"Italian Resuscitation Council" on Resuscitation Science and Emergencies—2nd Edition

Dear Colleagues,

This Special Issue is the second edition of ““Italian Resuscitation Council” on Resuscitation Science and Emergencies—Part I” (https://www.mdpi.com/journal/jcm/topical_collections/Resuscitation).

Cardiovascular and neurological emergencies represent a vast public health problem, being a leading cause of death in the world. In addition, nonfatal events lead to disabilities and disability-adjusted life years, representing a major healthcare concern. Novel therapeutic approaches have been introduced in recent decades, while newer ones are continuously being conceived and tested. Increasing knowledge and understanding of different emergency conditions, also known as “Resuscitation Science”, have led to the development of new successful therapies and novel tools to characterize these clinical conditions and provide better care for patients. Resuscitation is a relatively modern science that emerged only during the latter half of the 20th century, although its roots extend back centuries into the past. Advances in resuscitation science have improved the survival rate of cardiac arrest and other emergencies, and therefore, a dedicated Special Issue is needed to provide new evidence paving the way toward a better comprehension of the pathophysiology, mechanisms, and management of emergency conditions.

This Special Issue of the Journal of Clinical Medicine on “Resuscitation Sciences and Emergencies” is launched by the Italian Resuscitation Council, a non-profit scientific organization with the primary aim of improving and spreading resuscitation culture and emergency medical system organization in Italy and Europe. The Special Issue aims to collect brilliant contributions from worldwide experts in the field of resuscitation and emergency. Thus, we invite investigators to contribute with original research articles as well as review articles that will stimulate the continuing efforts to understand mechanisms accounting for outcomes of cardiovascular and neurological emergencies; the development of new interventional strategies (surgical and/or medical) to improve survival with good functional recovery; new approaches for evaluation and prediction of outcome; innovation and technology procurement to improve resuscitation and post-resuscitation care; better emergency medical system organization and deployment capabilities; and different training methodologies.

Important note: the Italian Resuscitation Council members can receive a 25% APC discount.

Dr. Alberto Cucino
Dr. Erik Roman-Pognuz
Dr. Giovanni Babini
Dr. Andrea Scapigliati
Guest Editors

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• resuscitation
• emergency
• cardiovascular emergency
• neurological emergency
• cardiac arrest
• stroke
• shock
• trauma
• critical care
• defibrillation
• emergency medical system
• system organization
• innovation and technology
• community response to emergency
• outcome

• “Italian Resuscitation Council” on Resuscitation Science and Emergencies—Part I in Journal of Clinical Medicine (18 articles)

1. How the E-FAST Method Applied by Adequately Trained Nursing Staff in Intra-hospital Triage Area Can Modify the Priority Code: A Case Report of Trauma in the Emergency Department of Urbino (AST 1 -Pesaro –Urbino)

Abstract: The E-FAST method is considered the gold standard for point-of-care evaluation of patients with blunt thoraco-abdominal trauma. In recent years, its use has increased among non-medical personnel, particularly those working within emergency departments. According to a systematic review of the literature, E-FAST performed by nurses is highly effective, with a sensitivity of 84% (95% CI 72.1-92.2) and a specificity of 97.37% (95% CI 92.55-99.10), and an average execution time of 156 seconds (2.6 minutes) (Storti M, Musella L, Cianci V, 2013). This exam allows identification and initiation of early treatment for potentially reversible causes of cardiac arrest/peri-arrest, and, in general, helps to accelerate traditional diagnostic processes in trauma patients (Storti et al., 2013). The clinical case discussed, involving closed abdominal trauma caused by a bicycle fall, illustrates how the triage assessment, integrated with E-FAST, made a difference in terms of priority access to the diagnostic-therapeutic pathway by identifying free peritoneal fluid early. This case represents an important example of the validity and applicability of the E-FAST protocol in an intra-hospital triage context performed by nursing staff. From the analysis of this clinical case and the review of the scientific literature, the importance of implementing specific training and integrating the useof E-FAST in triage is evident.

