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PubMed2000

Cardiac arrest induced by accidental inhalation of anoxic gases, is the cause always a lack of oxygen?

BACKGROUND: We experienced a case of accidental administration of 100% carbon dioxide (CO2) during anesthesia, which resulted in cardiac arrest. After successful cardio-pulmonary resuscitation the child recovered without brain damage. This outcome was quite different than that of the more commonly reported accidental administration of 100% nituous oxide (N2O), as the latter usually results in death from cerebral damage rather than cardiac arrest. We speculated that the cause of death and/or cardiac arrest may differ between these two anoxic gases. METHODS: Fourteen dogs were anesthetized and divided into two groups to receive either 100% CO2 or 100% N2O. Blood pressure (BP), heart rate (HR), cardiac output (CO), dp/dt, pulmonary artery pressure (PAP), central venous pressure (CVP) and blood gases (BG) were measured every 30 seconds until cardiac arrest (CA) occurred. RESULTS: The CO2 group showed a rapid decline in BP, HR, dp/dt, CO, pH, and PaO2 and a rise in PAP, CVP, and PaCO2, with CA occurring at 119 +/- 41 seconds. At the time of CA, the BG values were pH 6.6 +/- 0.09, PaCO2 375 +/- 69, and PaO2 62 +/- 15 mm Hg. The N2O group maintained BP, HR, dp/dt, pH, PaCO2, and experienced a rapid decline in PaO2 as in the CO2 group until 180 seconds, at which time the PaO2 was 12.3 +/- 3 mm Hg. CA occurred at 390 +/- 52 seconds. The values for pH, PaCO2 and PaO2 were 7.5 +/- 0.05, 25 +/- 15 and 4.8 +/- 1 mm Hg, respectively, at the time of CA. CONCLUSION: One hundred percent CO2-induced cardiac arrest occurred in 119 seconds and was not oxygen-dependent, whereas 100% N2O induced cardiac arrest occurred in 390 seconds and was clearly dependent on hypoxemia.

Acute Disease↗
PubMed2005

CPR before defibrillation in out-of-hospital cardiac arrest: a randomized trial.

OBJECTIVE: Current resuscitation guidelines recommend that defibrillation be undertaken as soon as possible in patients suffering a cardiac arrest where the cardiac rhythm is either ventricular fibrillation (VF) or ventricular tachycardia (VT). Evidence from animal and clinical studies suggests that outcomes may be improved if a period of cardiopulmonary resuscitation (CPR) is given prior to defibrillation. The objective of this study was to determine if 90 seconds of CPR before defibrillation improved survival. METHODS: Patients suffering non-paramedic witnessed VF/VT cardiac arrest were randomized to receive either 90 seconds of CPR before defibrillation (treatment) or immediate defibrillation (control). The study was carried out in Perth, Western Australia between June 2000 and June 2002. The primary endpoint was survival to hospital discharge with secondary endpoints of return of spontaneous circulation (ROSC) and survival at 1 year. RESULTS: A total of 256 patients underwent randomization. Baseline characteristics including response intervals were similar in both groups. Survival to hospital discharge in the CPR first group was 4.2% (5/119) compared with 5.1% (7/137) for the immediate defibrillation group (OR 0.81; 95%CI. 0.25-2.64). No difference in those achieving ROSC was observed between the groups (OR 1.16; 95% CI 0.49-2.80). CONCLUSION: Ninety seconds of CPR before defibrillation does not improve overall survival in patients suffering VF/VT cardiac arrests. Further studies to evaluate various aspects of this treatment strategy are required as published outcomes to date are inconclusive.

Adolescent↗
PubMed2001

Survival from out-of-hospital cardiac arrest in the Geelong region of Victoria, Australia.

OBJECTIVE: To study the outcome from prehospital cardiac arrest managed by ambulance personnel, and to examine overall survival rates from successful resuscitation. METHODS: A retrospective analysis was made of 115 patient care records of prehospital cardiac arrests with attempted resuscitation between July 1996 and September 1999. All cases had a presumed primary cardiac cause for their cardiac arrest. RESULTS: Overall survival, defined as admitted to hospital alive, was 22 subjects (19.1%), with five subjects (4.3%) being discharged from hospital neurologically intact. Of the patients who survived to the emergency department, six (5%) had initially presented in pulseless electrical activity and 16 (14%) presented with ventricular fibrillation. No patients presented with ventricular tachycardia and no survivors presented in asystole. Median response interval from time of call to arrival of initial crew at patient's side was 9 min. No patients survived when response interval was greater than 14 min. Bystander cardiopulmonary resuscitation was being performed on 55 patients (48%) on arrival of initial ambulance crew; 68.2% of patients surviving to hospital having had bystander cardiopulmonary resuscitation. CONCLUSION: Decreasing time delays in accessing the patient is crucial to improving outcome in out-of-hospital cardiac arrest.

