Abstract 11399: Time to Anti-Arrhythmic for Out-of-Hospital Cardiac Arrest

Introduction: Initial shockable rhythm is the strongest predictor of good outcomes for patients with out-of-hospital cardiac arrest (OHCA). While preclinical models have shown benefit of anti-arrhythmics, clinical trials have shown a very modest impact of anti-arrhythmic drugs, possibly related to real-life delays in drug administration. Little is known regarding the time to administration of anti-arrhythmic drugs or the association of time to drug and outcome. We utilized a national EMS registry to evaluate the time of drug administration and the association with outcomes. Methods: We evaluated the 2018 and 2019 NEMSIS dataset, including all non-traumatic, adult 911 EMS encounters for cardiac arrests with initial shockable rhythm. We then calculated the time from 911 call to administration of anti-arrhythmic. We excluded cases with time to administration less than 0 or greater than 120 minutes. Stratified by initial antiarrhythmic (amiodarone and lidocaine), we created a mixed-effect logistic regression model evaluating the association between every 5 minute increase in time to antiarrhythmic and ROSC. We modeled EMS agency as a random intercept and adjusted the analysis for age, sex, race, bystander witnessed arrest, location of arrest and EMS response time. We excluded EMS witnessed arrests and cases with missing ROSC data. Results: There were 449,630 adult, non-traumatic cardiac arrests identified with 55,142 patients (12.3%) having an initial shockable rhythm; 17,769 (32.2%) received amiodarone and 2,855 (5.2%) received lidocaine initially. The median time in minutes to initial dose of amiodarone was 20.4 with IQR (16-26.7). The median time in minutes to initial dose of lidocaine administration was 20.2 with IQR (15.7-27.0). Increasing time to initial antiarrhythmic was associated with decreased odds of ROSC for both amiodarone (aOR 0.9; 95% CI 0.9-0.94) and lidocaine (aOR 0.9; 95% CI 0.8-0.96). Conclusion: Time to administration of anti-arrhythmic medication varied, but most patients received the first does of anti-arrhythmic drug more than 20 minutes after the initial 911 call. Time to administration of antiarrhythmic was linked to ROSC.

Prolonged Cardiac Arrest in Severe Bupropion Intoxication: Everything You Should Know About Anti-Arrhytmics, Transesophageal Echocardiography Guided Resuscitation and Extracorporeal Membrane Oxygenation

A 30-year-old woman was admitted to the emergency department one and half hours after severe bupropion extended-release intoxication, estimated to be between 18 and 36 g. She initially presented with seizures and later developed signs of cardiotoxicity with persisting sustained ventricular tachycardia. Despite multiple defibrillation attempts and the administration of sodium bicarbonate, calcium gluconate and magnesium, restoration of sinus rhythm was found unsuccessful. In another attempt to treat this refractory ventricular tachycardia lidocaine was given followed by deterioration to asystole. During cardiopulmonary resuscitation (CPR), the quality of chest compression was assessed and optimised using transoesophageal echocardiography. Eventually venoarterial extracorporeal membrane oxygenation (VA-ECMO) was needed to achieve hemodynamic stability. In this case report we discuss the successful use of VA-ECMO after bupropion intoxication, which has only been reported in 3 other cases but should be considered as one of the treatment options in severe overdose cases. Also, the rare complication of asystole after lidocaine administration and the value of transoesophageal echocardiography during CPR will be discussed.

Complications associated with closure of the linea alba using a combination of interrupted vertical mattress and simple interrupted sutures in equine laparotomies

