Extracorporeal cardiopulmonary resuscitation (eCPR) is a rescue therapy for selected patients when conventional cardiopulmonary resuscitation (CPR) fails. Current evidence suggests that the success of eCPR depends on well-structured in- and out-of-hospital protocols. This article describes the Vienna eCPR program, and the interventions implemented to improve clinical processes and patient outcomes. In this retrospective study, we report on all patients with inhospital and out-of-hospital cardiac arrest treated with eCPR at our department between 2020 and 2023. During this period, the program was restructured, including the introduction of out-of-hospital and inhospital algorithms and interprofessional training. The primary endpoint was survival with favorable neurologic outcomes at 6 months, defined as a cerebral performance category score of 1 or 2. Overall, 192 patients were treated with eCPR. The proportion of patients with favorable neurologic outcomes was 25% (n=48), increasing each year: 15% (5/34) in 2020, 19% (8/42) in 2021, 23% (12/53) in 2022, and 37% (23/63) in 2023. This was particularly true for out-of-hospital cardiac arrest patients: 7% (2/29), 14% (4/29), 17% (7/41), and 32% (16/50), respectively. Simultaneously, rates of witnessed arrest, bystander CPR, and initial shockable rhythm increased, whereas low-flow durations decreased. After restructuring the Vienna eCPR program, we were able to improve survival rates with favorable neurologic outcomes after eCPR. This improvement was accompanied with increased case volumes, rates of witnessed arrest, bystander CPR, and initial shockable rhythm, and decreased low-flow durations. The learning curve we observed illustrates that outcomes can improve with experience, a summation effect of training, patient selection, and process standardization.

BACKGROUND Early outcome prediction in out-of-hospital cardiac arrest is still a challenge. End-tidal carbon dioxide (ETCO₂) has been shown to be a reliable parameter to reflect the quality of cardiopulmonary resuscitation and the chance of return of spontaneous circulation (ROSC). OBJECTIVES This study assessed the validity of early capnography as a predictive factor for ROSC and survival in out-of-hospital cardiac arrest victims with an underlying nonshockable rhythm. DESIGN Retrospective observational study. SETTING/PATIENTS During a 2-year observational period, data from 2223 out-of-hospital cardiac arrest victims within the city of Vienna were analysed. The focus was on the following patients: age more than 18 years, an underlying nonshockable rhythm, and advanced airway management within the first 15 min of advanced life support with subsequent capnography. INTERVENTION No specific intervention was set in this observational study. MAIN OUTCOME MEASURES The first measured ETCO₂, assessed immediately after placement of an advanced airway, was used for further analysis. The primary outcome was defined as sustained ROSC, and the secondary outcome was 30-day survival. RESULTS A total of 526 patients met the inclusion criteria. These were stratified into three groups according to initial ETCO₂ values (45 mmHg). Baseline data and resuscitation factors were similar among all groups. The odds of sustained ROSC and survival were significantly higher for patients presenting with higher values of initial ETCO₂ (>45 mmHg): 3.59 [95% CI, 2.19 to 5.85] P = 0.001 and 5.02 [95% CI, 2.25 to 11.23] P = 0.001, respectively. On the contrary ETCO₂ levels less than 20 mmHg were associated with significantly poorer outcomes. CONCLUSION Patients with a nonshockable out-of-hospital cardiac arrest who presented with higher values of initial ETCO₂ had an increased chance of sustained ROSC and survival. This finding could help decision making as regards continuation of resuscitation efforts.

Aims: Transoesophageal echocardiography (TOE) has increasingly been described as a possible complementary and point-of-care approach for patients with cardiac arrest (CA). It provides information about potentially reversible causes and prognosis and allows monitoring of resuscitation efforts without affecting ongoing chest compressions. The aim of this study was to assess the feasibility of TOE performed by emergency physicians (EPs) during CA in an emergency department (ED). Methods and results: This prospective study was performed at the Department of Emergency Medicine at the Medical University of Vienna from February 2020 to February 2021. All patients of ≥18 years old presenting with ongoing resuscitation efforts were screened. After exclusion of potential contraindications, a TOE examination was performed and documented by EPs according to a standardized four-view imaging protocol. The primary endpoint represents feasibility defined as successful probe insertion and acquisition of interpretable images. Of 99 patients with ongoing non-traumatic CA treated in the ED, a total of 62 patients were considered to be examined by TOE. The examination was feasible in 57 patients (92%) [females, 14 (25%), mean age 53 ± 13, and witnessed collapse 48 (84%)]. Within these, the examiners observed 51 major findings in 32 different patients (66%). In 21 patients (37%), these findings led to a direct change of therapy. In 18 patients (32%), the examiner found ventricular contractions without detectable pulse. No TOE-related complications were found. Conclusion: Our findings suggest that EPs may be able to acquire and interpret TOE images in the majority of patients during CA using a standardized four-view imaging protocol.