Adolescent↗
PubMed2002

[A case of cardiac arrest at induction of anesthesia for postpartum hysterectomy].

Although peripartum cardiac arrest is rare, the prognosis of the event may be worse than in nonpregnant patients because the events is often associated with pulmonary or amniotic embolisms. The following report is a case of cardiac arrest which occurred at the induction of anesthesia for the postpartum hysterectomy. A 31-year-old woman was treated with infusion of ritodrine chloride for preterm labor and placenta previa. Elective cesarean section was performed at 37 weeks' gestation for her delivery under epidural anesthesia. Following the operation, the total hysterectomy was scheduled due to the continuous massive bleeding. She rapidly developed ventricular tachycardia, following trachea intubation with propofol and suxamethonium. Since she was not resuscitated with cardiac massage, we started intravenous epinephrine, electronic cardioversion, the percutaneous cardiopulmonary support and intra-aortic balloon pumping with epinephrine and dopamine infusions leading to a successfully outcome. In this case, we believe that the combination of propofol and suxamethonium had the most impact on producing the cardiac arrest. Therefore, the case emphasizes the potential danger of using these combination for patients who have been treated with ritodrine.

Adult↗
PubMed1995

Improved outcome for patients with a cardiac arrest by supervision of the emergency medical services system.

BACKGROUND: The outcome for patients with an out-of-hospital cardiac arrest can only be improved through optimal pre-hospital therapy by the emergency medical services (EMS) system. So far it is not clear if physician supervision of the EMS system is necessary for an optimal result. METHODS: In a retrospective and prospective case series we describe the changes in outcome for patients with an out-of-hospital cardiac arrest after the implementation of limited physician supervision of the EMS system. We also analysed the factors that were responsible for these changes. RESULTS: We studied 479 consecutive patients with an out-of-hospital cardiac arrest. In the pre-intervention period, the survival rate for patients with an out-of-hospital cardiac arrest was 13%. This increased to 21.6% when physician supervision was implemented (p = 0.013). This increase in survival coincided with an improvement in pre-hospital advanced cardiac life support with an increase in the number of patients who arrived with a stable cardiac rhythm in the emergency department (p < 0.001). CONCLUSIONS: Limited physician supervision of an EMS system in a non-metropolitan area may improve the outcome for patients with an out-of-hospital cardiac arrest.

Adult↗
PubMed2006

Haemodynamics of cardiac arrest and resuscitation.

PURPOSE OF REVIEW: This review will summarize the available data regarding the haemodynamic changes occurring following cardiac arrest in humans and animal models. RECENT FINDINGS: Following cardiac arrest due to ventricular fibrillation without cardiopulmonary resuscitation, blood flow exponentially falls but continues for approximately 5 min until the pressure gradient between the aorta and the right heart is completely dissipated. During cardiopulmonary resuscitation forward flow occurs into the aorta during the compression phase. Coronary blood flow is retrograde during the compression phase and antegrade during the decompression phase. Carotid blood flow takes over a minute to reach plateau levels following the initiation of chest compressions, and even brief interruptions of compressions result in a dramatic reduction in carotid blood flow which takes a minute or so to recover to plateau levels when compressions are reinstituted. Coronary perfusion pressure during the release phase of cardiopulmonary resuscitation has been shown to be a powerful predictor of the likelihood of recovery of spontaneous circulation following restoration of electrical activity. SUMMARY: Recent studies have provided important insights into the haemodynamics of cardiac arrest and of cardiopulmonary resuscitation which may inform more effective strategies for the management of cardiac arrest in the future.

Animals↗
PubMed2005

Open-chest CPR improves survival and neurologic outcome following cardiac arrest.