2. Prone position and cardiopulmonary resuscitation in operating room: A scoping review

Abstract: Introduction: Cardiopulmonary resuscitation (CPR) in the prone position (P-RCP) is widely described and appears in international guidelines for specific contexts, but it does not appear to be a usual practice nor does it appear in any operating room algorithm. The purpose of this review is to provide an overview of the prone position CPR in patients with a protected airway undergoing spine surgery and interventional radiology. Methods: a scoping review was conducted according to the "PRISMA Extension for Scoping Reviews" protocol. The databases used were PubMed, CINAHL, ScienceDirect/Elsevier and Cochrane. Eligibility criteria were: adult and pediatric population; pathology emerged (cardiac arrest with rhythm of presentation and cause); type of intervention implemented (P-RCP), and outcome in the short term (understood as return to spontaneous circulation) and in the long term where it was described. Results: twenty international case reports and a pilot study conducted on a manikin have been considered, from which it appears that the performance of P-RCP is found to be effective in the specific operating room specific and also positively affects both short-term and long-term outcome. Conclusion: From this study emerges the importance of training health care personnel as a determinant of outcome emerges. Results suggest the importance to implement this procedure within the specific context of the operating room and sites where prone intervention procedures are implemented. At the end of this review, a context-specific algorithm is proposed based on existing international guidelines.

3. Use of Backboards in Cardiopulmonary Resuscitation: A Systematic Review and Meta-Analysis

To achieve optimal chest compression (CC) depth, victims of cardiac arrest should be placed on a firm surface. Backboards (BBs) are usually placed between the mattress and the back of a patient in the attempt to increase cardiopulmonary resuscitation (CPR) quality, but their effectiveness remains controversial. Therefore, this study was performed to answer the question: "do BBs improve CC quality during CPR"? After registration on PROSPERO (CRD42019119904), a systematic search included studies on humans and simulation manikins assessing CPR quality with or without BBs. The primary outcome of the meta-analysis was the difference in CC depth between these two conditions as the most tested CC quality indicator. Out of 557 records collected up to June 2020, 18 studies were included in the review. Most of the included studies were randomized trials, and all of them were performed in hospital settings. Interestingly, all were performed on manikins, probably because this subject is being perceived as too delicate to be studied on real cardiac arrests. After excluding two papers because CCs were mechanically performed and one because lacking data, the meta-analysis was performed on 15 papers and showed that using BBs during CPR increases CC depth by a mean difference of 1.46 mm (CI 95%, 0.62 to 2.31 mm; P-value = 0.0007) in manikins. This slight increase might have a positive impact on the rescuers’ performance, despite hardly perceived. The clinical benefits endowed by a 1.46 mm increase in CC depth are also questionable: previous literature showed improvements in survival or odds of defibrillation success even with a 5 mm improvement in CCs depth, but the time spent inserting a BB under a patient to achieve this small improvement should be carefully weighted, considering that CC interruptions have deleterious effects on coronary perfusion and survival. The studies showed a substantial heterogeneity of experimental conditions [I2 (total heterogeneity / total variability): 99.51%; Cochran’s Q = 2107.2772, P < .0001] limiting results application and effectiveness. The overall quality of the studies was moderate, with none of the papers except one fully meeting the “blinding of participants and personnel” criterion. Despite the limitations of our findings, this is undoubtedly a spur to perform clinical trials specifically testing this question.

5. Mortality in trauma patients: a 6-years retrospective analysis of Friuli Venezia Giulia’s Helicopter Emergency Medical Service (HEMS FVG).

