Good outcome in every fourth resuscitation attempt is achievable--an Utstein template report from the Stavanger region

Systematic review of the effectiveness of prehospital critical care following out-of-hospital cardiac arrest

BACKGROUND

Improving survival after out-of-hospital cardiac arrest (OHCA) is a priority for modern emergency medical services (EMS) and prehospital research. Advanced life support (ALS) is now the standard of care in most EMS. In some EMS, prehospital critical care providers are also dispatched to attend OHCA. This systematic review presents the evidence for prehospital critical care for OHCA, when compared to standard ALS care.

METHODS

We searched the following electronic databases: PubMed, EmBASE, CINAHL Plus and AMED (via EBSCO), Cochrane Database of Systematic Reviews, DARE, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, NIHR Health Technology Assessment Database, Google Scholar and ClinicalTrials.gov. Search terms related to cardiac arrest and prehospital critical care. All studies that compared patient-centred outcomes between prehospital critical care and ALS for OHCA were included.

RESULTS

The review identified six full text publications that matched the inclusion criteria, all of which are observational studies. Three studies showed no benefit from prehospital critical care but were underpowered with sample sizes of 1028-1851. The other three publications showed benefit from prehospital critical care delivered by physicians. However, an imbalance of prognostic factors and hospital treatment in these studies systematically favoured the prehospital critical care group.

CONCLUSION

Current evidence to support prehospital critical care for OHCA is limited by the logistic difficulties of undertaking high quality research in this area. Further research needs an appropriate sample size with adjustments for confounding factors in observational research design.

A nationwide survey of first aid training and encounters in Norway

Background

Bystander first aid can improve survival following out-of-hospital cardiac arrest or trauma. Thus, providing first aid education to laypersons may lead to better outcomes. In this study, we aimed to establish the prevalence and distribution of first aid training in the populace, how often first aid skills are needed, and self-reported helping behaviour.

Methods

We conducted a telephone survey of 1000 respondents who were representative of the Norwegian population. Respondents were asked where and when they had first aid training, if they had ever encountered situations where first aid was necessary, and stratified by occupation. First aid included cardio-pulmonary resuscitation (CPR) and basic life support (BLS). To test theoretical first aid knowledge, respondents were subjected to two hypothetical first aid scenarios.

Results

Among the respondents, 90% had received first aid training, and 54% had undergone first aid training within the last 5 years. The workplace was the most common source of first aid training. Of the 43% who had been in a situation requiring first aid, 89% had provided first aid in that situation. There were considerable variations among different occupations in first aid training, and exposure to situations requiring first aid. Theoretical first aid knowledge was not as good as expected in light of the high share who had first aid training. In the presented scenarios 42% of respondent would initiate CPR in an unconscious patient not breathing normally, and 46% would provide an open airway to an unconscious road traffic victim. First aid training was correlated with better theoretical knowledge, but time since first aid training was not.

Conclusions

A high proportion of the Norwegian population had first aid training, and interviewees reported high willingness to provide first aid. Theoretical first aid knowledge was worse than expected. While first aid is part of national school curriculum, few have listed school as the source for their first aid training.

Electronic supplementary material

The online version of this article (doi:10.1186/s12873-017-0116-7) contains supplementary material, which is available to authorized users.

Exploring How Lay Rescuers Overcome Barriers to Provide Cardiopulmonary Resuscitation: A Qualitative Study

BACKGROUND

Survival rates after out-of-hospital cardiac arrest (OHCA) vary considerably among regions. The chance of survival is increased significantly by lay rescuer cardiopulmonary resuscitation (CPR) before Emergency Medical Services (EMS) arrival. It is well known that for bystanders, reasons for not providing CPR when witnessing an OHCA incident may be fear and the feeling of being exposed to risk. The aim of this study was to gain a better understanding of why barriers to providing CPR are overcome.

METHODS

Using a semi-structured interview guide, 10 lay rescuers were interviewed after participating in eight OHCA incidents. Qualitative content analysis was used. The lay rescuers were questioned about their CPR-knowledge, expectations, and reactions to the EMS and from others involved in the OHCA incident. They also were questioned about attitudes towards providing CPR in an OHCA incident in different contexts.

RESULTS

The lay rescuers reported that they were prepared to provide CPR to anybody, anywhere. Comprehending the severity in the OHCA incident, both trained and untrained lay rescuers provided CPR. They considered CPR provision to be the expected behavior of any community citizen and the EMS to act professionally and urgently. However, when asked to imagine an OHCA in an unclear setting, they revealed hesitation about providing CPR because of risk to their own safety.

CONCLUSION

Mutual trust between community citizens and towards social institutions may be reasons for overcoming barriers in providing CPR by lay rescuers. A normative obligation to act, regardless of CPR training and, importantly, without facing any adverse legal reactions, also seems to be an important factor behind CPR provision. Mathiesen WT , Bjørshol CA , Høyland S , Braut GS , Søreide E . Exploring how lay rescuers overcome barriers to provide cardiopulmonary resuscitation: a qualitative study. Prehosp Disaster Med. 2017;32(1):27-32.

Epidemiology and outcomes from out-of-hospital cardiac arrests in England

INTRODUCTION

This study reports the epidemiology and outcomes from out-of-hospital cardiac arrest (OHCA) in England during 2014.

METHODS

Prospective observational study from the national OHCA registry. The incidence, demographic and outcomes of patients who were treated for an OHCA between 1st January 2014 and 31st December 2014 in 10 English ambulance service (EMS) regions, serving a population of almost 54 million, are reported in accordance with Utstein recommendations.