STUDY OBJECTIVE: To determine if 15 min of open-chest cardiac massage (OC-CPR) versus closed-chest compressions (CC-CPR) improves 72-h survival and neurologic outcome (behavioral and histologic) after 5 min of untreated cardiac arrest. METHODS: Mongrel dogs were anesthetized and instrumented. Cardiac arrest was induced by KCl injection and after a 5-min period of non-intervention, dogs were randomized to receive either CC-CPR (N = 7) or OC-CPR (N = 5) performed for 15 min. The dogs were then resuscitated and physiologic data was recorded. Surviving dogs were scored at 72 h using canine neurodeficit score of Safar et al. (NDS; 0 = behaviorally normal, 500 = brain death). Dogs that could not be resuscitated or died before 72 h were assigned a score of 500. Brain histology was performed on all survivors. RESULTS: All OC-CPR dogs were successfully resuscitated and were behaviorally normal at 72 h (NDS = 0). Histology in OC-CPR dogs showed little to no injury. Only three out of the seven CC-CPR dogs survived to 72 h. Of the survivors, one dog exhibited minor ataxia (NDS = 15), and two had incapacitating deficits (both NDS = 180). Two dogs died within 24 h after extubation, and one could not be resuscitated and the other could not be weaned from the ventilator (each NDS = 500). Histology of the CC-CPR survivors revealed moderate to severe lesions. NDS between groups was statistically significant (p < 0.0079). CONCLUSION: In our canine model of cardiac arrest, OC-CPR significantly improved 72-h survival and neurologic outcome when compared to CC-CPR.

Animals↗
PubMedDate not supplied

Protective effects of combined superoxide dismutase and deferoxamine on recovery of cerebral blood flow and function after cardiac arrest in dogs.

Oxygen free radicals generated during reoxygenation after cardiac arrest may impair recovery of cerebral blood flow and function. In a randomized study in vivo, we tested the following anti-free radical combination therapy administered at the beginning of cardiopulmonary resuscitation after apnea-induced cardiac arrest of 7 minutes: 1) ventilation with 100% nitrogen for 30 seconds to allow the delivery of therapy before oxygen, 2) 10 mg/kg i.a. superoxide dismutase followed by 10 mg/kg i.v. over 1 hour to scavenge the superoxide anion radical, and 3) 20 mg/kg i.v. deferoxamine over 1 hour to prevent membrane lipid peroxidation. We evaluated the effects of this combined treatment on the recovery of cardiovascular variables, cerebral blood flow and oxygen consumption, and somatosensory evoked potentials in 20 dogs 6 hours after resuscitation. Compared with standard treatment (n = 10), the combined treatment (n = 10) did not affect cardiovascular variables, significantly mitigated cerebral blood flow changes after cardiac arrest, and enhanced recovery of somatosensory evoked potentials. We conclude that oxygen free radicals play a role in the pathogenesis of the arrest-related derangements of cerebral blood flow and function that are effectively reduced by this combined treatment; we recommend evaluation of its components in outcome studies.

Animals↗
PubMed2004

Prediction rules for estimating neurologic outcome following out-of-hospital cardiac arrest.

BACKGROUND: No valid model has been developed to predict survival following out-of-hospital cardiac arrest. The purpose of this study was to develop a prediction model for meaningful survival following out-of-hospital cardiac arrest using variables available during resuscitation. METHODS: This was a retrospective cohort study. Consecutive adult cardiac arrest patients were studied between 1994 and 2001. Variables included age, sex, race/ethnicity, arrest location, whether the arrest was witnessed, initial rhythm, whether CPR was performed, patient downtime, paramedic response time, survival to hospital discharge, and Glasgow Coma Score (GCS) at hospital discharge. Classification and Regression Tree analysis was used to develop decision rules to predict meaningful survival, as defined by the patient's discharge GCS. RESULTS: Of the 754 patients, 16 (2%) survived with a GCS > or =13, 15 (2%) survived with a GCS = 14, and 5 (0.7%) survived with a GCS = 15. The decision rule for survival with a GCS > or = 13 incorporated whether the arrest was witnessed and the patient's age, resulting in a negative predictive value (NPV) of 99.8%. The rule for survival with a GCS > or = 14 incorporated the initial arrest rhythm, whether the arrest was witnessed, and the patient's age, resulting in a NPV of 99.6%. The rule for survival with a GCS = 15 incorporated only the interval between collapse and the initiation of life support, resulting in a NPV of 99.8%. CONCLUSIONS: This study reports decision rules for potential meaningful survival following out-of-hospital cardiac arrest with high NPVs for each. Future studies need to be performed to prospectively validate these models.

