complete a web survey and telephone interview. We used descriptive statistics to analyze the survey data and thematic analysis to analyze the interview data. Quantitative and qualitative data integration occurred at multiple levels. RESULTS: We sent survey invitations to 126 family members of 115 SCD victims; 50 completed the web-based survey between September 2022 and February 2024. We interviewed a subset of 17 participants. Most received initial communication by phone (n=30, 60%) or in-person (n=13, 26%). Although many (n=39; 78%) received a timeline for death investigation results, 16 (32%) did not receive results within the expected timeframe. In interviews, family members described effective communication as clear, with the coroners’ demeanor being important, in particular, perceived as kind, accessible, and approachable. When communication needs went unmet, families relied on external support networks (outside of the coroner system) to fill information gaps. Suggestions for improved communication included repeating information and using multiple communication modes to enhance understanding. CONCLUSIONS: Findings emphasize the need for coroners to use empathetic approaches and provide timely, clear information. Addressing communication gaps may better meet the needs of grieving SCD families.

The Double Sequential External Defibrillation for Refractory Ventricular Fibrillation (DOSE VF) trial demonstrated improved outcomes for patients randomized to double sequential external defibrillation (DSED) in comparison to standard defibrillation, yet large-scale data on prehospital DSED use remain limited. We evaluated prehospital DSED use before and after publication of DOSE VF. We conducted a retrospective analysis of adult (>18 years of age) non-traumatic out-of-hospital cardiac arrest (OHCA) patients who had an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia and at least 4 successive defibrillation attempts in the ESO Data Collaborative from 2018-2024. We excluded patients with return of spontaneous circulation prior to the fourth defibrillation, resuscitation-limiting advanced directives, or OHCA due to drowning or overdose. To minimize the influence of agencies joining the Collaborative during the study period, we excluded agencies that did not contribute data during the first study year. We identified DSED using three methods: 1.) documentation of "Dual Sequence Defibrillation (DSD)", 2.) defibrillation at a 400J or 720J energy setting, or 3.) two defibrillations within 5 seconds. The DOSE VF trial was published in November 2022, and Q4 2022 was used as a washout period. We classified patients as treated pre-DOSE VF if treated before Q4 2022, and post-DOSE VF if treated after Q4 2022. We compared pre- and post-DOSE VF use of DSED using Pearson's 𝜒² test and an interrupted time-series analysis using segmented Poisson regression with 3-month non-overlapping segments. We identified 16,450 DSED-eligible patients treated by 906 emergency medical services agencies. Estimates of DSED use varied by ascertainment method (Method 1: 3.7%, Method 2: 1.8%, Method 3: 4.4%, any method: 7.6%). The use of DSED detected by any method increased post-DOSE VF (pre vs. post: 822/11,228 (7.3%) vs. 381/4,625 (8.2%), p = 0.048). Segmented Poisson regression suggested an increase in the rate of DSED use (slope change) after DOSE VF (RR: 1.09 (1.04, 1.14) per quarter). Our findings suggest an increasing rate of DSED use after publication of DOSE VF, but the proportion of eligible patients receiving DSED remains low. Limitations include the potential for patient misclassification by our DSED ascertainment methods.