RESULTS

28,729 OHCA cases of EMS treated cardiac arrests were reported (53 per 100,000 of resident population). The mean age was 68.6 (SD=19.6) years and 41.3% were female. Most (83%) occurred in a place of residence, 52.7% were witnessed by either the EMS or a bystander. In non-EMS witnessed cases, 55.2% received bystander CPR whilst public access defibrillation was used rarely (2.3%). Cardiac aetiology was the leading cause of cardiac arrest (60.9%). The initial rhythm was asystole in 42.4% of all cases and was shockable (VF or pVT) in 20.6%. Return of spontaneous circulation at hospital transfer was evident in 25.8% (n=6302) and survival to hospital discharge was 7.9%.

CONCLUSION

Cardiac arrest is an important cause of death in England. With less than one in ten patients surviving, there is scope to improve outcomes. Survival rates were highest amongst those who received bystander CPR and public access defibrillation.

Epidemiology and outcomes of out-of-hospital cardiac arrest in Qatar: A nationwide observational study

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) studies from the Middle East and Asian region are limited. This study describes the epidemiology, emergency health services, and outcomes of OHCA in Qatar.

METHODS

This was a prospective nationwide population-based observational study on OHCA patients in Qatar according to Utstein style guidelines, from June 2012 to May 2013. Data was collected from various sources; the national emergency medical service, 4 emergency departments, and 8 public hospitals.

RESULTS

The annual crude incidence of presumed cardiac OHCA attended by EMS was 23.5 per 100,000. The age-sex standardized incidence was 87.8 per 100,000 population. Of the 447 OHCA patients included in the final analysis, most were male (n=360, 80.5%) with median age of 51years (IQR=39-66). Frequently observed nationalities were Qatari (n=89, 19.9%), Indian (n=74, 16.6%) and Nepalese (n=52, 11.6%). Bystander cardiopulmonary resuscitation (CPR) was carried out in 92 (20.6%) OHCA patients. Survival rate was 8.1% (n=36) and multivariable logistic regression indicated that initial shockable rhythm (OR 13.4, 95% CI 5.4-33.3, p=0.001) was associated with higher odds of survival while male gender (OR 0.27, 95% CI 0.1-0.8, p=0.01) and advanced cardiac life support (ACLS) (OR 0.15, 95% CI 0.04-0.5, p=0.02) were associated with lower odds of survival.

CONCLUSIONS

Standardized incidence and survival rates were comparable to Western countries. Although expatriates comprise more than 80% of the population, Qataris contributed 20% of the total cardiac arrests observed. There are significant opportunities to improve outcomes, including community-based CPR and defibrillation training.

Medical students and physical education students as CPR instructors: an appropriate solution to the CPR-instructor shortage in secondary schools?

Background

Integrating cardiopulmonary resuscitation (CPR) training in secondary schools will increase the number of potential CPR providers. However, currently too few certified instructors are available for this purpose. Training medical students and physical education student teachers to become CPR instructors could decrease this shortage.

Aim

Examine whether medical students and physical education student teachers can provide CPR training for secondary school pupils as well as (i. e., non-inferior to) registered nurses.

Methods

A total of 144 secondary school pupils were randomly assigned to CPR training by a registered nurse (n = 12), a  medical student (n = 17) or a physical education student teacher (n = 15). CPR performance was assessed after training and after eight weeks in a simulated cardiac arrest scenario on a resuscitation manikin, using manikin software and video recordings.

Results

No significant differences were found between the groups on the overall Cardiff Test scores and the correctness of the CPR techniques during the post-training and retention test. All pupils showed sufficient CPR competence, even after eight weeks.

Conclusion

Training by medical students or physical education student teachers is non-inferior to training by a registered nurse, suggesting that school teachers, student teachers and medical students can be recruited for CPR training in secondary schools.

Potential cardiac arrest - an observational study of pre-hospital medical response

OBJECTIVES

A previous study showed that Norwegian GPs on call attended around 40% of out-of-hospital medical emergencies. We wanted to investigate the alarms of prehospital medical resources and the doctors' responses in situations of potential cardiac arrests.

DESIGN AND SETTING

A three-month prospective data collection was undertaken from three emergency medical communication centres, covering a population of 816,000 residents. From all emergency medical events, a sub-group of patients who received resuscitation, or who were later pronounced dead at site, was selected for further analysis.

RESULTS

5,105 medical emergencies involving 5,180 patients were included, of which 193 met the inclusion criteria. The GP on call was alarmed in 59 %, and an anaesthesiologist in 43 % of the cases. When alarmed, a GP attended in 84 % and an anaesthesiologist in 87 % of the cases. Among the patients who died, the GP on call was alarmed most frequently.

CONCLUSION

Events involving patients in need of resuscitation are rare, but medical response in the form of the attendance of prehospital personnel is significant. Norwegian GPs have a higher call-out rate for patients in severe situations where resuscitation was an option of treatment, compared with other "red-response" situations. Key points This study investigates alarms of and call-outs among GPs and anaesthesiologists on call, in the most acute clinical situations: Medical emergencies involving patients in need of resuscitation were rare. The health care contribution by pre-hospital personnel being called out was significant. Compared with other acute situations, the GP had a higher attendance rate to patients in life-threatening situations.

Reactions and coping strategies in lay rescuers who have provided CPR to out-of-hospital cardiac arrest victims: a qualitative study

OBJECTIVE

Cardiopulmonary resuscitation (CPR) provided by community citizens is of paramount importance for out-of-hospital cardiac arrest (OHCA) victims' survival. Fortunately, CPR rates by community citizens seem to be rising. However, the experience of providing CPR is rarely investigated. The aim of this study was to explore reactions and coping strategies in lay rescuers who have provided CPR to OHCA victims.