Aged↗
PubMedDate not supplied

Arterial blood gases during cardiac arrest: markers of blood flow in a canine model.

Measures of CO2 have been shown to correlate with coronary perfusion pressure and cardiac output during cardiac arrest. We evaluated arterial pH (pHa) relative to blood flow during cardiac arrest in a canine electromechanical dissociation (EMD) model of cardiac arrest using different resuscitation techniques. Following 15 min of cardiac arrest, 24 mongrel dogs received epinephrine with continued CPR or closed-chest cardiopulmonary bypass. Central arterial blood gases, end-tidal carbon dioxide (PetCO2), coronary perfusion pressure and cardiac output were measured. During CPR, prior to epinephrine or bypass, there was no correlation of pHa, PACO2 and PetCO2, with cardiac output or coronary perfusion pressure. Immediately after instituting the resuscitation techniques, both pHa and PaCO2 showed a significant correlation with cardiac output (pHa; R = -0.78, P less than 0.001 and PaCO2; R = 0.87, P less than 0.001) and with coronary perfusion pressure (pHa; R = -0.75, P less than 0.001 and PaCO2; R = 0.75, P less than 0.001). Eventual survivors (n = 15) had an early significant decrease in pHa, base excess and a significant increase in PaCO2 which was not present in non-survivors (n = 9). Neither pHa nor PaCO2 correlate with blood flow under low flow conditions of CPR. However, with effective circulatory assistance, pHa and PaCO2 reflect systemic blood flow and reperfusion washout.

Animals↗
PubMed1992

The epidemiology of cardiac arrest in young adults.

STUDY OBJECTIVE: To describe the epidemiology of cardiac arrest in young adults and to determine if there are characteristics unique to this group in terms of etiology, rhythm, and outcome. DESIGN: Retrospective, case review. SETTING: King County, Washington. TYPE OF PARTICIPANTS: All out-of-hospital victims of cardiac arrest who received emergency aid. MEASUREMENTS: The etiology, cardiac rhythm, and outcome were identified for each case. MAIN RESULTS: During the 13-year period from 1976 to 1989, there were 8,054 cardiac arrests; 252 of these were among young adults 18 to 35 years of age. Of those 252 cases, 61 (24%) were caused by ischemic heart disease, and 60 (24%) were caused by overdose. Asystole was the most common rhythm (48%), followed by ventricular fibrillation or tachycardia (31%). Long-term survival following these rhythms was 4% and 28%, respectively. In terms of age, etiology, and rhythm, young adults appear to represent a transitional group between children and older adults. There were no unique characteristics specific to young adults. Long-term survival is dependent more on rhythm than on age. CONCLUSION: In terms of age, etiology, and rhythm, young adults appear to represent a transitional group between children and older adults.

Adolescent↗
PubMed1993

EMS system performance: the use of cardiac arrest timelines.

The time data used to analyze the significance of time-to-treatment intervals on times from sudden cardiac arrest vary by definition of time and individual system design, making it difficult to compare these data and to extrapolate findings from one study to another to achieve generalizable conclusions. A model is proposed to describe the time-to-treatment/time-to-patient response intervals sought by most researchers to evaluate quality of care and system performance. It provides a mechanism for incorporating system design elements into the cardiac arrest timeline proposed by the Utstein Conference. The present model is composed of generic patient management intervals (classes of intervals common to all systems) that are composed of component intervals (intervals particular to each system) that describe the system's conduct of an emergency medical services call, which, in turn, are constructed of data (activity) points unique to each system. Because each system defines its own data points, the present model permits rigorous definition and analysis of the time data produced by all systems. Each system thereby constructs reliable component intervals, producing a system-specific, real-time depiction of the events related to a cardiac arrest call. Because all systems share the same generic patient management intervals, the resulting cardiac arrest timeline can be compared with those from other systems to assess system performance. The goal of the present model is to facilitate further the standardization of cardiac arrest data acquisition and reporting and evaluation of emergency medical services system performance.

Data Collection↗
PubMed1977

Management of cardiac arrest: seven steps to survival.