Background: Helicopter Emergency Medical Service (HEMS) is a highly specialized resource for care of critical trauma and acute medical patients. HEMS in Friuli Venezia Giulia (Italy) plays an important role in pre-hospital emergency medical care. Performing outcome studies in this field is very complex and difficult because available data are often lacking and incomplete. The aim of this study was to investigate the mortality rates in our trauma population. Methods: A retrospective analysis over a 6-year period of the HEMS FVG. All trauma patients pronounced dead on scene or treated by HEMS in the field and airlifted or ground transported by HEMS physicians were included. Patient characteristics, type of flight, mechanism of injury, type of accident, prehospital Revised Trauma Score (RTS), National Advisory Committee for Aeronautics (NACA) and level of admission were analysed using univariate and regression models analyses. The outcome measure was at the scene mortality and in-hospital mortality. Results: In-hospital mortality rate was 3.4%, compared to 9.3% for the overall sample. During the 6-year period, 3347 trauma patients were included and classified in survivors and non-survivors, showing no significant differences in gender (p=0.45). Statistically significant differences between survivors and non-survivors were observed for patients when stratified by age, with high mortality rate in 60≥age<80 (p value <0.001). Significant differences were also found in patients rescued at night (p=0.02), who had a higher mortality rate than those rescued during the day. Among the types of accidents, road traffic is the most common (1907, 57%), while among the mechanisms of injury, car accidents are the most common (964, 41%). Analyzing patients' prehospital status, significant differences were found for RTS when dichotomized at two cutoffs, 4 and 7 (p < 0.001 for each comparison), for NACA score (p < 0.001), and for the three levels of admission (p < 0.001 for each comparison). Mortality rates were calculated within RTS and NACA score classes, yielding values of 61.5%, 21.6% and 0.5% for RTS≤4, 4>RTS<7 and RTS≥7, respectively. For NACA scores, mortality was 28% for 4≥NACA≤6 and 0% for 1≥NACA≤3. Finally, regarding the level of admission, we found a mortality rate of 47% for level 1*, 8% for level 2** and 0% for level 3***.

Conclusion: Friuli Venezia Giulia Helicopter Trauma Study (STE FVG) provides an accurate epidemiological picture of trauma patients rescued by FVG HEMS. The mortality rate (9.3%) is comparable with the results of two national registries1,2. As described in other studies, the analyses confirm the relationship between the decrease in RTS and the increase in mortality3 and showing a mortality rate of 21.8% for NACA scores greater than 4, when stratified into two levels (1-3; 4-6)4. However, this study should only be considered as a first step towards more accurate research that includes hospital data of airlifted patients admitted to intensive care, such as injury severity score (ISS) and length of stay (LOICU).

4. Knowledge and Attitudes in Intensive Care Unit Towards Cardiac Arrest Survivors: ICArS Pilot Study

Background: Each year, cardiac arrest affects over 750,000 individuals in Europe, with less than 10% surviving out-of-hospital cardiac arrest (OHCA). Among patients who achieve return of spontaneous circulation (ROSC) but remain comatose upon hospital admission, about half survive with favorable neurological outcomes. Post-cardiac arrest syndrome (PCAS), characterized by myocardial dysfunction, systemic inflammation, and progressive brain injury due to ischemia-reperfusion, is a significant cause of in-hospital mortality and neurological impairment. Current guidelines advise delaying neurological prognostication for at least 72 hours after cardiac arrest to account for confounding factors, yet withdrawal of life-sustaining treatment (WLST) based on perceived poor neurological outcomes accounts for two-thirds of ICU deaths in OHCA patients, often occurring before this recommended window. Objectives: The ICArS study aims to evaluate the knowledge, attitudes, and practices of ICU staff regarding WLST and neurological prognostication in cardiac arrest survivors. By identifying influences on decision-making and adherence to international guidelines, the study seeks to improve compliance with recommendations and decrease preventable mortality. The purpose of the pilot is assessing feasibility and identifying any possible issues that could negatively impact on data collection. Methods: ICArS is a multinational, factorial survey designed to assess ICU staff perspectives on WLST and prognostication. The survey employs vignette-based scenarios with randomized independent variables to simulate real-life clinical situations, enabling indirect measurement of awareness and the factors guiding decision-making, both explicit and implicit. Participants will assess prognostic outcomes using Likert scales. This factorial approach, widely used in sociological research, is effective for investigating complex behaviors and attitudes in healthcare settings. Results: The ICArS study is in its pretesting phase. Preliminary interview-style surveys and a pilot test have been conducting with a sample population to refine the survey and ensure clarity and consistency in responses. Conclusions: Understanding ICU staff attitudes towards WLST and neurological prognostication is critical for aligning practices with international guidelines and enhancing outcomes for cardiac arrest survivors. By identifying key factors that shape these complex decisions, the ICArS study aims to inform strategies for promoting standardized, evidence-based care for post-cardiac arrest patients and reducing variability in clinical practice.

