The European Resuscitation Council (ERC) Congress - Resuscitation 2025 was held in Rotterdam as a fully in-person international meeting and served as the official launch platform for the ERC Resuscitation Guidelines 2025. The congress brought together nearly 3000 participants from 77 countries, representing a multidisciplinary community of clinicians, educators, scientists, survivors of out-of-hospital cardiac arrest and their co-survivors, policymakers, and system leaders. The programme featured guideline presentations, scientific abstract sessions, debates, poster discussions, workshops, networking activities, and industry exhibitions, reflecting the breadth of modern resuscitation research and practice. Core themes included epidemiology, systems of care, basic and advanced life support, post-resuscitation management, paediatric and neonatal care, ethics, education, and first aid. Sessions also addressed innovations such as physiology-guided advanced life support, extracorporeal resuscitation, and digital or AI-based detection and decision-support tools, as well as personalised post-cardiac arrest care. Late-breaking studies presented findings on neurophysiology, temperature management, double-sequence defibrillation, and early hypothermia. The congress also highlighted survivorship, rehabilitation, co-survivor perspectives, diversity and equity in resuscitation outcomes, and global training capacity. Young ERC initiatives supported mentorship, research collaboration, and career development for students and early-career professionals. Overall, the congress demonstrated the growing maturity and complexity of resuscitation science by integrating clinical evidence, systems innovation, ethics, education, and equity, while providing a collaborative platform to shape future research priorities and support implementation of the new ERC Guidelines across diverse healthcare contexts.
Approximately 10% of neonates require respiratory or cardiovascular support at birth, making evidence-based neonatal resuscitation guidelines critical to clinical practice. This narrative review compares the most recent neonatal resuscitation guidelines published by the American Heart Association/American Academy of Pediatrics (AHA/AAP), the Australian and New Zealand Committee on Resuscitation (ANZCOR), and the European Resuscitation Council (ERC), all derived from the 2025 International Liaison Committee on Resuscitation (ILCOR) recommendations. While the three guidelines share common foundations, some notable differences exist in the method of grading and transparency of assessment of evidence certainty, and strength of recommendations. Key comparisons include umbilical cord management, airway and ventilation strategies, oxygen use, vascular access, and pharmacologic interventions during resuscitation. All guidelines recommend delayed cord clamping in vigorous infants, discourage routine airway suctioning for meconium-stained fluid, and support ventilation within 60 s of delivery when indicated. However, recommendations diverge regarding intact cord stabilization, cord milking in extremely preterm infants, initial oxygen concentrations, ventilation parameters, and the use of devices such as video laryngoscopes, laryngeal mask airways, and high-flow nasal cannula. Although the AHA/AAP, ANZCOR, and ERC neonatal resuscitation guidelines are all derived from the same ILCOR evidence summaries, important differences exist in their structure, transparency, and specific clinical recommendations. In part, differences in recommendations are due to a paucity of evidence around specific interventions. Standardized methods of reporting certainty of evidence and strength of recommendations may help clinicians deliver consistent, effective delivery room care.
Medical resuscitation is more common than trauma in pediatric emergency departments (PEDs), yet it lacks nationally standardized programs for clinical care, education, quality improvement (QI), and research. We sought to describe current structures and resources as a step toward standardization. We surveyed PEDs affiliated with the AAP Section on Emergency Medicine Special Interest Group, Pediatric Emergency Medicine Resuscitation of Children (PEM-ResCue). One physician leader per site completed a structured survey spanning clinical practice, education, research, quality assurance (QA), and QI. Items included annual counts of critical procedures (eg, tracheal intubation) and full-time equivalent (FTE) support for resuscitation leadership, plus open-ended questions on strengths and challenges. Twenty of 39 centers (51%) responded; 19/20 had Pediatric Emergency Medicine fellowships and 18 were level I trauma centers. Reported annual percenter averages were 79 tracheal intubations, 8 chest tubes, 4 central lines, and 20 chest compression events. Six centers had formal resuscitation leadership roles; 4 of 6 reported dedicated FTE support. Education (17 sites), QA (18), and QI (19) activities were common but varied in structure and frequency. Research activity ranged from robust to none. Reported strengths included video review and interdisciplinary collaboration; challenges included limited funding, lack of standardization, and absence of centralized data systems. Across 20 academic PEDs, medical resuscitation practices and infrastructure varied widely, with notable gaps in dedicated leadership and standardized education and QA/QI processes. Findings highlight opportunities to build coordinated, standardized systems for pediatric medical resuscitation.