METHODS, PARTICIPANTS

This is a qualitative study of 20 lay rescuers who have provided CPR to 18 OHCA victims. We used a semistructured interview guide focusing on their experiences after providing CPR.

SETTING

The study was conducted in the Stavanger region of Norway, an area with very high bystander CPR rates.

RESULTS

Three themes emerged from the interview analysis: concern, uncertainty and coping strategies. Providing CPR had been emotionally challenging for all lay rescuers and, for some, had consequences in terms of family and work life. Several lay rescuers experienced persistent mental recurrences of the OHCA incident and had concerns about the outcome for the cardiac arrest victim. Unknown or fatal outcomes often caused feelings of guilt and were particularly difficult to handle. Several reported the need to be acknowledged for their CPR attempts. Health-educated lay rescuers seemed to be less affected than others. A common coping strategy was confiding in close relations, preferably the health educated. However, some required professional help to cope with the OHCA incident.

CONCLUSIONS

Lay rescuers experience emotional and social challenges, and some struggle to cope in life after providing CPR in OHCA incidents. Experiencing a positive patient outcome and being a health-educated lay rescuer seem to mitigate concerns. Common coping strategies are attempts to reduce uncertainty towards patient outcome and own CPR quality. Further studies are needed to determine whether an organised professional follow-up can mitigate the concerns and uncertainty of lay rescuers.

Short structured feedback training is equivalent to a mechanical feedback device in two-rescuer BLS: a randomised simulation study

BACKGROUND

Resuscitation guidelines encourage the use of cardiopulmonary resuscitation (CPR) feedback devices implying better outcomes after sudden cardiac arrest. Whether effective continuous feedback could also be given verbally by a second rescuer ("human feedback") has not been investigated yet. We, therefore, compared the effect of human feedback to a CPR feedback device.

METHODS

In an open, prospective, randomised, controlled trial, we compared CPR performance of three groups of medical students in a two-rescuer scenario. Group "sCPR" was taught standard BLS without continuous feedback, serving as control. Group "mfCPR" was taught BLS with mechanical audio-visual feedback (HeartStart MRx with Q-CPR-Technology™). Group "hfCPR" was taught standard BLS with human feedback. Afterwards, 326 medical students performed two-rescuer BLS on a manikin for 8 min. CPR quality parameters, such as "effective compression ratio" (ECR: compressions with correct hand position, depth and complete decompression multiplied by flow-time fraction), and other compression, ventilation and time-related parameters were assessed for all groups.

RESULTS

ECR was comparable between the hfCPR and the mfCPR group (0.33 vs. 0.35, p = 0.435). The hfCPR group needed less time until starting chest compressions (2 vs. 8 s, p < 0.001) and showed fewer incorrect decompressions (26 vs. 33 %, p = 0.044). On the other hand, absolute hands-off time was higher in the hfCPR group (67 vs. 60 s, p = 0.021).

CONCLUSIONS

The quality of CPR with human feedback or by using a mechanical audio-visual feedback device was similar. Further studies should investigate whether extended human feedback training could further increase CPR quality at comparable costs for training.

Impact of an emergency medical dispatch system on survival from out-of-hospital cardiac arrest: a population-based study

Background

In countries where a single public emergency telephone number is not in operation, different emergency telephone numbers corresponding to multiple dispatch centres (police, fire, emergency medical service) may create confusion for the population about the most appropriate service to call. In particular, out-of-hospital cardiac arrest (OHCA) requires a prompt and effective response. We compare two different dispatch systems on OHCA patient survival at 30 days in a national system with multiple emergency telephone numbers.

Methods

We conducted an observational retrospective study of 6871 patients aged 18 years or older with presumed OHCA of cardiac origin between 2005 and 2013 in three counties of the Northern French Alps region. One county had a single dispatch centre combining medical and fire emergencies, and two had multiple dispatch centres. Propensity score matching analyses were performed to compare patient survival at 30 days.

Results

A total of 2257 emergency calls for OHCA were managed by a single dispatch centre and 4614 by a multiple dispatch centre. A single dispatch centre was associated with an increase in survival (adjusted odds ratio [OR] for all patients: 1.7; 95 % confidence interval [CI] = 1.3–2.2; p <0.001; adjusted OR for propensity-matched patients: 2.0; 95 % CI = 1.2–3.4; p = 0.012).

Conclusions

A single dispatch centre was associated with a markedly improved increase of survival among OHCA patients at 30 days in a system with several emergency telephone numbers.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-016-0247-y) contains supplementary material, which is available to authorized users.

Cortical somatosensory evoked high-frequency (600Hz) oscillations predict absence of severe hypoxic encephalopathy after resuscitation

OBJECTIVE

Following cardiac arrest (CA), hypoxic encephalopathy (HE) frequently occurs and hence reliable neuroprognostication is crucial to decide on the extent of intensive care. Several investigations predict severe HE leading to persistent unresponsive wakefulness or death, with high specificity. Only few studies attempted to predict absence of severe HE. Cortical somatosensory evoked high-frequency (600Hz) oscillation (HFO) bursts indicate the presence of highly synchronized spiking activity in the primary somatosensory cortex. Since global neuronal damage characterizes severe HE preserved cortical HFOs may early exclude severe HE.

METHODS

We determined amplitudes of early and late HFO bursts in 302 comatose CA patients after median nerve somatosensory evoked potential (SSEPs) and clinical outcome upon intensive care unit discharge using the cerebral performance category (CPC) scale.

RESULTS

We detected significant early HFO bursts in 146 patients and late HFO bursts in 95 patients. Only one of 27 unresponsive wakefulness patients had a late HFO burst amplitude above 70nV and all seventeen patients who died despite higher amplitudes died from non-neurological causes.