6. Improvement of Medical Emergency Teamwork Performance: ILS Development Between Technical And Non-Technical Skills
7. Intra-Hospital Cardiac Arrest Register (Ihca-R): A Study In The Province Of Lodi

Background The annual incidence of in-hospital cardiac arrest (IHCA) in Europe ranges from 1.5 to 2.8 per 1,000 hospital admissions. Factors associated with survival include the initial rhythm, the location of the arrest, and the level of monitoring at the time of collapse. One of the most significant challenges of our time is the continuous and efficient collection of IHCA data, defining and analyzing key variables recommended by the Utstein model, especially in resource-limited seEngs. To address this issue, improvements adapted to the specific situation of each hospital are necessary, with the ultimate goal of continuous, comprehensive, and accurate data collection. The ASST of Lodi project aims to create an IHCA registry with the primary objective of analyzing demographic factors, predisposing factors, intervention methodology, immediate prognosis, and, in the case of survival, at discharge, 1 month, and 1 year aGer the event, with particular aHention to quality of life. The secondary objectives of the study will be: (1) to evaluate the training path of the staff involved in the management of patients with IHCA, (2) to assess the overall adherence to international guidelines regarding the management of IHCA situations; (3) to improve the standardized intervention plan for IHCA by creating a support and debriefing system for the staff involved in unexpected IHCA cases; (4) to evaluate the survival and quality of life of patients who have experienced an IHCA. Materials and Methods A retrospective study, preliminary to the prospective registry, was conducted by analyzing all IHCAs from January 1 to December 31, 2023, to refine the case report form (CRF) and consolidate the data extraction methods for each variable from medical records based on the terminology used by emergency teams to describe IHCA. For data collection in the study, a dedicated CRF was developed and tested, where the main clinical and medical history data were collected according to Utstein criteria at the time of admission (age, sex, origin, type, comorbidities, vital signs, and laboratory parameters, reason for hospitalization and admission diagnosis), during hospitalization (procedures and interventions, diseases, and organ dysfunctions occurred), and at discharge. Data were initially extracted by two junior operators and then double-checked and validated in a double-blind mode by two expert operators. Preliminary Results In 2023, 69 IHCAs were included, with a mean age of ti6.3 years (SD 11.3 years), predominantly male (68.1%). The presenting rhythm was PEA in 51.1% of cases, asystole in 29.0%, ventricular fibrillation in 10.1%, and ventricular tachycardia in 5.8%. Return of spontaneous circulation (ROSC) was observed in 21.ti% of cases. The month with the highest incidence of IHCA was November (24.6%), predominantly on Sundays (21.ti%) and during nighEme hours (3ti.ti%). Conclusion The ASST of Lodi project aims to improve the management of in-hospital cardiac arrests through the creation of a dedicated registry, which will allow the collection of key data according to the Utstein model. The expected outcomes include a beHer understanding of the factors influencing survival, a thorough evaluation of staff competencies, and an analysis of post-arrest quality of life. By implementing a support and debriefing system, the project aims not only to improve the response to IHCA but also to strengthen the training of healthcare personnel, thereby ensuring more effective and safer management of patients in critical situations. This approach will contribute to establishing more standardized and evidence-based practices, with the ultimate goal of increasing survival rates and improving long-term outcomes for patients.

8. Pre-Arrival Instructions in Out-of-Hospital Cardiac Arrest: The Role of the Dispatcher Nurse in the Emergency Operations Center