Heart rate (HR), a readily available clinical parameter, has proven prognostic value in cardiovascular disease and may provide similar insights following cardiac arrest. This study investigated whether post-resuscitation HR might predict functional recovery in a preclinical porcine model of cardiac arrest and cardiopulmonary resuscitation (CPR). Retrospective analyses were conducted in data from earlier prospective animal studies. Ninety-six pigs successfully resuscitated after 8-12 min of ischemically induced ventricular fibrillation, followed by 5 min of CPR prior to defibrillation attempt, were included in the study. HR, arterial and central venous pressures were continuously monitored for 4 h after resuscitation. Survival with neurological function was assessed up to 96 h post-resuscitation by the optimal performance category (OPC) score, with 1-2 considered as good outcome and 3-5 as poor outcome. Fifty-four animals (56%) presented a 96-h good outcome, while 42 (44%) had a poor outcome. Animals with favorable neurological outcome showed significantly lower HR during the 4-h post-resuscitation period compared with those with poor outcome (p < 0.01). Lower HR, shorter no-flow and low-flow durations, higher diastolic, mean, and coronary perfusion pressures were associated with good outcome. However, only HR was an independent predictor of good neurological recovery (OR 0.971 [0.947-0.995] per 1 bpm increase); a HR > 135 bpm predicted poor outcome with 80% sensitivity and 70% specificity. In this model, lower post-resuscitation HR was independently associated with survival with favorable neurological recovery.
Cardiac arrest and cardiopulmonary resuscitation represent a major cause of mortality. Cerebral ischemia-reperfusion injury following Cardiac arrest and cardiopulmonary resuscitation leads to severe neurological deficits and significantly worsens patient prognosis. Current clinical guidelines recommend targeted temperature management as a standard therapeutic approach following cardiopulmonary resuscitation. Multiple animal studies have demonstrated that mild hypothermia treatment exerts definite neuroprotective effects. However, the precise mechanisms of hypothermic neuroprotection remain incompletely understood. The renin-angiotensin system, a critical humoral regulatory system, operates through two opposing axes: the Angiotensin Converting Enzyme-Angiotensin II-Angiotensin II Type 1 Receptor axis (pro-inflammatory) and the Angiotensin-Converting Enzyme 2-Angiotensin-(1-7)-Mas Receptor axis (cytoprotective). A brain renin-angiotensin system has been implicated in neurological disorders including Parkinson's disease and blood-brain barrier dysfunction. However, currently there are no studies that have explored the dynamic changes of the intracerebral renin-angiotensin system following resuscitation and the modulatory effects of hypothermia on it. Our study investigates that mild hypothermia treatment improves neurological outcomes in post-resuscitation rats by shifting the balance of local brain renin-angiotensin system activity toward the protective Angiotensin Converting Enzyme 2-Angiotensin-(1-7)-Mas Receptor axis, while suppressing the deleterious Angiotensin-Converting Enzyme-Angiotensin II-Angiotensin II Type 1 Receptor pathway through downregulation of Angiotensin II Type 1 Receptor expression. This demonstrates renin-angiotensin system involvement in post-resuscitation brain injury and suggests new directions for studying hypothermic neuroprotection mechanisms and clinical applications.