Objectives(1) Evaluate the occurrence and variables associated with incisional morbidities (IMs) after ventral median laparotomy when using interrupted vertical mattress sutures (IVMS) and (2) determine the occurrence of abdominal bandage-associated complications in horses.MethodsOccurrence of IM and bandage-associated complications were determined after single laparotomies (SL group; n=546 horses) and repeat laparotomies (RL group: multiple laparotomies within four weeks; n=30 horses) in horses that survived ≥7 days postoperatively. Univariate analysis and multivariate logistic regression were performed to evaluate variables associated with IM.ResultsThe IM rate was 9.52 per cent in the SL group and 33.33 per cent in the RL group. The actual infection rate was 5.31 per cent in the SL group and 26.67 per cent in the RL group. Overall, long-term clinically relevant wound complications was 1.68 per cent. After multivariate analysis, increased anaesthesia duration was associated with IM and performing an enterotomy and postoperative intravenous lidocaine administration were associated with incisional infection in the SL group; no parameter remained significant in the RL group. Bandage-related complications were recorded in 2.95 per cent of the cases.ConclusionsThese results suggest that the use of IVMS for closure of the linea alba is another viable option for closure and that an abdominal bandage does not appear to cause significant complications.

Effect of two-week continuous epidural administration of 2% lidocaine on mechanical allodynia induced by spinal nerve ligation in rats

Background: Lidocaine is an effective against certain types of neuropathic pain. This study aimed to investigate whether timing of initiating continuous epidural infusion of lidocaine affected the glial activation and development of neuropathic pain induced by L5/6 spinal nerve ligation (SNL) in rats. Methods: Following L5/6 SNL, rats were epidurally infused 2% lidocaine (drug infusion initiated on days 1, and 7 post SNL model establishment) or saline (saline infusion initiated on day 1 post SNL model establishment) continuously for 14 days. Mechanical allodynia of the hind paw to von Frey filament stimuli was determined prior to surgery, postoperative day 3, and once weekly after SNL model establishment. At 7 days after the infusion of saline or lidocaine ended, spinal activation of proinflammatory cytokines and astrocytes was evaluated immunohistochemically, using antibodies to interleukin-6 (IL-6) and glial fibrillary acidic protein (GFAP).Results: Continuous epidural administration of 2% lidocaine for 14 days increased the mechanical withdrawal threshold regardless of the difference in timing of initiating lidocaine administration. Epidurally infusing 2% lidocaine inhibited nerve ligation-induced IL-6 and GFAP activation. In the 2% lidocaine infusion group, rats maintained the increased mechanical withdrawal threshold even at 7 days after the discontinuation of 2% lidocaine infusion. Conclusions: Continuous epidural administration of 2% lidocaine inhibited the development of SNL-induced mechanical allodynia and suppressed IL-6 and GFAP activation regardless of the difference in timing of initiating lidocaine administration.

848Ultrasound-guided axillary vein puncture feasibility for complex cardiac devices implantation

Background The axillary route use for cardiac devices implantation has recently expanded either with fluoroscopy or ultrasounds guidance. Few studies included defibrillators (ICD), cardiac resynchronization therapy (CRT) and upgrade procedures for ultrasound-guided axillary vein puncture (UGVP). Puropose To assess the feasibility/safety of UGVP for complex cardiac devices implantation including CRT/ICD. Methods Consecutive patients eligible for a pacemaker or ICD implantation were included. All procedures were performed by three operators (one experienced and two fellows). Guidewires insertion time (from lidocaïne administration), and complications were systematically studied. A group of patients implanted with alternative techniques was used for comparison (cephalic, subclavian). Results In 176 consecutive patients in whom UGVP was used, a total of 68 complex procedures were analyzed (74 ± 8 y, male 61 %) with 138 leads implanted including 42 ICD, 48 CRT and 16 upgrade procedures. A majority (83 %) was under anti-thrombotic therapy. UGVP was successful in 96.8 %. Mean insertion time for 1.78 guidewires per patient was 4.4 ± 4.4 min. Guidewires insertion time reached its plateau after 10 patients. One pocket hematoma (1.4 %) was drained during a mean follow-up of 12 ± 5 months. The control group included 28 patients (12 subclavian, 16 cephalic; 15 ICD, 18 CRT, 4 upgrade procedures), with a mean insertion time of 10 ± 8 min, for 1.95 guidewires per patient (p < 0.0005). Conclusion UGVP is feasible and safe even for complex device implantations including CRT/ICD and upgrade procedures.