CONCLUSIONS

High-frequency SSEP components can reliably be studied in comatose CA patients using standard equipment.

SIGNIFICANCE

Late HFO burst amplitudes above 70nV largely exclude severe HE incompatible with regaining consciousness.

'Kids save lives': why schoolchildren should train in cardiopulmonary resuscitation

PURPOSE OF REVIEW

Quick initiation of basic life support (BLS) by laypersons is one of the most successful strategies in the fight against sudden cardiac death. In developed countries, cardiac arrest is still a major contributor to avoidable death, and despite the fact that more than 50% of all cardiac arrests are witnessed, layperson BLS is performed in less than 20%. To improve this situation, BLS training in schools has been established.

RECENT FINDINGS

Cardiopulmonary resuscitation (CPR) instruction including the use of automatic external defibrillators (AEDs) has shown to be feasible even for young schoolchildren, and there is an indication that respective programmes are effective to enhance patient outcome on a population basis. Earlier training may even lead to more sustainable results; however, it is reasonable to implement adjusted curricula for different child ages. The programme 'Kids Save Lives' recently endorsed by the WHO will help promoting school-based BLS training worldwide demanding education on CPR for all pupils starting at least at age 12.

SUMMARY

Resuscitation training in schools can help to increase the amount of BLS-trained population. Social skills of pupils can be improved and training can be successfully implemented independently of the pupils' age and physique.

Bystander first aid in trauma - prevalence and quality: a prospective observational study

Background

Bystander first aid and basic life support can likely improve victim survival in trauma. In contrast to bystander first aid and out‐of‐hospital cardiac arrest, little is known about the role of bystanders in trauma response. Our aim was to determine how frequently first aid is given to trauma victims by bystanders, the quality of this aid, the professional background of first‐aid providers, and whether previous first‐aid training affects aid quality.

Methods

We conducted a prospective 18‐month study in two mixed urban–rural Norwegian counties. The personnel on the first ambulance responding to trauma calls assessed and documented first aid performed by bystanders using a standard form.

Results

A total of 330 trauma calls were included, with bystanders present in 97% of cases. Securing an open airway was correctly performed for 76% of the 43 patients in need of this first‐aid measure. Bleeding control was provided correctly for 81% of 63 patients for whom this measure was indicated, and prevention of hypothermia for 62% of 204 patients. Among the first‐aid providers studied, 35% had some training in first aid. Bystanders with documented first‐aid training gave better first aid than those where first‐aid training status was unknown.

Conclusions

A majority of the trauma patients studied received correct pre‐hospital first aid, but still there is need for considerable improvement, particularly hypothermia prevention. Previous first‐aid training seems to improve the quality of first aid provided. The effect on patient survival needs to be investigated.

Outcomes for out-of-hospital cardiac arrests across 7 countries in Asia: The Pan Asian Resuscitation Outcomes Study (PAROS)

BACKGROUND

The Pan Asian Resuscitation Outcomes Study (PAROS) Clinical Research Network (CRN) was established in collaboration with emergency medical services (EMS) agencies and academic centers in Japan, Singapore, South Korea, Malaysia, Taiwan, Thailand, and UAE-Dubai and aims to report out-of-hospital cardiac arrests (OHCA) and provide a better understanding of OHCA trends in Asia.

METHODS AND RESULTS

This is a prospective, international, multi-center cohort study of OHCA across the Asia-Pacific. Each participating country provided between 1.5 and 2.5 years of data from January 2009 to December 2012. All OHCA cases conveyed by EMS or presenting at emergency departments were captured. 66,780 OHCA cases were submitted to the PAROS CRN; 41,004 cases were presumed cardiac etiology. The mean age OHCA occurred varied from 49.7 to 71.7 years. The proportion of males ranged from 57.9% to 82.7%. Proportion of unwitnessed arrests ranged from 26.4% to 67.9%. Presenting shockable rhythm rates ranged from 4.1% to 19.8%. Bystander cardiopulmonary resuscitation (CPR) rates varied from 10.5% to 40.9%, however <1.0% of these arrests received bystander defibrillation. For arrests that were with cardiac etiology, witnessed arrest and VF, the survival rate to hospital discharge varied from no reported survivors to 31.2%. Overall survival to hospital discharge varied from 0.5% to 8.5%. Survival with good neurological function ranged from 1.6% to 3%.

CONCLUSIONS

Survival to hospital discharge for Asia varies widely and this may be related to patient and system differences. This implies that survival may be improved with interventions such as increasing bystander CPR, public access defibrillation and improving EMS.

The secular trends in the incidence rate and outcomes of out-of-hospital cardiac arrest in Taiwan--a nationwide population-based study

OBJECTIVE

This study investigated the trends in incidence and mortality of out-of-hospital cardiac arrest (OHCA), as well as factors associated with OHCA outcomes in Taiwan.

METHODS

Our study included OHCA patients requiring cardiopulmonary resuscitation (CPR) upon arrival at the hospital. We used national time-series data on annual OHCA incidence rates and mortality rates from 2000 to 2012, and individual demographic and clinical data for all OHCA patients requiring mechanical ventilation (MV) care from March of 2010 to September of 2011. Analytic techniques included the time-series regression and the logistic regression.

RESULTS

There were 117,787 OHCAs in total. The overall incidence rate during the 13 years was 51.1 per 100,000 persons, and the secular trend indicates a sharp increase in the early 2000s and a decrease afterwards. The trend in mortality was also curvilinear, revealing a substantial increase in the early 2000s, a subsequent steep decline and finally a modest increase. Both the 30-day and 180-day mortality rates had a long-term decreasing trend over the period (p<0.01). For both incidence and mortality rates, a significant second-order autoregressive effect emerged. Among OHCA patients with MV, 1-day, 30-day and 180-day mortality rates were 31.3%, 75.8%, and 86.0%, respectively. In this cohort, older age, the female gender, and a Charlson comorbidity index score ≥ 2 were associated with higher 180-day mortality; patients delivered to regional hospitals and those residing in non-metropolitan areas had higher death risk.