Approximately 10% of term newborns require resuscitation at birth. Training healthcare providers in standardised formal neonatal resuscitation training (SFNRT) programmes may improve neonatal outcomes. In the current update we focused on whether new literature confirmed our previous findings of a decrease in neonatal mortality and provided new reports of neonatal morbidity, particularly hypoxic ischaemic encephalopathy and neurodevelopmental outcomes. To determine whether SFNRT programmes reduce neonatal mortality and morbidity, improve teamwork behaviour, or improve acquisition and retention of knowledge and skills. We searched CENTRAL, MEDLINE, three other databases, and two trial registers, together with reference checking, citation and errata/retractions checking, to identify studies for inclusion in the review. The latest search date was June 2025. We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs in newborn infants that compared SFNRT with no SFNRT, with basic resuscitation training, or with SFNRT plus additional components such as booster (refresher) training. Our critical outcomes of interest were neonatal mortality (mortality in the first 28 days of life) and its components (mortality within 24 hours, within 7 days, and between 8 and 28 days of life) and neonatal morbidity. We assessed risk of bias in the included studies using the Cochrane RoB 1 tool. We used the fixed-effect model for meta-analysis and reported risk ratio (RR), risk difference (RD), mean difference (MD), and number needed to treat for an additional beneficial outcome (NNTB) and number needed to treat for an additional harmful outcome (NNTH) (all with 95% confidence intervals (CI)). We analysed cluster-RCTs using the generic inverse-variance and the approximate analysis methods. Where this was precluded by the nature of the data, we summarised the results narratively. We used GRADE to assess the certainty of evidence for each outcome. We included a total of 27 studies (528,366 newborns) in the review. However, only a maximum of four studies provided data for each outcome. SFNRT compared to no SFNRT SFNRT likely decreases 24-hour mortality (RR 0.73, 95% CI 0.66 to 0.82; I² = 0%; 2 studies, 353,527 participants; moderate-certainty evidence) and early neonatal mortality (RR 0.82, 95% CI 0.75 to 0.89; I² = 0%; 2 studies, 354,358 participants; moderate-certainty evidence). Neonatal mortality in the first 28 days, late neonatal mortality, and neonatal morbidities were not reported. SFNRT compared to basic resuscitation training SFNRT may decrease mortality in the first 28 days (RR 0.55, 95% CI 0.33 to 0.91; I² not applicable; 1 study, 3355 participants; low-certainty evidence). SFNRT likely decreases 24-hour mortality (RR 0.59, 95% CI 0.51 to 0.67; I² = 82%; 3 studies, 169,331 participants; moderate-certainty evidence) and early neonatal mortality (RR 0.88, 95% CI 0.77 to 0.99; I² = 68%; 4 studies, 69,264 participants; moderate-certainty evidence). SFNRT may not decrease late neonatal mortality (RR 0.47, 95% CI 0.20 to 1.11; I² not applicable; 1 study, 3274 participants; low-certainty evidence). Neonatal morbidities were not reported. SFNRT compared to SFNRT with boosters The evidence is very uncertain about the effect of SFNRT with boosters on mortality in the first 28 days (RR 1.23, 95% CI 0.46 to 3.27; I² not applicable; 1 study, 511 participants; very low-certainty evidence). Twenty-four-hour mortality, early neonatal mortality, late neonatal mortality, and neonatal morbidities were not reported. The overall risk of bias of the included studies was mixed due to high risk of performance bias in all RCTs. The available studies reporting mortality outcomes were conducted exclusively in low- and middle-income countries (LMICs). SFNRT, compared with no training, likely decreases mortality at 24 hours of life and in the first 7 days of life. SFNRT, compared with basic resuscitation training, may decrease mortality in the first 28 days of life, likely decreases mortality at 24 hours and 7 days of life, but may not decrease late neonatal mortality. The evidence is very uncertain whether SFNRT with boosters affects mortality in the first 28 days of life. This update confirms our 2015 review findings of decreased neonatal mortality, but did not identify any reports on neonatal morbidity, particularly hypoxic ischaemic encephalopathy and neurodevelopmental outcomes. This Cochrane review had no dedicated funding. Protocol (2011) DOI: 10.1002/14651858.CD009106. Original review (2015) DOI: 10.1002/14651858.CD009106.pub2.
Competence in neonatal resuscitation is acquired and maintained through accredited life support courses and short in-situ booster training sessions. To ensure effective knowledge and skills integration into practice, valid tools for assessing performance are essential. The aim of this scoping review was to identify all available tools assessing overall performance neonatal resuscitation and evaluate their reported validity evidence. In January 2024 and July 2025, MEDLINE, Embase, and the Cochrane Library were searched to identify studies describing assessment tools for neonatal resuscitation and their associated validity evidence. All study types describing neonatal resuscitation assessment tools for simulation and clinical practice were included. Two reviewers independently screened titles and abstract followed by full-text screening. Data were extracted using predefined forms. A total of 146 sources were included, identifying 82 unique assessment tools for neonatal resuscitation. The number of included items in these tools varied widely, ranging from 5 to 133 (median = 22, IQR = 15-36). Some form of validity evidence was reported for 73.2% of these tools. Most studies reported items from classical frameworks for validity evidence; however, only 30.0% reported more than two items of these frameworks. Contemporary frameworks for validity evidence, considered the preferred standard, were only (partly) applied in three studies. Multiple assessment tools for neonatal resuscitation have been reported, most lack proper validity evidence. There is a clear need for further research and development of a comprehensive, up-to-date, properly validated, and widely applicable assessment tool to support high-quality training, reliable assessment, and ultimately improve patient outcomes.