Cardiac arrest is a common medical emergency. It usually occurs suddenly and results in irreversible brain damage unless prompt, effective treatment is instituted. One plan for dealing effectively with this emergency consists of seven steps of cardiopulmonary resuscitation: (1) establishing the diagnosis and deciding whether to resuscitate; (2) administering a precordial thump, noting the time and summoning aid; (3) establishing a patent airway and performing artificial ventilation and external cardiac compression; (4) instituting general supportive measures; (5) diagnosing the cardiac arrhythmia responsible for the arrest; (6) treating the arrhythmia; and (7) managing the patient after resuscitation.

Airway Obstruction↗
PubMed1990

The effect of bolus injection on circulation times during cardiac arrest.

Previous investigations have shown that peripheral injection of medication during cardiac arrest leads to prolonged circulation times and low peak drug levels. Current Advanced Cardiac Life Support guidelines suggest that administering a bolus of flush solution after injection of medication may hasten drug delivery, but there is little evidence to support this. The purpose of this study is to investigate the effect of peripheral bolus injection on circulation times during cardiac arrest. Measurements of circulation times were made following injection of indocyanine green dye both with and without a bolus of 20 mL saline flush into a peripheral vein of mongrel dogs. There was no difference in systolic, diastolic, or coronary perfusion pressures during the injections with or without bolus injection. Similarly, there was no difference in end-tidal CO2 or in arterial-venous PO2, PCO2, or pH gradient. The circulation time without bolus injection was 77.7 +/- 42.7 seconds while circulation time with the saline flush was 48.3 +/- 20.9 seconds (P less than .001). Peak dye concentration without saline flush was 3.0 +/- 1.0 mg/L, and peak dye concentration with saline flush was 3.8 +/- 0.9 mg/L (P less than .001). We conclude that a bolus injection of 20 mL of saline enhances dye circulation times and peak levels during cardiac arrest in this animal model. The clinical application of this technique warrants further investigation.

Animals↗
PubMed2002

Tissue plasminogen activator in cardiac arrest with pulseless electrical activity.

BACKGROUND: Coronary thrombosis and pulmonary thromboembolism are common causes of cardiac arrest. We assessed whether the administration of tissue plasminogen activator (t-PA) during cardiopulmonary resuscitation would benefit patients with cardiac arrest and pulseless electrical activity of unknown or presumed cardiovascular cause. METHODS: Patients who were older than 16 years of age and who had more than one minute of pulseless electrical activity that was unresponsive to initial therapy outside the hospital or in the emergency department were eligible. Patients were randomly assigned to receive 100 mg of t-PA or placebo intravenously over a 15-minute period in a double-blind fashion. Standard resuscitation was then continued for at least 15 minutes. The primary outcome was survival to hospital discharge. RESULTS: During the study period, 1583 patients with cardiac arrest were treated and 233 patients were enrolled (117 in the t-PA group and 116 in the placebo group). The characteristics of the patients in the two groups were similar. One patient in the t-PA group survived to hospital discharge, as compared with none in the placebo group (absolute difference between groups, 0.9; 95 percent confidence interval, -2.6 to 4.8; P=0.99). The proportion of patients with return of spontaneous circulation was 21.4 percent in the t-PA group and 23.3 percent in the placebo group (absolute difference between groups, -1.9; 95 percent confidence interval, -12.6 to 8.8; P=0.85). CONCLUSIONS: We found no evidence of a beneficial effect of fibrinolysis in patients with cardiac arrest and pulseless electrical activity of unknown or presumed cardiovascular cause. Our study had limited statistical power, and it remains unknown whether there is a small treatment effect or whether selected subgroups may benefit.

Cardiopulmonary Resuscitation↗
PubMed2004

A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial).