CONCLUSIONS

Overall, both the 30-day and the 180-day mortality rates after OHCA had a long-term decreasing trend, while the 1-day mortality had no long-term decline. Among OHCA patients requiring MV, those delivered to regional hospitals and those residing in non-metropolitan areas tended to have higher mortality, suggesting a need for effort to further standardize and improve in-hospital care across hospitals and to advance pre-hospital care in non-metropolitan areas.

Urban and rural differences in out-of-hospital cardiac arrest in Ireland

BACKGROUND

More than a third of Ireland's population lives in a rural area, defined as the population residing in all areas outside clusters of 1500 or more inhabitants. This presents a challenge for the provision of effective pre-hospital resuscitation services. In 2012, Ireland became one of three European countries with nationwide Out-of-Hospital Cardiac Arrest (OHCA) register coverage. An OHCA register provides an ability to monitor quality and equity of access to life-saving services in Irish communities.

AIM

To use the first year of national OHCAR data to assess differences in the occurrence, incidence and outcomes of OHCA where resuscitation is attempted and the incident is attended by statutory Emergency Medical Services between rural and urban settings.

METHODS

The geographical coordinates of incident locations were identified and co-ordinates were then classified as 'urban' or 'rural' according to the Irish Central Statistics Office (CSO) definition.

RESULTS

1798 OHCA incidents were recorded which were attended by statutory Emergency Medical Services (EMS) and where resuscitation was attempted. There was a higher percentage of male patients in rural settings (71% vs. 65%; p = 0.009) but the incidence of male patients did not differ significantly between urban and rural settings (26 vs. 25 males/100,000 population/year p = 0.353). A higher proportion of rural patients received bystander cardiopulmonary resuscitation (B-CPR) 70% vs. 55% (p ≤ 0.001), and had defibrillation attempted before statutory EMS arrival (7% vs. 4% (p = 0.019), respectively). Urban patients were more likely to receive a statutory EMS response in 8 min or less (33% vs. 9%; p ≤ 0.001). Urban patients were also more likely to be discharged alive from hospital (6% vs. 3%; p = 0.006) (incidence 2.5 vs. 1.1/100,000 population/year; p ≤ 0.001). Multivariable analysis of survival showed that the main variable of interest i.e. urban vs. rural setting was also independently associated with discharge from hospital alive (OR 3.23 (95% CI 1.43-7.31)).

CONCLUSION

There are significant disparities in the incidence of resuscitation attempts in urban and rural areas. There are challenges in the provision of services and subsequent outcomes from OHCA that occur outside of urban areas requiring novel and innovative solutions. An integrated community response system is necessary to improve metrics around OHCA response and outcomes in rural areas.

Therapeutic hypothermia after nonshockable cardiac arrest: the HYPERION multicenter, randomized, controlled, assessor-blinded, superiority trial

BACKGROUND

Meta-analyses of nonrandomized studies have provided conflicting data on therapeutic hypothermia, or targeted temperature management (TTM), at 33°C in patients successfully resuscitated after nonshockable cardiac arrest. Nevertheless, the latest recommendations issued by the International Liaison Committee on Resuscitation and by the European Resuscitation Council recommend therapeutic hypothermia. New data are available on the adverse effects of therapeutic hypothermia, notably infectious complications. The risk/benefit ratio of therapeutic hypothermia after nonshockable cardiac arrest is unclear.

METHODS

HYPERION is a multicenter (22 French ICUs) trial with blinded outcome assessment in which 584 patients with successfully resuscitated nonshockable cardiac arrest are allocated at random to either TTM between 32.5 and 33.5°C (therapeutic hypothermia) or TTM between 36.5 and 37.5°C (therapeutic normothermia) for 24 hours. Both groups are managed with therapeutic normothermia for the next 24 hours. TTM is achieved using locally available equipment. The primary outcome is day-90 neurological status assessed by the Cerebral Performance Categories (CPC) Scale with dichotomization of the results (1 + 2 versus 3 + 4 + 5). The primary outcome is assessed by a blinded psychologist during a semi-structured telephone interview of the patient or next of kin. Secondary outcomes are day-90 mortality, hospital mortality, severe adverse events, infections, and neurocognitive performance. The planned sample size of 584 patients will enable us to detect a 9% absolute difference in day-90 neurological status with 80% power, assuming a 14% event rate in the control group and a two-sided Type 1 error rate of 4.9%. Two interim analyses will be performed, after inclusion of 200 and 400 patients, respectively.

DISCUSSION

The HYPERION trial is a multicenter, randomized, controlled, assessor-blinded, superiority trial that may provide an answer to an issue of everyday relevance, namely, whether TTM is beneficial in comatose patients resuscitated after nonshockable cardiac arrest. Furthermore, it will provide new data on the tolerance and adverse events (especially infectious complications) of TTM at 32.5-33.5°C.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01994772 .

Survival After Out-of-Hospital Cardiac Arrest in Relation to Age and Early Identification of Patients With Minimal Chance of Long-Term Survival

BACKGROUND

Survival after out-of-hospital cardiac arrest has increased during the last decade in Denmark. We aimed to study the impact of age on changes in survival and whether it was possible to identify patients with minimal chance of 30-day survival.