Medical professionals often attend national academic meetings, which may temporarily reduce available human resources and potentially worsen outcomes for patients with out-of-hospital cardiac arrest (OHCA). This study investigated whether the proportion of patients with OHCA who received in-hospital resuscitation treatments differed during meeting days compared to non-meeting days. This nationwide, retrospective, observational study utilized data from the Japanese Association for Acute Medicine-Out-of-Hospital Cardiac Arrest (JAAM-OHCA) registry recorded between 2014 and 2021. Adult patients who experienced OHCA on meeting days were defined as the exposure group, while those who on the same calendar days one week before and after were designated as the control group. The primary outcome was the proportion of patients receiving targeted temperature management (TTM), extracorporeal cardiopulmonary resuscitation (ECPR) and coronary angiography (CAG), assessed using multiple logistic regression analysis. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Among 3932 patients (1357 in the meeting days and 2575 in the non-meeting days), in-hospital resuscitation treatments showed no significant differences: TTM (5.5% [75/1357] vs. 5.6% [143/2575]; adjusted OR, 1.15; 95% CI, 0.84-1.59), ECPR (3.8% [51/1357] vs. 4.0% [103/2575]; adjusted OR, 1.26; 95% CI, 0.86-1.85), and CAG (7.4% [101/1357] vs. 6.4% [164/2575]; adjusted OR, 0.93; 95% CI, 0.68-1.27). The proportion of 1-month survival with favorable neurological outcomes did not differ significantly between the groups. There was no significant difference in in-hospital resuscitation treatments between patients who experienced OHCA during meeting days and non-meeting days.
Decision-making surrounding cardiopulmonary resuscitation (CPR) presents persistent ethical challenges in acute and critical care. Existing evidence points to ambiguous do-not-resuscitate pathways, moral distress, family-driven demands, and systemic pressures, yet these influences are often examined separately. This review synthesizes current evidence to clarify the ethical, relational, and organizational dynamics that influence CPR-related decisions. We conducted a structured narrative review of four databases (Web of Science, PubMed, Scopus, Embase) for studies published between 2020 and 2025. Eligible studies included. Data was analyzed using reflexive thematic analysis. Twenty-two studies were included. Seven interrelated themes emerged: (1) Futility, inappropriate and symbolic CPR; (2) Moral distress, emotional burden and moral residue; (3) Ethical ambiguity and unclear decision pathways; (4) Hierarchy, power and constrained nursing moral agency; (5) Family influence, cultural and religious norms, and truth-telling practices; (6) Systemic, legal and organizational drivers of ethically problematic practice; and (7) Ethical competence, moral sensitivity, advocacy and ethics support. Together, these findings informed the development of an Ethical Pathways Model (EPM) that conceptually depicts how contextual, relational, and individual determinants may converge to shape ethical decision trajectories in resuscitation and how conflicted pathways may contribute to symbolic or non-beneficial CPR and clinician moral distress. Ethical challenges in resuscitation are largely system-produced rather than individual failings. The EPM offers an integrative conceptual framework that may help inform clearer policies, strengthen communication, and guide the development of accessible ethics support to promote more value-concordant resuscitation care and reduce clinician moral distress.
Ward resuscitation requires both technical and teamwork skills, however conventional drills rarely address teamwork. We evaluated whether a brief Team Resource Management (TRM) curriculum combined with in-situ simulations could improve the quality of resuscitation and safety culture. This retrospective study analyzed data from a hospital-wide quality-improvement project at a 250-bed regional hospital. Ward teams (physicians, nursing specialists, and nurses) completed three training cycles at baseline, 6 months, and 12 months. Each cycle included 30-min online modules plus two in-situ simulations with TRM-focused debriefs. The primary outcome was resuscitation protocol adherence (RPA) using a 28-item checklist based on the 2020 ILCOR recommendations. The secondary outcomes were Safety Attitudes Questionnaire (SAQ) and Teamwork Perception Questionnaire (TPQ) scores. Fifty-three of 94 eligible staff (56%) provided complete responses. The mean RPA rate increased from 76.5 ± 16.5% at baseline to 92.6 ± 9.7% after cycle three (p = 0.030), primarily driven by improvements in the "Transmission of Rescue Information" domain (62.5% vs. 90.6%, p = 0.028). No significant changes occurred in composite SAQ/TPQ scores. Three low-fidelity TRM in-situ simulations significantly increased the rate of RPA, particularly team communication, without immediate changes in the overall safety culture. Short, recurring TRM drills rapidly enhanced process reliability; sustained coaching may be needed for broader cultural transformation.