Extracorporeal cardiopulmonary resuscitation (eCPR) is a rescue therapy for refractory cardiac arrest, with evidence suggesting improved outcomes when performed at experienced centres. Unlike conventional CPR (cCPR), eCPR patients often exhibit delayed recovery. Current guidelines recommend outcome assessment at 1 month or hospital discharge, potentially missing late neurological improvements. This study investigates longitudinal changes in neurological outcomes among eCPR and cCPR patients. We conducted a single-centre, retrospective cohort study at the Cardiac Arrest Centre Vienna, including adult patients treated with eCPR or cCPR between January 2020 and May 2024. Patients who survived at least 1 month were analysed. The primary endpoint was the difference in the temporal change in favourable neurological outcome (Cerebral performance category, CPC 1-2) between 1 and 6 months in eCPR versus cCPR patients. Secondary endpoints included CPC distribution, survival rates, and patterns of delayed recovery. Of 912 included patients (209 eCPR, 703 cCPR), 435 were alive at 1 month. In eCPR patients (n = 63), favourable neurological outcome increased from 59 % at 1 month to 87 % at 6 months (p < 0.001), while in cCPR patients (n = 372), it increased from 81 % to 84 % (p = ns). This corresponded to a 29 % versus 3 % increase in patients with a favourable neurological outcome (p < 0.001). There was no change in neurological outcome between 6 and 12 months in either group. Overall, recovery in eCPR patients was prolonged compared to patients after successful resuscitation with cCPR. Neurological outcomes in eCPR patients frequently continue to improve after 1 month after cardiac arrest. Future eCPR trials should therefore use outcome assessments beyond 1 month to fully capture recovery potential and patient-centred outcomes.

Background: The clinical value of a prognostic score depends on its out-of-sample validity because inaccurate outcome prediction can be not only useless but potentially fatal. We aimed to evaluate the out-of-sample validity of a recently developed and highly accurate Korean prognostic score for predicting neurologic outcome after cardiac arrest in an independent, plausibly related sample of European cardiac arrest survivors. Methods: Analysis of data from a European cardiac arrest center, certified in compliance with the specifications of the German Council for Resuscitation. The study sample included adults with nontraumatic out-of-hospital cardiac arrest admitted between 2013 and 2018. Exposure was the PROgnostication using LOGistic regression model for Unselected adult cardiac arrest patients in the Early stages (PROLOGUE) score, including 12 clinical variables readily available at hospital admission. The outcome was poor 30-day neurologic function, as assessed using the cerebral performance category scale. The risk of a poor outcome was calculated using the PROLOGUE score regression equation. Predicted risk deciles were compared to observed outcome estimates in a complete-case analysis, a best-case analysis, and a multiple-data-imputation analysis using the Markov chain Monte Carlo method. Results: A total of 1051 patients (median 61 years, IQR 50–71; 29% female) were analyzed. A total of 808 patients (77%) were included in the complete-case analysis. The PROLOGUE score overestimated the risk of poor neurologic outcomes in the range of 40% to 100% predicted risk, involving 63% of patients. The model fit did not improve after missing data imputation. Conclusions: In a plausibly related sample of European cardiac arrest survivors, risk prediction by the PROLOGUE score was largely too pessimistic and failed to replicate the high accuracy found in the original study. Using the PROLOGUE score as an example, this study highlights the compelling need for independent validation of a proposed prognostic score to prevent potentially fatal mispredictions.

Acute pulmonary embolism is a frequent potentially reversible cause of sudden cardiac arrest. The early diagnosis is challenging but essential for further treatment. New therapeutic options in resuscitation, such as extracorporeal resuscitation, are leading to frequent transports of patients to emergency rooms with ongoing resuscitation. A transoesophageal echo performed during resuscitation can give hints for reversible causes for the cardiac arrest. We present a case of a 40-year-old female patient who was transferred to our department with ongoing resuscitation and received a transoesophageal echo immediately on arrival. The examination showed a massive intracardiac thrombus. The subsequent thrombolysis and following resuscitation were observed and documented via transoesophageal echo.