METHODS AND RESULTS

Using data from the nationwide Danish Cardiac Arrest Registry (2001─2011), we identified 21 480 patients ≥18 years old with a presumed cardiac-caused out-of-hospital cardiac arrest for which resuscitation was attempted. Patients were divided into 3 preselected age-groups: working-age patients 18 to 65 years of age (33.7%), early senior patients 66 to 80 years of age (41.5%), and late senior patients >80 years of age (24.8%). Characteristics in working-age patients, early senior patients, and late senior patients were as follows: witnessed arrest in 53.8%, 51.1%, and 52.1%; bystander cardiopulmonary resuscitation in 44.7%, 30.3%, and 23.4%; and prehospital shock from a defibrillator in 54.7%, 45.0%, and 33.8% (all P<0.05). Between 2001 and 2011, return of spontaneous circulation on hospital arrival increased: working-age patients, from 12.1% to 34.6%; early senior patients, from 6.4% to 21.5%; and late senior patients, from 4.0% to 15.0% (all P<0.001). Furthermore, 30-day survival increased: working-age patients, 5.8% to 22.0% (P<0.001); and early senior patients, 2.7% to 8.4% (P<0.001), whereas late senior patients experienced only a minor increase (1.5% to 2.0%; P=0.01). Overall, 3 of 9499 patients achieved 30-day survival if they met 2 criteria: had not achieved return of spontaneous circulation on hospital arrival and had not received a prehospital shock from a defibrillator.

CONCLUSIONS

All age groups experienced a large temporal increase in survival on hospital arrival, but the increase in 30-day survival was most prominent in the young. With the use of only 2 criteria, it was possible to identify patients with a minimal chance of 30-day survival.

Emergency medical service treated out-of-hospital cardiac arrest: Identification of weak links in the chain-of-survival through an epidemiological study

BACKGROUND

In-depth analysis of emergency medical services (EMSs) performances in out-of-hospital cardiac arrest (OHCA) promotes quality improvement.

AIMS

The purpose of this study was to identify the improvable factors of the EMS response to OHCA through the description and analysis of OHCA incidence, characteristics, management and outcome.

METHODS

This was a retrospective cohort study on all OHCA patients treated by the EMSs of the district of Trieste, Italy (236,556 inhabitants) in 2011.

RESULTS

A total of 678 OHCAs occurred and 142 (20.1%) underwent cardiopulmonary resuscitation (CPR), with a respective incidence of 287/100,000/year and 60/100,000/year. The incidence of shockable rhythms in the CPR group was 13/100,000. OHCAs occurred mainly during daytime, though the proportion of patients receiving CPR was significantly higher by night-time (p=0.01). Thirty-four CPR patients (23.9%) restored spontaneous circulation on scene; 12 (8.5%) survived to hospital discharge (11 with good neurological recovery). Survival was not correlated with age, while was significantly higher for patients with shockable rhythms (32.3%; p<0.001). Mean response time was 8 min. Direct intervention of physician-staffed units did not improve the outcome when compared with two-tiered activation. Patients immediately identified as OHCA by dispatch nurses and those undergoing therapeutic hypothermia showed a non-significant trend towards improved survival (p=0.09 and 0.07, respectively).

CONCLUSIONS

OHCA identification by dispatch nurses and reduction of response time were the factors most susceptible to improvement.

Epidemiology of ruptured abdominal aortic aneurysms in a well-defined Norwegian population with trends in incidence, intervention rate, and mortality

OBJECTIVE

Ruptured infrarenal abdominal aortic aneurysms (rAAAs) represent both a life-threatening emergency for the affected patient and a considerable health burden globally. The aim of this study was to investigate the contemporary epidemiology of rAAA in a defined Norwegian population for which both hospital and autopsy data were available.

METHODS

This was a retrospective, single-center population-based study of rAAA. The study includes all consecutively diagnosed prehospital and in-hospital cases of rAAA in the catchment area of Stavanger University Hospital between January 2000 and December 2012. Incidence and mortality rates (crude and adjusted) were calculated using national demographic data.

RESULTS

A total of 216 patients with primary rAAA were identified. The adjusted incidence rate for the study period was 11.0 per 100,000 per year (95% confidence interval [CI], 9.6-12.5). Twenty patients died out of the hospital, and 144 of the 196 patients (73%) admitted to the hospital underwent surgery. The intervention rate varied from 48% to 81% during the study period. The adjusted mortality rate was 7.5 per 100,000 per year (95% CI, 6.3-8.8). No differences in the incidence and mortality rates were found in comparing early and late periods. The 90-day standardized mortality ratio for the study period was 37.2 (95% CI, 31.6-43.7). The overall 90-day mortality was 68% (146 of 216 persons) and 51% (74 of 144 persons) for the patients treated for rAAA.

CONCLUSIONS

We found a stable incidence and mortality rate during a decade. The prehospital death rate was lower (9%), the intervention rate (73%) higher, and the total mortality (68%) lower than in most other studies. Geographic and regional differences may influence the epidemiologic description of rAAA and hence should be taken into consideration in comparing outcomes for in-hospital mortality and intervention rates.

Cognitive function and health-related quality of life four years after cardiac arrest

AIM

Neuropsychological testing has uncovered cognitive impairment in cardiac arrest survivors with good neurologic outcome according to the cerebral performance categories. We investigated cognitive function and health-related quality of life four years after cardiac arrest.

METHODS

Thirty cardiac arrest survivors over the age of 18 in cerebral performance category 1 or 2 on hospital discharge completed the EQ-5D-5L and HADS questionnaires prior to cognitive testing using the Cambridge Neuropsychological Test Automated Battery. The results were compared with population norms.

RESULTS

Twenty-nine per cent of patients were cognitively impaired. The pattern of cognitive impairment reflects dysfunction in the medial temporal lobe, with impaired short-time memory and executive function slightly but distinctly affected. There was a significant reduction in quality of life on the EQ-VAS, but not on the EQ index.