INTRODUCTION: The outcome after out of hospital cardiac arrest is dismal. Thrombolysis during CPR has been advocated. Our hypothesis was that early administration of bolus thrombolysis could lead to improved survival from out of hospital cardiac arrest. METHODS: A prospective, randomised, double blind placebo controlled trial. All victims of out of hospital cardiac arrest brought to the Emergency Department (ED) by the emergency medical system were eligible for inclusion. All patients received standard advanced cardiac life support, except that the first drug the patient received was either tenecteplase 50 mg or placebo. The primary end point was return of spontaneous circulation (ROSC). RESULTS: Of 35 patients enrolled, 19 received tenecteplase and 16 placebo. The tenecteplase group was younger (63 vs 72 years P = 0.04) and had significantly more ventricular fibrillation as the initial rhythm (63% versus 19%, 44% difference, 95% CI 15-73%). There was no difference in rhythm on arrival at the ED. ROSC occurred in 8 (42%) patients receiving tenecteplase and one (6%) placebo (36% difference, 95% CI 11-61%). Two tenecteplase and one placebo patient survived to leave ED, and one in each group survived to hospital discharge. Autopsy results were available on eight patients, five of whom had a thrombotic cause of death. CONCLUSION: In this pilot study, we found the use of early bolus tenecteplase for OHCA to be feasible, and that it appears to increase the rate of ROSC. Larger studies are required to determine if this translates into a survival benefit. Appropriate patient selection for OHCA studies remains problematic.

Aged↗
PubMed1989

Myocardial acidosis associated with CO2 production during cardiac arrest and resuscitation.

Previous studies from our institution demonstrated significant hypercarbic acidosis in the mixed venous (pulmonary artery) blood in animals and human patients during cardiac arrest and cardiopulmonary resuscitation (CPR). In the present study, the acid-base state of the myocardium during cardiac arrest was investigated. Cardiac arrest was electrically induced in 11 pentobarbital-anesthetized and mechanically ventilated domestic pigs. Precordial compression was begun 3 minutes after onset of ventricular fibrillation and continued for 8 minutes. During CPR, there was rapid onset of profound myocardial acidosis with an increase in intramyocardial [H+] from 54 +/- 5 to 146 +/- 20 nmol/l (7.27 +/- 0.04 to 6.88 +/- 0.20 pH units). Great cardiac vein PCO2 increased from 57 +/- 2 to 158 +/- 12 mm Hg. Profound hypercarbic acidosis in great cardiac vein blood was associated with myocardial lactate production to levels of 8.1 +/- 0.7 mmol/l. Only moderate decreases in cardiac vein bicarbonate concentrations from 31 +/- 1 to 23 +/- 1 mmol/l were observed. These acid-base changes were almost completely reversed over an interval of 60 minutes after the animals were successfully resuscitated by DC countershock. The PCO2 in cardiac vein blood was significantly greater than that of mixed venous blood, demonstrating disproportionate myocardial production of CO2 during CPR. Accordingly, it is CO2 production during ischemia that is implicated as the predominant mechanism accounting for myocardial [H+] increases during cardiac arrest. Important clinical implications for buffer therapy during CPR and, in particular, treatment with bicarbonate emerge from these observations.

Acidosis↗
PubMed1991

Prognostic significance of early intracranial and cerebral perfusion pressures in post-cardiac arrest anoxic coma.

The prognosis of prolonged cardiac arrests is generally related to brain damage due to the cerebral anoxia. A neurological worsening leading to irreversibility is sometimes associated with an increase in intracranial pressure. We studied for 5 years the early intracranial and cerebral perfusion pressures in 84 patients with deep anoxic coma after cardiac arrest. Intracranial pressure monitoring was set up as soon as possible with an extradural screw over a period of 6 days. No complications occurred using this technique. We recorded the percentage of patients suffering from intracranial pressure peaks over 15 mmHg (a), over 25 mmHg (b) or cerebral perfusion pressures drops under 50 mmHg (c). We obtained during the 1st day of monitoring: (a) 46.4%, (b) 21.4%, (c) 39%; during the 2nd day: (a) 73.6%, (b) 26.3%, (c) 55.9%. Eight patients (9.5%) were still alive after a couple of months, 4 of whom had no neurological sequelae; among the 76 non-survivors 63 (82.9%) had died because of cerebral anoxic damage. A daily comparison between survivors and non-survivors points out that the survivors' intracranial pressures were always lower than in the non-survivors and the survivors' cerebral perfusion pressures higher than in the non-survivors. Moreover, none of the patients showing intracranial peak pressures over 25 mmHg survived without after-effects. It is clear that many patients suffer early periods of high intracranial pressures and low cerebral perfusion pressures leading to a bad neurological prognosis. Intracranial pressure monitoring may allow assessment of patients' neurological status and prognosis after cardiac resuscitation.

Adolescent↗