Effective communication is paramount for neonatal resuscitation. Best practices emphasize clear, coordinated team communication. High-performing teams use both routine and critical communication modes, adjusting their approach as acuity evolves. However, the degree to which interprofessional neonatal intensive care unit (NICU) teams share an understanding of when each mode is optimal is unknown. We conducted a cross-sectional study of NICU providers participating in a team-development day at a large children's hospital. After an instructional session defining routine and critical communication, participants reviewed a hypothetical unplanned extubation and cardiac arrest scenario including 14 steps split into pre-code, code, and post-code phases. Participants rated optimal mode of team communication for each step using a 5-point Likert scale. Consensus was defined as ≥60% agreement on communication mode for each step. We compared physicians and non-physicians across scenario phases. Forty-eight providers participated, representing physicians, nurses, advanced practice providers, and respiratory therapists. Participants reached consensus on all code phase steps, selecting critical communication. No consensus was achieved for pre-code or post-code. Physicians selected more critical communication than non-physicians during the pre-code phase (median 4.0 vs 3.0, p = 0.001) with no differences during code or post-code. Providers within a cohesive NICU team showed divergent mental models regarding optimal communication during early and late phases of a hypothetical resuscitation. This heterogeneity may hinder rapid team alignment and represent an important target for quality-improvement efforts. Future work should evaluate communication during real resuscitations and develop strategies to support shared communication expectations across roles.
Successfully resuscitated out-of-hospital cardiac arrest (OHCA) patients often experience cerebral malperfusion, possibly due to impaired autoregulation. Understanding the link between arterial pressure and cerebral blood flow (CBF) is essential for optimising cerebral oxygenation. This study examined early post-resuscitation CBF autoregulation and assessed the feasibility of identifying patient-specific optimal mean arterial pressure (MAPopt) from data obtained during prehospital care. We performed a post hoc analysis of 12 OHCA patients treated by a physician-staffed helicopter emergency services unit. Frontal lobe regional oxygen saturation (rSO2) and invasive arterial pressure were recorded during prehospital post-resuscitation care. The cerebral oximetry index (COx), defined as the correlation coefficient between rSO2 and MAP, was calculated as a time series for each patient. COx values were plotted in 5 mmHg MAP increments and reviewed by two independent experts to determine patient specific MAPopt. The mean duration of near-infrared spectroscopy monitoring was 47 min. MAPopt was identifiable in eight of 12 patients (66%). Seven patients (58%) showed impaired autoregulation, as mean COx > 0.3. Map and rSO2 demonstrated a nonlinear relationship, with lower MAP associated with reduced cerebral oxygenation. MAPopt for the cohort was approximately 80 mmHg. Cerebral autoregulation assessment after OHCA is feasible with physiological data recorded in prehospital setting. Low blood pressure was associated with reduced cerebral oxygenation. Impaired autoregulation was found in most patients. Large inter-individual variation in optimal blood pressure precluded the determination of a common target pressure and emphasises the need for personalised haemodynamic management in the ultra-acute post-resuscitation phase.
Effective ventilation during cardiopulmonary resuscitation (CPR) is challenging, with limited evidence to guide optimal rates, volumes, and other parameters. This systematic review, part of the continuous evidence evaluation process for the International Liaison Committee on Resuscitation, examined whether specific tidal volumes, respiratory rates, inspiratory times, or positive end-expiratory pressure (PEEP) improve outcomes. Studies of adults in any setting (in-hospital or out-of-hospital cardiac arrest) receiving ventilation were included if they compared specific tidal volumes, respiratory rates, inspiratory times, or PEEP. MEDLINE, EMBASE, and CENTRAL were searched from inception to November 10, 2025. Risk of bias was assessed using RoB 2.0 and ROBINS-I; certainty of evidence was evaluated with GRADE. Registered in PROSPERO (CRD420251070065). Of 3021 records, 11 studies (3 randomized trials, 8 observational) met eligibility criteria. Certainty of evidence was very low, limited by bias, inconsistency, indirectness, and imprecision. Due to heterogeneity, results were reported narratively using Synthesis Without Meta-Analysis (SWiM) guidelines. Ventilation rates showed mixed associations with neurological, survival, and return of spontaneous circulation (ROSC) outcomes; some studies indicated harm with lower ventilation rates. Most found no differences between higher and lower tidal volumes, although very low tidal volumes were associated with worse outcomes in some studies. When impedance-detected ventilations occurred in ≥50% of chest compression pauses during 30:2 CPR, survival and ROSC were higher. Evidence on optimal ventilation during CPR is inconsistent and of very low certainty. Very low ventilation rates and tidal volumes may be harmful. Future research should use robust designs to define evidence-based ventilation targets.
Extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly used for refractory paediatric in-hospital cardiac arrest (IHCA). Although rapid initiation of extracorporeal life support (ECLS) is widely considered critical, the relative contributions of cannulation timing and early physiologic recovery to survival outcomes remain incompletely defined. We conducted a retrospective cohort study of paediatric patients who underwent ECPR for IHCA at a tertiary cardiac centre between 2010 and 2022. The primary exposure was the interval from cardiac arrest to initiation of ECLS flow. Outcomes included survival to ECLS decannulation and survival to hospital discharge. Multivariable logistic regression was used to evaluate associations between clinical variables, metabolic markers, and outcomes. Seventy-nine patients were included. Median time to ECLS flow was 35 min (interquartile range 22-50). Survival to ECLS decannulation and to hospital discharge were 80.8% and 52.1%, respectively. Shorter time to ECLS flow was independently associated with survival to ECLS decannulation (adjusted odds ratio 0.96 per minute increase in time to ECLS flow; 95% confidence interval 0.93-0.99; p = 0.008) but not with survival to hospital discharge. Higher initial lactate (aOR 0.85; 95% CI 0.72-0.98), higher 4-h lactate (aOR 0.81; 95% CI 0.67-0.97), and lower initial pH (aOR 1.34 per 0.1-unit decrease; 95% CI 1.04-1.86) were independently associated with reduced survival to decannulation. Four-hour lactate was independently associated with survival to hospital discharge (adjusted odds ratio 0.78; 95% confidence interval 0.66-0.94; p = 0.007). In paediatric IHCA treated with ECPR, early metabolic derangement and impaired metabolic recovery after cannulation appear to reflect the severity of post-arrest physiology and are associated with survival outcomes. These findings suggest that, in addition to the rapid deployment of ECPR, early physiologic recovery following initiation of extracorporeal support may be an important determinant of meaningful survival.
Sufficient ventilation during cardiopulmonary resuscitation (CPR) is increasingly recognised as a critical determinant of patient outcomes. The effectiveness of ventilation training, however, likely depends on the anatomical and mechanical fidelity of CPR manikins. While chest compression mechanics of manikins have been studied extensively, ventilation-related anatomy, airflow pathways, and respiratory mechanics have not been evaluated systematically. This study analysed 10 adult CPR manikins from three manufacturers. Airway and lung replicas were documented using photography, video laryngoscopy, and bronchoscopy. Expiratory tidal volume and air leakage were measured during volume-controlled mechanical ventilation via facemask, supraglottic airway devices and endotracheal tube. Mechanics of the respiratory system were described by the peak and plateau airway pressures and respiratory compliance. Manikins differed substantially in airway design and expiratory airflow design. Three distinct expiratory mechanisms were identified, of which only one permitted exhalation through the airway and thus quantification of expiratory tidal volumes. Air leakage varied across manikins and airway devices, including during ventilation via advanced airway devices. Respiratory mechanics showed marked variability, with peak inspiratory pressures ranging from 21 ± 1 to 56 ± 1 mbar and compliances from 7 ± 0 to 51 ± 4 mL/mbar. Several models exhibited substantial leakage via the gastric channel of the i-gel® supraglottic airway. CPR manikins exhibited substantial variability in ventilation-related anatomy, airflow pathways, leakage and respiratory mechanics. None of the assessed manikins consistently approximated human ventilation characteristics across airway devices, underscoring the need for local evaluation of manikin-airway device combinations to optimise ventilation fidelity in CPR training.