CONCLUSION

Cognitive impairment four years after cardiac arrest affected more than one quarter of the patients. Short-term memory was predominantly affected.

A pilot study of angiotensin converting enzyme (ACE) genotype and return of spontaneous circulation following out-of-hospital cardiac arrest

Objective

In the last few years the genetic influence on health and disease outcome has become more apparent. The ACE genotype appears to play a significant role in the pathophysiology of several disease processes. This pilot study aims at showing the feasibility to examine the genetic influence of the ACE genotype on return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA).

Methods

We performed a prospective observational study of all OHCAs of presumed cardiac origin in a well-defined population. We collected prehospital blood samples for the determination of ACE genotype and used this information together with Utstein template parameters in a multivariable analysis to examine the relationship between ROSC and ACE genotype.

Results

We collect blood samples in 156 of 361 patients with OHCA of presumed cardiac origin, 127 samples were analysed (mean age 67 years, 86% male, 79% witnessed OHCA, 80% bystander CPR, 62% had a shockable rhythm, ROSC 77%). Distribution of the ACE gene polymorphisms: insertion polymorphism (II) n=22, 17%, insertion/deletion polymorphism (ID) n=66, 52% and deletion polymorphism (DD) n=39, 31%. We found no significant association between ACE II vs ACE DD/DI and ROSC (OR 1.72; CI 0.52 to 5.73; p=0.38). Other ACE genotype groupings (II/ID vs DD or II vs DD) did not change the overall finding of lack of impact of ACE genotype on ROSC.

Conclusions

This pilot study did not indicate a significant association between ACE gene polymorphism and ROSC. However, it has demonstrated that prehospital genetic studies including blood sampling are feasible and ethically acceptable.

Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival

AIMS

To describe out-of-hospital cardiac arrest (OHCA) in Sweden from a long-term perspective in terms of changes in outcome and circumstances at resuscitation.

METHODS AND RESULTS

All cases of OHCA (n = 59,926) reported to the Swedish Cardiac Arrest Register from 1992 to 2011 were included. The number of cases reported (n/100,000 person-years) increased from 27 (1992) to 52 (2011). Crew-witnessed cases, cardiopulmonary resuscitation prior to the arrival of the emergency medical service (EMS), and EMS response time increased (P < 0.0001). There was a decrease in the delay from collapse to calling for the EMS in all patients and from collapse to defibrillation among patients found in ventricular fibrillation (P < 0.0001). The proportion of patients found in ventricular fibrillation decreased from 35 to 25% (P < 0.0001). Thirty-day survival increased from 4.8 (1992) to 10.7% (2011) (P < 0.0001), particularly among patients found in a shockable rhythm and patients with return of spontaneous circulation (ROSC) at hospital admission. Among patients hospitalized with ROSC in 2008-2011, 41% underwent therapeutic hypothermia and 28% underwent percutaneous coronary intervention. Among 30-day survivors in 2008-2011, 94% had a cerebral performance category score of 1 or 2 at discharge from hospital and the results were even better if patients were found in a shockable rhythm.

CONCLUSION

From a long-term perspective, 30-day survival after OHCA in Sweden more than doubled. The increase in survival was most marked among patients found in a shockable rhythm and those hospitalized with ROSC. There were improvements in all four links in the chain of survival, which might explain the improved outcome.

Schoolchildren as lifesavers in Europe - training in cardiopulmonary resuscitation for children

Sudden cardiac arrest is a major contributor to avoidable deaths in Europe. Immediate initiation of basic life support (BLS) by lay bystanders is among the most successful strategies in its treatment. Despite the fact that more than half of all cardiac arrests are witnessed in a number of European countries, layperson resuscitation is initiated in only one-fifth of all cases. One strategy to promote bystander BLS is to establish cardiac resuscitation training in schools. BLS instructions for schoolchildren - including the use of automatic external defibrillators (AEDs) - have been shown to be feasible independently of the children's age or physical ability. Nonetheless, it appears reasonable to implement age-adjusted curricula. The earlier in the course of life-long learning BLS instruction begins, the more sustainable training may be.

Basic life support knowledge, self-reported skills and fears in Danish high school students and effect of a single 45-min training session run by junior doctors; a prospective cohort study

Background

Early recognition and immediate bystander cardiopulmonary resuscitation are critical determinants of survival after out-of-hospital cardiac arrest (OHCA). Our aim was to evaluate current knowledge on basic life support (BLS) in Danish high school students and benefits of a single training session run by junior doctors.

Methods

Six-hundred-fifty-one students were included. They underwent one 45-minute BLS training session including theoretical aspects and hands-on training with mannequins. The students completed a baseline questionnaire before the training session and a follow-up questionnaire one week later. The questionnaire consisted of an eight item multiple-choice test on BLS knowledge, a four-level evaluation of self-assessed BLS skills and evaluation of fear based on a qualitative description and visual analog scale from 0 to 10 for being first responder.

Results

Sixty-three percent of the students (413/651) had participated in prior BLS training. Only 28% (179/651) knew how to correctly recognize normal breathing. The majority was afraid of exacerbating the condition or causing death by intervening as first responder. The response rate at follow-up was 61% (399/651). There was a significant improvement in correct answers on the multiple-choice test (p < .001). The proportion of students feeling well prepared to perform BLS increased from 30% to 90% (p < .001), and the level of fear of being first responder was decreased 6.8 ± 2.2 to 5.5 ± 2.4 (p < .001).

Conclusion

Knowledge of key areas of BLS is poor among high school students. One hands-on training session run by junior doctors seems to be efficient to empower the students to be first responders to OHCA.

Clinical and translational aspects of hypothermia in major trauma patients: from pathophysiology to prevention, prognosis and potential preservation

The human body strives at maintaining homeostasis within fairly tight regulated mechanisms that control vital regulators such as core body temperature, mechanisms of metabolism and endocrine function. While a wide range of medical conditions can influence thermoregulation the most common source of temperature loss in trauma patients includes: exposure (environmental, as well as cavitary), the administration of i.v. fluids, and anaesthesia/loss of shivering mechanisms, and blood loss per se. Loss of temperature can be classified either according to the aetiology (i.e. accidental/spontaneous versus trauma/haemorrhage-induced temperature loss), or according to an unintended, accidental induction in contrast to a medically intended therapeutic hypothermia. Hypothermia occurs infrequently (prevalence<10% of all injured), but more often (30-50%) in the severely injured. Hypothermia usually come together with and may aggravate acidosis and coagulopathy (the "lethal triad of trauma"), which again may be associated with a high mortality. However, recent studies disagree in the independent predictive role of hypothermia and mortality. Prevention of hypothermia is imperative through all phases of trauma care and must be an interest among all team members. Hypothermia in the trauma setting has attracted focus in the past from a pathophysiological, preventive and prognostic perspective; yet recent focus has shifted towards the potential for using hypothermia for pre-emptive and cellular protective purposes. This paper gives a brief update on some of the clinically relevant aspects of hypothermia in the injured patient.

Comparison of in-hospital and out-of-hospital cardiac arrest outcomes in a Scandinavian community

BACKGROUND

Reported incidence and survival from in-hospital and out-of-hospital cardiac arrest show great variability, making it difficult to compare the groups. In order to eliminate effects of time and culture, we investigated out-of-hospital cardiac arrest compared with in-hospital cardiac arrest in our community over a 1-year period.

METHODS

We conducted a cohort study including patients with in-hospital and out-of-hospital cardiac arrest. Multiple data sources were screened in order to identify all cardiac arrest patients. Utstein style data were collected prospectively from 1 December 2008 to 30 November 2009 with subsequent analysis.

RESULTS

A total of 380 resuscitations because of cardiac arrest were included, 154 (40.6%) in-hospital and 226 (59.4%) out-of-hospital. The in-hospital cardiac arrest group was older, had higher proportions of witnessed cardiac arrest, bystander cardiopulmonary resuscitation, bystander direct current (DC) shock and professional first rescuer. Survival to hospital discharge was 16.2% for in-hospital cardiac arrest vs. 16.8% for out-of-hospital cardiac arrest.

CONCLUSION

Survival from in-hospital and out-of-hospital cardiac arrest in this cohort is similar.

Students' and parents' attitudes toward basic life support training in primary schools

Aim

To assess attitudes of students and their parents toward basic life support (BLS) training in primary schools, along with their perceptions of students’ fears toward applying and training BLS.

Methods

In October 2011, a specifically designed, voluntary and anonymous questionnaire was distributed to 7th and 8th grade students and to their parents in two primary schools in Split, Croatia. Completed questionnaires were analyzed to determine the validity of the scale, and to determine sex and group differences in individual items and the whole scale.

Results

The questionnaires were completed by 301 school children and 361 parents. Cronbach’s alpha of the whole scale was 0.83, indicating good internal consistency. The students’ score for the whole attitude scale was 73.7 ± 11.1 out of maximum 95, while the parents’ score was 68.0 ± 11.9. Students’ attitude was significantly more positive than that of the parents (U = 29.7, P < 0.001). The greatest perceived students’ fear toward applying BLS was that they would harm the person in need of BLS.

Conclusion

Our study showed that in Croatia both students in their last two years of primary school and their parents had a positive attitude toward BLS training in primary schools. Implementing compulsory BLS training in Croatia’s primary schools could help increase students’ confidence, quell their fears toward applying BLS, and possibly even increase the survival of bystander-witnessed cardiac arrests.

Automated External Defibrillators Inaccessible to More Than Half of Nearby Cardiac Arrests in Public Locations During Evening, Nighttime, and Weekends

Background—

Despite wide dissemination, use of automated external defibrillators (AEDs) in community settings is limited. We assessed how AED accessibility affected coverage of cardiac arrests in public locations.

Methods and Results—

We identified cardiac arrests in public locations (1994–2011) in terms of location and time and viewed them in relation to the location and accessibility of all AEDs linked to the emergency dispatch center as of December 31, 2011, in Copenhagen, Denmark. AED coverage of cardiac arrests was defined as cardiac arrests within 100 m (109.4 yd) of an AED and further categorized according to AED accessibility at the time of cardiac arrest. Daytime, evening, and nighttime were defined as 8 am to 3:59 pm , 4 to 11:59 pm , and midnight to 7:59 am , respectively. Of 1864 cardiac arrests in public locations, 61.8% (n=1152) occurred during the evening, nighttime, or weekends. Of 552 registered AEDs, 9.1% (n=50) were accessible at all hours, and 96.4% (n=532) were accessible during the daytime on all weekdays. Regardless of AED accessibility, 28.8% (537 of 1864) of all cardiac arrests were covered by an AED. Limited AED accessibility decreased coverage of cardiac arrests by 4.1% (9 of 217) during the daytime on weekdays and by 53.4% (171 of 320) during the evening, nighttime, and weekends.

Conclusions—

Limited AED accessibility at the time of cardiac arrest decreased AED coverage by 53.4% during the evening, nighttime, and weekends, which is when 61.8% of all cardiac arrests in public locations occurred. Thus, not only strategic placement but also uninterrupted AED accessibility warrant attention if public-access defibrillation is to improve survival after out-of-hospital cardiac arrest.