To externally validate previously published prognostic models developed exclusively from pre-extracorporeal cardiopulmonary resuscitation (ECPR) variables in a contemporary ECPR cohort. We conducted a bicenter retrospective external validation of four published pre-ECPR prognostic models (Lee, RESCUE-IHCA, CHIU-S1, and CHIU-S2) in adult patients treated with ECPR between January 2015 and December 2024. Model performance was evaluated for in-hospital survival and favorable neurological outcome (FNO; Cerebral Performance Category 1-2) in the overall cohort, in-hospital cardiac arrest (IHCA), and cardiac-origin cardiac arrest (Cardio_CA) subgroups. Discrimination (the area under the receiver operating characteristic curve, AUROC), calibration, overall model fit (Brier score), and decision curve analysis (DCA) were assessed. For point-based CHIU scores, validation focused on observed outcome rates across predefined risk strata. Among 214 patients, 79.0% (169/214) had IHCA; survival to discharge was 45.8% and FNO occurred in 24.8%. Discrimination for survival was modest across models (overall ECPR AUROC 0.608-0.709; IHCA 0.586-0.672; Cardio_CA 0.591-0.689) but was higher for FNO (overall ECPR 0.709-0.764; IHCA 0.696-0.744; Cardio_CA 0.698-0.718). The Lee model showed poor calibration with slopes far below 1, whereas RESCUE-IHCA model underestimated survival but demonstrated better calibration (slopes close to 1), higher overall accuracy (lower Brier scores) and broader clinical utility (wider net-benefit ranges in DCA). CHIU models provided limited risk separation between adjacent strata. In this external validation, pre-ECPR models showed modest performance, with better discrimination for neurological outcome than for survival. RESCUE-IHCA showed the most favorable overall performance. Future studies should develop and validate more robust, transportable tools.
Systemic thrombolysis has been proposed as a routine treatment for cardiac arrest, given potential benefits in treating fibrin formation and/or in treating the etiology of the cardiac arrest (e.g. ST-elevation myocardial infarction and pulmonary embolism [PE]). This systematic review and meta-analysis aimed to evaluate the effect of intra-arrest thrombolysis on survival and neurological outcomes in patients with cardiac arrest. We searched MEDLINE, EMBASE, CENTRAL, and the Web of Science from inception until September 30, 2025 for randomized controlled trials evaluating systemic thrombolytic therapy versus standard care during cardiopulmonary resuscitation (CPR). The primary outcome was survival to hospital discharge, and the secondary outcomes were favorable neurological outcome at hospital discharge, return of spontaneous circulation (ROSC), and survival to hospital admission. We performed meta-analyses using a random-effects model. We evaluated bleeding complications and examined Utstein-based subgroups. We evaluated risk of bias using the Cochrane Risk of Bias 2 tool and evidence certainty using GRADE. We included three RCTs, which enrolled a total of 1318 participants. Thrombolysis did not improve survival (RR 0.86; 95% CI 0.65-1.14) or favorable neurological outcome (RR 0.99; 95% CI 0.69-1.40) at hospital discharge. No benefit was observed for ROSC or survival to admission. Thrombolysis increased the risk of any intracranial hemorrhage (RR 6.96, 95% CI 1.59-30.47). Among cases with bystander CPR, thrombolysis led to decreased survival; other subgroup analyses were neutral. Available evidence demonstrates that routine intra-arrest thrombolysis in unselected patients does not improve hospital-discharge survival, however does increase bleeding risk.
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The conventional one-handed grip during bag-valve-mask (BVM) ventilation often fails to achieve guideline recommendations. We evaluated a modified BVM ventilation method that allows a single practitioner to compress the bag while maintaining a two-handed mask seal and compared it with the conventional BVM ventilation method in simulated manikin in non-CPR and CPR settings. In a randomized, crossover manikin study, we compared the two methods in two scenarios: Manual Ventilation-No CPR (n = 60) and Manual Ventilation-CPR (n = 56). In each scenario, participants used both BVM methods in a randomized order. The primary outcome was the proportion of ventilations with adequate tidal volume. A ventilation with a tidal volume between 350 mL and 600 mL was considered adequate. Tidal volume, inspiratory time, and ventilation rate, chest compression quality metrics, chest compression fraction (CCF) were also evaluated. In Manual Ventilation-No CPR scenario, the modified method significantly increased the proportion of adequate ventilations (p < 0.001). In Manual Ventilation-CPR scenario, the modified BVM ventilation method significantly increased the proportion of adequate ventilations (p < 0.001), with a comparable performance in chest compression quality (chest compressions depth, rate and recoil) and no compromise to the CCF. Our simulated manikin study demonstrated that a modified BVM ventilation method improves ventilation performance within an adequate range in both CPR and non-CPR settings. Future studies are warranted to further assess this proposed method.